Health and Pain Mind

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 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.