Health and Pain Mind

Seeking help and advocating for yourself are the first steps to treating your pain. Your physician’s goals in treating you are to reduce your pain, improve your physical functioning, reduce your psychological distress and improve your overall quality of life.11 There are many different ways to treat depression and anxiety related to pain. Your physician may suggest one or more of the following therapies to reduce your psychological distress:

• medication,
• cognitive-behavioral therapy,
• stress management (eg, relaxation techniques, hypnosis, biofeedback),
• supportive counseling, and
• family counseling.12

It’s important to remember that being depressed is not a sign of personal weakness—depression and anxiety are related to chemical imbalances in your brain.13 Depressive and anxiety disorders are illnesses that can be treated. Taking medication and going to therapy to treat your depression is the same as taking antibiotics to treat an infection—the necessary steps you take to get better.

It’s also important to keep in mind that not every medication or therapy works immediately or even works in every person. Medications used to treat depression often take up to six weeks to be effective. If you and your physician decide a particular therapy isn’t effective for you, you may need to try different medications or different combinations of therapies to find the right ones for you. Try not to become frustrated or give up—you and your physician need to work together to achieve results.

Counseling and behavioral therapy—alone or combined with medication—are effective and important techniques in treating depression and pain.14 They also require your active participation in your care and recovery. Following are some suggestions for actively participating in your care and helping you and your physician work together to treat your pain and your depression:

• Keep a diary and record changes in your pain and emotions. Visit the My Pain section of http://www.nationalpainfoundation.org keep pain journal online. You can print it out and bring it with you to your doctors’ appointments to remind yourself of how you were feeling and when you were feeling better or worse.
• Identify a support network. Support persons could include family members, friends, support groups. The National Pain Foundation’s My Community area is an online support group for persons in pain.
• Educate yourself through books, reputable Web sites, and organizations.
• Set realistic treatment goals.
• Stay active—with your doctor’s advice and approval, begin an exercise program, try yoga, or other stretching activities.
• Try the stress management techniques you learn in counseling and use them regularly. Guided imagery, hypnosis, biofeedback, and relaxation techniques really can work if you work at using them.

Depression is an illness, and ignoring it will not make it go away. Seek the treatment you need to get better and be involved in your care—

Chronic pain affects all aspects of life. It affects your quality of life as it limits your physical functioning, your ability to perform activities of daily living, and your ability to work. It has social consequences for your marital and family relationships, it may limit intimacy with your partner, and it may prevent interaction with friends. Chronic pain has societal consequences in terms of increased health care costs, increased disability costs, and lost productivity that is a consequence of missed workdays.

Given the pervasiveness of pain, it’s no wonder that chronic pain affects your psychological well-being as well.3 Research indicates that as number and severity of a patient’s physical symptoms increase, the number and severity of psychological complaints increase.4 In other words, the more places you feel pain and the more severe the pain, the more likely you are to have a depression or problems such as difficulty sleeping or anxiety and the more severe these symptoms are. Some of the signs and symptoms related to depression reported by chronic pain patients treated at pain clinics include:

• physical deconditioning,
• sleep disturbance,
• reduced sexual activities,
• family stress,
• work issues,
• legal issues,
• financial concerns,
• decreased self-esteem,
• fear of injury, and
• altered mood, including irritability, anxiety, and depression.5

Why do pain and depression co-exist so often? Scientists have been studying this relationship through neurosciences and epidemiology and have made important discoveries. First of all, both depression and the suffering of pain are located in the same area of the brain.6 Second, the same chemical messengers are involved in regulating pain and mood.7 What are the mechanisms that affect these parts of the brain and these chemical systems? We find that depression runs in families, so that the stress of having pain may trigger the chemical changes in the brain leading to depression in persons who may be vulnerable because of a family tendency (genetic) to depressive illness. More commonly, however, a person has no family vulnerability to depression, but may get “worn down” by all the stress, losses and problems encountered by having pain over many months.8 Either way, this “wearing down” is biochemical, such that certain important chemicals (similar to vitamins) that are responsible for regulating both pain and mood appear to be functionally depleted. This is why the same medications that are helpful in depression may also effectively treat pain, because they enhance the pain and mood regulating effects of these chemical systems in your brain.

Approximately 40% to 60% of patients being treated at pain clinics report experiencing symptoms of depression.9 Unfortunately, people experiencing pain do not always receive the treatment they need to combat their depression and their pain, especially if they do not see physicians with the training and background to treat both together (eg, pain medicine specialists, psychiatrists, or primary care physicians with this training). Given the nature of today’s health care system, most Americans receive mental health care by visiting their primary care physician, but research studies indicate that 50% of patients who are clinically depressed are not diagnosed by their primary care physicians.10 So be on the lookout for depression in yourself and loved ones and seek treatment before the negative effects occur.

Pain and depression are inexorably linked in a complex way. Pain causes depression—depression causes pain. About 30% of patients with persistent pain conditions suffer from clinical depression related to their pain, and almost all persons will experience some mood changes. 75% of patients with clinical depression present to their doctors because of physical symptoms, including pain.1 People in pain who have symptoms of depression experience more impairment associated with pain than those who do not have depressive symptoms.2

To successfully treat your chronic pain, you and your physician need to examine the emotional factors that may influence your pain level and physical disability. One of the first steps to treating pain is recognizing that depression often accompanies pain and that increases in pain or widespread pain (ie, pain in many areas of your body) can be a symptom of depression. Understanding this aspect of your pain experience may help you identify your own symptoms and seek the care you need to lessen your pain.

Pain may be acute or chronic. Acute pain begins suddenly and usually does not last long. Chronic pain lasts for weeks or months. Usually, pain is considered chronic if it does one of the following:

• Lasts for more than 1 month longer than expected based on the illness or injury
• Recurs off and on for months or years
• Is associated with a chronic disorder (such as cancer, arthritis, diabetes, or fibromyalgia) or an injury that does not heal

When severe, acute pain may cause anxiety, a rapid heart rate, an increased breathing rate, elevated blood pressure, sweating, and dilated pupils. Usually, chronic pain does not have these effects, but it may result in other problems, such as depression, disturbed sleep, decreased energy, a poor appetite, weight loss, decreased sex drive, and loss of interest in activities.

During treatment for chronic pain, many people experience a brief, often severe flare-up of pain. It is called breakthrough pain because it breaks through in spite of regularly scheduled pain treatment. Typically, breakthrough pain begins suddenly, lasts up to 1 hour, and feels much like the original chronic pain except it is more severe. Breakthrough pain may differ from person to person and is often unpredictable.

Chronic pain can make the nervous system more sensitive to pain. For example, chronic pain repeatedly stimulates the nerve fibers and cells that detect, send, and receive pain signals. Repeated stimulation can change the structure of nerve fibers and cells or make them more active and can thus increase pain transmission to the spinal cord and brain. As a result, pain may result from stimulation that might not ordinarily be painful, or painful stimuli may be felt as more severe.

When pain occurs repeatedly, people may anticipate it by becoming fearful and anxious. These emotions can stimulate the body to produce substances that make pain feel more intense. An example is prostaglandins, which make nerve cells more likely to respond to pain signals. Fear and anxiety can also reduce the production of substances that reduce the sensitivity of nerve cells to pain. An example is endorphins, the body’s natural pain relievers. Fatigue can have the same effects on pain as fear and anxiety.

These changes in pain sensitivity partly account for pain that persists after its cause resolves and for pain that feels more severe than expected.