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8 Things That Can Lead to “Payback” for the Chronically Ill

When you are sick or in pain, it doesn't take much to trigger a flare.
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Reprinted with the kind permission of Toni Bernhard.

“Payback” in the chronic pain and illness community means exactly what it implies: We do something that’s beyond our limitations and then have to “pay” for it. That payment comes in the form of a flare in symptoms. To name just three: The flare may be in pain levels, fatigue levels, and/or the ability to concentrate. Payback may make it impossible for us to continue the day as we’d planned. Serious payback can land us in bed for the day—or for weeks.

I think of this kind of payback as the chronic pain and illness equivalent of a bad hangover after drinking too much alcohol. The difference is that it doesn’t take much for those of us who struggle with our health to put ourselves into that “too much” category. That’s one reason why we often feel like shouting “No fair. All I was doing was [fill in the blank].”

What follows is how I’d fill in that blank. Based on what people with chronic pain and illness tell me, this list is not unique to me:

1. Taking a shower

You read that right: taking a shower. On a good day, I have the luxury of taking a simple shower without it leading to payback; but if that shower includes washing my hair, payback is always waiting for me afterward.

It seems unfair that basic hygiene can trigger a flare, but it can. I have a strategy when I start to moan that life is unfair. I bring to mind the words of Zen teacher Charlotte Joko Beck, as quoted in my book How to Be Sick:

Our life is always all right. There’s nothing wrong with it. Even if we have horrendous problems, it’s just our life.

Her words help me put the brakes on feelings of frustration and anger over being chronically ill—feelings that can escalate fast and make me miserable emotionally. This quotation reminds me that illness and pain are part of life. They happen to everyone at some point. This is how they’ve happened to me. No matter how awful I feel, I try to remember that “it’s just my life.” Then I take a deep breath and make the best I can of the day.

2. Making the bed and other household tasks

Making the bed doesn’t always lead to payback, but it can, and is more likely to if the day is already off to a bad start (for me, usually from sleeping poorly the night before). Sometimes, after getting the bed made, I have no choice but to lie down on it for a while until the payback subsides enough for me to move to the next household task.

If making the bed can lead to payback, it’s not hard to believe that these household activities are on my list too: getting breakfast or another meal, washing dishes, doing laundry, or picking up around the house. The fact that these simple, everyday tasks can lead to payback can be incredibly discouraging. Enter that Joko Beck quotation again to help put me back on track!

3. Staying on the computer too long

What’s “too long” before payback kicks in differs for each person, depending on his or her health challenges. And it often differs depending on the day. This is one of the top causes of payback for me because both my personal life and my “writing life” take place almost exclusively on the computer. I don’t see people in person very often, nor do I talk on the phone except to call the doctor or a repair person or do the occasional interview. And that takes me to the next source of payback…

4. Talking on the phone, Skyping, FaceTiming

Some chronically ill people are able to socialize on the phone. Some are even able to engage in video chats, using digital age tools such as Skype or FaceTime. Video chats enable people who are all or mostly housebound to see the faces of friends and family, so it’s the next best thing to being with them in person.

I’ve tried to figure out why both using the phone and video chatting extract such a big payback from me. I think it’s because my energy output has to go into non-stop high gear. By contrast, when I’m typing an email or a text at my computer, I can stop and take a short break.

In addition, when I’m visiting with people in-person, short silences are part of the natural cadence of the conversation. But with the telephone and video chats, silences feel uncomfortable and so everyone (including me) rushes in to fill the gaps. That runs my battery down fast. I can be so exhausted after even a 15-minute phone or video chat that I need to lie down for at least an hour.

5. Engaging in aerobic exercise (or, for me, just about any exercise)

One of the conditions that accompanies my ongoing illness is called POTS or postural orthostatic tachycardia syndrome. That’s a long name for something that’s simple to describe: When I’m standing, whether I’m still or moving around, my heart rate goes up faster than it should. For example, taking a slow walk with my the dog up and down the block can increase my heart beat to over 130 times a minute. The result is that I tire fast and, yes, that means payback.

POTS is dysfunction in the autonomic nervous system, and a recent study indicates it may be an autoimmune disorder. Whatever it is, it sure is frustrating. I put “aerobic exercise” in the heading because it triggers payback almost always for the chronically ill. But I experience payback after any kind of physical exertion with the exception that, on some days, I can lie on the bed and do some resistance band exercises.

6. Doing anything for so long that adrenaline kicks in to enable completing the activity

That “anything” can be something I started doing because I enjoy it—such as visiting with a friend. Or, it can be a “have to,” such as waiting in chairs at the doctor’s office. “Too long” is the operative phrase here. Even healthy people can experience payback after running on adrenaline (for example, staying up all night to study for a test or to meet a work deadline). So you can imagine how much more severe that payback is for people who are already sick and/or in pain.

Once in a while, if something is truly important for me to do—medically, personally, or socially—I do it, knowing I’ll have to use adrenaline to get through and that this will lead to major payback in the form of being bedbound for a period of time.

In fact, I did this just a few days ago. My son and daughter-in-law and granddaughter came to visit for the day, and then a close family friend joined us for an early dinner. Usually when people visit, if they stay into the evening, my husband gently prompts me between 6 and 7 P.M., indicating that I should probably excuse myself and go lie down (after all, he’s the one who has to witness the payback).

But this particular evening, all of us were having a great time. The conversation was rich and full of laughter. My husband could tell what a wonderful time I was having, and so he kept quiet. I was well aware that I was running on adrenaline, but I was willing to pay the price because it was such a rare occasion for me. Everyone left at about 8:30 P.M. and, yup, as soon as the adrenaline wore off, I crashed. I spent the rest of that evening and the next day on the bed, in what we call “stun gun” state. But it was worth it.

7. Excessive stress

It’s not surprising that stress can trigger payback since emotions are felt in the body. I try to counter stress by practicing mindfulness—and not necessarily while meditating. Sometimes all I do is take a few deep breaths, paying attention to the physical sensations in my body and trying to relax any muscles that have tightened due to the stress. Then I remind myself that stress never solves a problem or lessens a worry, and I focus my attention on something pleasant at one of my sense doors. If I’m lucky, the stress takes the hint and makes a hasty exit. If I’m not so lucky, you know what happens: stress is followed by payback. (You can read about how to handle excessive stress here.)

8. Too many days in a row with commitments

I work hard to spread out commitments. If I have a doctor’s appointment, I try to be sure that I have nothing on my calendar the day before or the day after–no phone interviews, no writing deadline to meet. (This is a form of pacing, which you can read about here.) But, as we all know, the best-laid plans sometimes get hijacked by life. No one put it better than John Lennon: “Life is what happens to you while you’re busy making other plans.” In the case of commitments, my “plan” is always to have “no plan” on either side of the commitment. But my plumbing doesn’t know that, and so if I need to host the plumber during one of my “non-commitment” days, so be it. I call it losing control of the day…or the week. All it will mean is payback. Payback payback payback.


If some activity leads to payback for you, I hope you’ll share it in the comments section. It might help other people know what to watch out for to avoid this “side-effect” of chronic pain and illness.

Toni Bernhard is the author of the award-winning How to Be Sick: A Buddhist-Inspired Guide for the Chronically Ill and their Caregivers, now in a revised and updated edition (2018). She is also the author of How to Wake Up: A Buddhist-Inspired Guide to Navigating Joy and Sorrow and How to Live Well with Chronic Pain and Illness: A Mindful Guide. Before becoming chronically ill, she was a law professor and dean of students at the University of California—Davis. Her blog, “Turning Straw Into Gold” is hosted by Psychology Today online. Visit her website at www.tonibernhard.com.

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By ProHealth-Editor

Karen Lee Richards is ProHealth’s Editor-in-Chief. A fibromyalgia patient herself, she co-founded the nonprofit organization now known as the National Fibromyalgia Association (NFA) and served as its vice-president for eight years. She was also the executive editor of Fibromyalgia AWARE, the very first full-color, glossy magazine devoted to FM and other invisible illnesses. After leaving the NFA, Karen served as the Guide to Fibromyalgia and Chronic Fatigue Syndrome for the New York Times website About.com, and then for eight years as the Chronic Pain Health Guide for The HealthCentral Network.To learn more about Karen, see “Meet Karen Lee Richards.”

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