Chronic Pain and Depression

So here’s one of my pet peeves: someone saying “it’s all in your head” and all the stigma that goes along with this statement. Often times, when a client comes to see me for the first time, someone has suggested their chronic pain is psychological. But what they mean by this often is “it’s all in your head.” And let’s be honest, uninformed people often think less of someone with a “psychological issue.” So why is this one of my pet peeves? Here is the truth… Wait for it… EVERYTHING is all in your head.

That’s right, everything you experience comes from your perceptions of your body and the world around you. All of our experience is being perceived through nerve signals that get processed through the brain and spinal cord. Our brain and body are not separate organisms. They interact together to create our reality or lived experience.

But sadly, most of my clients do not come to me with this understanding. They have taken on the statement that “it’s all in their head” and experience shame and guilt because they now feel defective. This idea of separation is perpetuated by our Western European division of the fields of medicine and psychology. In this view, your medical doctor focuses on identifying disease processes in the body while your psychologist or other mental health professional focuses on disorders of emotions, thinking, or behavior (e.g., processes of the mind). While this simplifies areas of study and treatment, it unnaturally separates how we think about our functioning.

So what do we mean when we say chronic pain and depression? One typical definition of chronic pain is pain for most days for at least a month. When I say depression, I am actually referring to Major Depressive Disorder (MDD). The symptoms of MDD include sadness or irritability, diminished interest or pleasure in activities, changes in appetite, sleep changes, psychomotor agitation or retardation, fatigue or loss of energy, feelings of worthlessness or inappropriate guilt, diminished ability to think or concentrate or indecisiveness, and recurrent thoughts of death, recurrent suicidal ideation without plan, or suicide attempt or a specific plan for suicide. If you’ve had 5 or more of these symptoms most days for 2 weeks or longer, you may be having a Depressive Episode and need to be evaluated for MDD, ideally by a qualified mental health professional.

In most cases, people with chronic pain and/or depression first go to their primary health physician with physical complaints. Going here first is appropriate because physical illness should be ruled out or treated. What many people don’t know and medical doctors may miss (one study said up to 50%) is that physical complaints, especially pain, can indicate undiagnosed depression.

Chronic Pain and depression (MDD) have been found to be related in that as pain symptoms increase, the incidence of depression increases, and vice versa. As depression symptoms increase, the likelihood of pain symptoms increases (http://archinte.jamanetwork.com/article.aspx?articleid=216320). A review of the literature (http://archinte.jamanetwork.com/article.aspx?articleid=216320) found the following. Those with pain symptoms had a two fold increase in risk for depression. In general, as severity, frequency, duration, and number of pain symptoms increased, so did the risk of depression. People with pain from multiple sources (i.e., back pain, headache, abdominal pain, chest pain, and facial pain) were three to five times more likely to be depressed. And, people with chronic pain were three times as likely to meet depression criteria.

The same review noted an important understanding of how pain perception works, what neurochemicals are involved, and how the dysregulation of the same neurochemicals and pathway are associated with depression. Here’s their explanation.

Recent research has provided evidence of a central pain modulation system that can either dampen or amplify nociceptive signals from the periphery. Both serotonin and norepinephrine have been shown to dampen peripheral pain signals. This explains how depression, which is associated with a dysregulation of these key modulating neurotransmitters along a shared pathway, may contribute to the frequent presence of painful symptoms. Thus the decrease in one or both of these neurotransmitters may increase peripheral pain messages and affect how antidepressants that increase these neurotransmitters decrease pain signals. (http://archinte.jamanetwork.com/article.aspx?articleid=216320, retrieved November 20, 2014)

What does this mean? If you have depression and experience physical complaints be sure to tell your psychiatrist or medical doctor. They may suggest a change to an SNRI (Serotonin Norepinephrine Reuptake Inhibitor) so that those two neurochemicals mentioned above are made more available to your nervous system. Also, make sure you get the correct diagnosis. I had one patient who had been diagnosed with sciatica and depression. However, they later found out from a back specialist that the leg pain was actually neuropathy. So, they changed their meds to an anti-seizure medication (meds like Lyrica or Gabapentin) and an (SNRI, in this instance Cymbalta) and profoundly changed this person’s life. Before, they were on a super strength pain killer (the Fentanol patch) and still in pain. On the new meds, they went down to practically no hydrocodone and had complete remission from pain. Their depression also decreased significantly. The take away: stay after your health care team (e.g., medical doctors, physical therapists, and mental health professionals). Get a 2nd, 3rd, and 4th opinion if you feel something isn’t being treated effectively.

It is important to note, however, that when other medical issues have been ruled out, that some pain is somatic and would respond well to psychological treatment. Also research has shown your emotional state can affect your perception of pain. In this study, women who were angry or sad experienced more pain (http://psychcentral.com/news/2010/09/24/emotions-increase-perception-of-pain-in-women/18672.html). Also, other cognitive issues can increase and worsen pain. As an example, catastrophizing, which is a cognitive distortion also seen in people who are depressed, can increase the experience of pain (http://brain.oxfordjournals.org/content/127/4/835) and affect depression.

Finally, I want to specifically mention that chronic pain increases the risk of suicide. A study done using data from a large number of people (n = 4,863,086) found “that elevated suicide risks were observed for some noncancer pain conditions with the greatest risks being for those with back pain, migraine, and psychogenic pain.” It should be noted that “psychogenic pain had the highest incidence of suicide” (http://www.ncbi.nlm.nih.gov/pubmed/23699975, retrieved November 20, 2014). Psychogenic is another way of saying that the pain originates from the mind, not a physical/physiological cause. (To get more info on Suicide and Depression see my 1st blog entry and the Facts, Stats, and Helpful Info about Suicide and Depression posting.)

So here’s the good news. Treatment with a qualified mental health professional can help. Sometimes mental health treatments can actually reduce psychogenic pain. And, while we may not be able to make the pain go away (note: sometimes this does happen), we can help people cope more effectively regardless of the source of the pain. Personally, I have found CBT (Cognitive Behavioral Therapy), ACT (Acceptance and Commitment Therapy), and EMDR (Eye Movement Desensitization and Reprocessing) to be helpful treatments. The important thing to remember is that there is hope. Finding out “it’s all in your head” can be a good thing because now you can get the focused treatment that’s most likely to work. And, frankly, when dealing with any chronic issue just have an emotionally supportive ally can make all the difference in the world.

I hope that this information was interesting and helpful to you, and that you will consider returning in the future.

Michelle E. Mason, PhD, Clinical Psychologist, PSY23467

November 21, 2014

If you would like additional information about me or my practice you may find it on my website (www.adiffpath.com), or you can call me at 510-506-50921, or email at mmasonphd@comcast.net.