When TMJ Pain Becomes a Catastrophe
By Ann McCulloch | Reviewed by Brad Eli DMD, MS
“Pain catastrophizing” is when the emotional part of our brain amplifies and magnifies pain. Learn how this relates to TMJ pain and mindfulness techniques that help.
Understanding how acute pain becomes chronic is one of the most important topics in pain research for back pain, neck pain, and TMJ pain. When acute pain is sustained for days, the wiring in our brain can become maladapted. Neurons in our sensory cortex may sense pain long after the painful stimulus is gone. This process is called central sensitization. We know that the emotional part of our brain plays an important role in how we experience pain.
One of the ways the emotional brain influences pain is by attaching fear emotions to painful stimuli.
Table of Contents
- What is Pain Catastrophizing?
- What Causes Pain?
- What is the Amygdala or “Fear Center” of the Brain?
- What is the Pain Catastrophizing Scale?
- How is Mindfulness Used to Treat Pain Catastrophizing?
- Mindfulness Protocol for TMJ Pain Management
- Trait Mindfulness Comes From Practicing State Mindfulness
What is Pain Catastrophizing?
The term “pain catastrophizing” is when physical pain, either actual or anticipated, is coupled with negative emotional states like anxiety. Researchers now know that “pain catastrophizing” plays a key role in the transition from acute to chronic pain. Pain catastrophizing can also make chronic pain a heavier burden.
Temporomandibular joint (TMJ) pain is one of the most common forms of chronic pain. It can be categorized into 30 different subtypes, collectively called temporomandibular disorders (TMDs). Pain catastrophizing can play an important role in how people experience TMD pain. For instance, a 2023 study by the Journal of Clinical Dentistry found that for people with TMDs, pain catastrophizing increases the chances of reporting a low quality of life .
One of the key strategies in treating chronic pain is developing emotional resources to deal with the pain. This is sometimes called pain self-efficacy. A recent BMC Psychology study documented an inverse relationship between pain self-efficacy and pain catastrophizing . However, pain self-efficacy tools can be learned.
One of the most powerful of these is the practice of mindfulness. As a pain management technique, it is most effective when applied to pain-catastrophizing behavior. This article explores how pain catastrophizing works in the brain and how simple mindfulness tools can be used to improve pain self-efficacy.
What Causes Pain?
Historically, there was a simple answer to this. When some part of our bodies becomes injured, sensory neurons travel from the injured part of our bodies to the “sensory cortex” of our brain. This signal is how we “feel” pain. While this is true, missing factors that also contribute to the experience of pain became evident.
“Extra-sensory” contributors to TMJ pain include:
- Our emotional reactions to pain.
- Our genetic tolerance for pain.
- Our cultural understanding of pain.
The National Academies of Sciences released a landmark publication on TMJ pain and TMD conditions in 2020. They embraced what is called the “biopsychosocial” model of pain (see featured image above). Once we understand the biological, psychological, and social contributions to pain, we can truly understand what causes it and what can be done about it.
The biopsychosocial model of pain provides a comprehensive heuristic for understanding and managing pain… It assumes that pain and its associated disability are the results of complex and dynamic interactions among physiological, psychological, and social factors that can maintain and amplify pain and disability.” 
The biopsychosocial model of pain is adopted by the National Academies of Sciences as the best way to understand the complexities of TMJ-related pain.
Our concern today are the psychological factors that exacerbate pain. Expectations and adaptation skills are among many psychological factors that contribute to pain; they are central to our topic of “pain catastrophizing.”
Before we get to the psychological component of pain, it’s important to acknowledge how the anatomy of our brain supports the theories about how fear and emotions contribute to pain.
What is the Amygdala or “Fear Center” of the Brain?
The amygdala is a part of a system of structures that regulate emotions and behaviors, called the “limbic system”. The amygdala itself is responsible for integrating emotions, behavior, motivation, and fear. In fact, historically it was considered to be the “fear center” of the brain.
Our understanding of the amygdala has broadened over the years. We now understand that just as sensory nerves map to specific areas of the sensory cortex, they also map to specific portions of the amygdala . “Nociception” is the physiological process where specific neurons throughout our body (nociceptors) respond to harmful or noxious stimulus.
The mapping of these nociceptors in the amygdala is now collectively termed the “nociceptive amygdala”. Hence, in a very simplified manner, what the amygdala does is to take incoming pain signals and translate them into “threat” signals. In short, it’s responsible for how we learn to “fear pain”. And because it also integrates the cognitive signals in our brain, it shapes our reaction to both current pain and our anticipation of future pain.
As illustrated in our featured image, TMJ pain signals travel through the trigeminal nerve (V3) to the brainstem (TNC), then up to the thalamus, and finally to the amygdala.
What is the Pain Catastrophizing Scale?
It includes the folling pain catastrophizing factors: magnification, rumination, & helplessness
Researchers began better understanding the impact of fear emotions on the experience of pain. The need for a framework to translate these various contributions into categories emerged. They are helpful in the study of a psychological paradigm when TMJ pain becomes a catastrophe. The term “pain catastrophizing” began as a general term for the negative mental framework associated with both the real-time experience of pain and the anticipation of pain. Other researchers see when a patient is magnifying a threat value. Another framework is to worry and fear about pain and be unable to consciously divert attention away from the pain.
Soon, the concept of pain catastrophizing was refined by the development of a standardized test called the Pain Catastrophizing Scale (PCS) . This identified a construct of three factors, each building on each other: magnification, rumination, and helplessness. Each factor has a set of questions that are graded, such that each factor could be scored (above table).
Importantly, pain catastrophizing can have a closer association to high-impact chronic pain (HICP) than general anxiety or depression. In a 2023 population based study, feelings of helplessness (a form of pain catastrophizing) was a significant risk factor for HICP, whereas anxiety and depression were not . This is especially true for domestic abuse victims that are slapped in the face or hit on the head. Trauma to the head coupled with fear of a partner opens up risks of TMJ developing.
Since the introduction of PCS, there’s been multiple other attempts to measure and validate the importance of pain catastrophizing. This includes both the experience of pain and its contribution to the transition to chronic pain. While the results of these tests vary, it’s clear that pain catastrophizing is a powerful predictor of outcomes in pain-related clinical scenarios. As stated in a 2022 meta-analysis on the subject, “among individuals with various pain conditions, pain catastrophizing, fear of pain, and pain vigilance have medium to large associations with pain-related negative affect, anxiety, and depression, pain intensity, and disability”. .
What is the Fear Avoidance Model?
One final and important point to understand is where pain catastrophizing fits a temporal model of chronic pain development. A general framework for the psychological component of pain is called the “fear avoidance” model.
This captures the process whereby an original pain signal leads to the development and perpetuation of chronic pain through psychological factors. Importantly, pain catastrophizing is only a portion of this model, but it appears very early on in the process. The implication is that if you address pain catastrophizing, you may be able to avoid the downstream negative behaviors associated with fear avoidance. 
How is Mindfulness Used to Treat Pain Catastrophizing?
We established how pain catastrophizing is the gateway to pain avoidance behaviors. The question remains, how do you treat it? You may have heard of mindfulness as a technique to treat chronic pain. Emerging evidence signals how mindfulness helps with pain by specifically interrupting the process of pain catastrophizing. Further, people with low mindfulness skills tend to have higher levels of pain catastrophizing, and ultimately, greater struggles with chronic pain.
And while mindfulness is typically used to treat chronic pain, the fact that it’s effectiveness is in decreasing pain catastrophizing suggest that mindfulness may be a powerful tool for preventing the transition from acute to chronic pain.
Mindfulness is all about modulating one’s attention. The goal is to focus attention on real-time present moment thoughts and feelings in a way that is non-judgmental. Try balancing your TMJ pain with a neutral observer’s point of view. Other aspects of mindfulness include a backdrop of kindness, compassion, and curiosity. It’s easy to see the added dimension this brings by consciously observing internal phenomenon and doing so with an attitude of kindness.
The practice of mindfulness can be divided into two general categories:
- State of mindfulness
- Trait of mindfulness
State mindfulness refers to a specific intentional practice, such as yoga or meditation. This lets you train your mind with intentional focus on the present moment. Trait mindfulness, sometimes called dispositional mindfulness, refers to the habitual practice of mindfulness in all activities throughout the day.
In this sense, it’s more like a personality component than it is a practice. Research shows that trait mindfulness is the type that’s important in addressing pain catastrophizing . The way to develop trait mindfulness is to regularly practice state mindfulness, such that mindful awareness becomes part of the day .
Mindfulness Protocol for TMJ Pain Management
Because of the multitude of different kinds of mindfulness techniques, getting started sometimes seems complicated and out of reach. For this reason, we put together a simple protocol that you can use to start your mindfulness journey. This mindfulness protocol is designed specifically for those suffering for TMDs. You’ll find our additional JAMSS protocols helpful.
Preliminary points when starting your mindfulness journey to reduce TMJ pain:
- The N-Resting Position: Just as with the practice of yoga and meditation where correct posture is important, having the correct jaw posture is important for using mindfulness to treati TMJ pain. The N-resting position is when you gently push your tongue up, so its flush with the roof of your mouth. Importantly, the teeth should be slightly open. This should have the effect of relaxing the entire face. See Figure 5.
- Use an Anchor: One of the biggest challenges of mindfulness meditation is to learn to let thoughts come and go. The way to do this is to choose an anchor, something you can bring your mind back to when it wanders. Most commonly this is the breath. However, with mindfulness for TMD pain, try using the N-resting position as your anchor.
- Kindness, Compassion, and Curiosity: Commit yourself to these three dispositions as you start your mindfulness practice. This is especially important when mindfulness is being used to address something as powerful as pain.
With this as background, consider these steps as a simple protocol for TMJ pain management. This protocol combines several elemental mindfulness practices, including mindful breathing, focused attention, acceptance, and kindness.
Steps to Control TMJ Pain Catastrophizing
- Find someplace quiet. Seat yourself comfortably. Close your eyes.
- Assume the N-resting position. This is your anchor. If you get lost in thought, bring yourself back to your anchor.
- Focus on your breath, breathing in through your nose and out through your nose. Notice how the N-resting position establishes your breathing posture. Use slow, steady breathing to pace yourself as you move through the exercise.
- Start to explore the sensations in your head and neck. Start from the scalp to the temples, to the eyes, to the nose, to the cheeks, to the lips, to the tongue, to the neck, to the shoulders.
- Is there pain? If so, observe the raw painful sensations in real-time as you breathe. Mentally smile at the pain with kindness. Then move on.
- Is there tension? If so, let yourself breathe into the tension, and as you breath out, let the tension go. Then move on.
- Once you’ve finished your scan, take a final deep breath and open your eyes.
If a pain patient is prone to pain catastrophizing, providers should assess anxiety, depression, sleep disturbance, teeth grinding, and unique needs for emotional support. Included in the Speed2Treat Kit is a mindfulness meditation with Dr. James Fricton.
SUMMARY: Trait Mindfulness Comes From Practicing State Mindfulness
That’s it! It’s not complicated and there’s no right or wrong way to do it. You can add or subtract based on what fits for you. The most important thing is to just get started and keep going. Remember, trait mindfulness comes from practicing state mindfulness. Eventually, you’ll be able to slip into the mindfulness state many times throughout the day.
Ann McCulloch, MBA is co-founder and president of Orofacial Therapeutics, this site, and oversees the company’s expanding portfolio of resources and tools for jaw and headache pain diagnosis and treatment. Her chronic jaw pain issues continue to inspire her to investigate the needs and challenges of patients suffering from orofacial pain.
Dr. Brad Eli, DMD, MS is a graduate of UCLA’s post-doctoral Orofacial Pain program. The field of orofacial pain, temporomandibular disorders, and treatment of sleep disorders became the 12th specialty of dentistry in 2020. Over the past 29 years of clinical practice specializing in orofacial pain and sleep, Dr. Eli has also been on the educational staff at university hospitals, pain centers, and the clinical staff of Southern California hospitals.
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 “The Difference Between Mindfulness and Dispositional Mindfulness”, Jul 06, 2022, https://psychcentral.com/blog/dispositional-mindfulness-noticing-what-you-notice