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Chronic Pain and Mental Health: The Empowered Patient’s Guide

The pain is excruciating. Piercing. Throbbing. Persistent. And that’s just the physical part of it. Your emotions are just as intense. Will this ever change? How can you do what you need to do when you’re worried and hurting?By Cara Roberts Murez

Physical and emotional pain often go hand in hand. Chronic pain can trigger anxiety, depression, and other mental health issues. It also increases your risk of substance abuse and suicide. Treating your mental health can sometimes lead to pain relief.

When you’re experiencing chronic pain combined with mental health issues, this is life.The consequences of chronic pain on mental health are enormous. Finding a solution to manage them is essential.

If it seems like you’re alone in dealing with physical and emotional pain, you’re not. About 50 million U.S. adults have chronic pain, according to the Centers for Disease Control and Prevention, and 20 million have the type of pain that’s so intense or persistent, it interferes with work or life on a near-daily basis.¹You may be interested in these related articles:

• The Empowered Patient’s Guide to Migraine and Headache
• Opioids and Chronic Pain Management: Why It’s So Complicated
• Are You Missing Two-Thirds of Your Potential Pain Treatment Plan?

Feelings of depression and anxiety are common too. Chronic pain and mental health are inextricably associated, says Nilanjana Bose, MD, a rheumatologist at Memorial Hermann Southeast Hospital in Houston. Anxiety and depression can worsen chronic pain, and pain can exacerbate mental health issues like depression, anxiety, and panic disorders, and even the inability to sleep.

That explains a lot about how you’re feeling when you have aches and pains, in addition to sadness and worry.²

To make matters worse, chronic pain conditions are notoriously difficult to diagnose, so you can bounce from specialist to specialist trying to chase down a diagnosis and effective treatment. Going from one doctor to another in search of help for the complex pain you’re experiencing mentally, emotionally, and physically can in itself be frustrating.

But while there are significant challenges, there is also hope: Many effective treatments go a long way toward improving the quality of life for people living with chronic pain and mental health conditions.

Anxiety and Depression: Chronic Pain’s Unwanted Companions 

Chronic pain, by definition, is any kind of lasting pain that doesn’t resolve within six months, according to Kiran Rajneesh, MBBS, a neurologist and interventional pain specialist at The Ohio State University Wexner Medical Center, Columbus, Ohio.

Many different conditions can cause it, and a continual change in the peripheral or central nervous systems can maintain that pain over time, says Sarah Buday, PhD, a clinical psychologist at Washington University Pain Center, Washington University School of Medicine, St. Louis.

The way the brain processes those signals can be complicated. The X-rays of two people might look the same, but the way they experience their pain can be totally different, says Dr. Buday, who specializes in pain psychology. One might feel pain and one might not. It’s also true that the mental impacts of pain are very individual. Not everyone becomes depressed or worries about their condition. This different experience of pain speaks to why it can be difficult to treat and even study, Dr. Rajneesh says.

While tens of millions of people experience chronic pain, about 17.3 million adults experience depression in the U.S., according to the National Institute of Mental Health.³ In terms of its closely related cousin, anxiety, about 40 million Americans have those feelings of fear, worry, and impending catastrophe each year, according to the Anxiety and Depression Association of America.⁴

Two studies completed within the past few years found that half of all people with chronic pain also have depression and/or anxiety.⁵ The social isolation that can come with staying home because of pain can lead to a cycle of pain and depression, Dr. Rajneesh says.

These 8 Chronic Pain Conditions Are Hardest on Mental Health 

Here are the most common chronic pain conditions that come with a heavy emotional impact:

1. Fibromyalgia can be difficult to diagnose, and its cause isunknown. It affects about 2%—or 4 million—adults inthe U.S. Women are twice as likely to experience itswidespread body pain and stiffness, painful response to pressure, debilitating fatigue, trouble sleeping, depression, memory problems, headaches, and anxiety. Being of middle age and having a diagnosis of lupus or rheumatoid arthritis increase the risk. Treatments range from medication to lifestyle changes and cognitive behavioral therapy.^{6, 7}
2. Migraines, whichaffect 12%of the population,can feel like throbbing or pounding in the head, face, or neck. They may also include visual auras; a sensitivity to light, noise, or smells; and nausea. Having chronic migraines means they occur on 15 or more days each month. Treatment includes lifestyle changes, vitamins, and prescription medications.⁸ Some risk factors include depression, stress, obesity, and even the overuse of acute migraine medication.⁹
3. Back pain can have a variety of causes, including illness, accidents, and infection, but some back pain also has an emotional connection or an emotional impact. It is experienced more often by people who have anxiety or depression. Symptoms can include sharp pain in one or more regions of the back or neck, aches, or stiffness. About 16 million people experience persistent or chronic back pain.¹⁰ Treatment optionsinclude medications (including antidepressants), surgery, and physical therapy.^{11, 12}
4. Osteoarthritis is a degenerative joint disease, affectingmore than 32.5 million Americans. It is more common in women than men. It happens as cartilage within joints breaks down or wears away. Osteoarthritis causes stiffness, pain, and swelling. Treatment may involvemedications, surgery, physical therapy, exercise, and weight loss. Risk factors include genetics, obesity, age, and joint injury or overuse.¹³
5. Rheumatoid Arthritis, or RA for short,is an inflammatory, autoimmune disease that affects 1.5 million people in the U.S.¹⁴ Women are three times more likely to develop the disease, and it typically starts between about age 30 and age 60. RA causes your immune system to attack yourbody’s healthy cells, inflaming joint tissue and causing pain and swelling. Though RA is known for its impact on joints, it can affect the lungs, heart, skin, eyes, and blood vessels, as well as cause fatigue. A variety of medications are available tohelp stop the symptoms of RA and even limit its progression.
6. Psoriatic Arthritis affects the skin, joints, areas where tendons or ligaments connect with a bone, and the nails, causing painful red patches and joint swelling. The condition usually runs in families, and it affectsabout 30%of people who have psoriasis,¹⁵men and women equally. A variety of medications can help.
7. Pelvic pain affects about 15% of U.S. women of childbearing age.¹⁶ It can be sudden or chronic, starting in genital or other pelvic organs or be due topsychological reasons. Among the many causes are uterine fibroids, endometriosis or endometrial polyps, scar tissue, cancer, or menstrual cramps. Treatment can include surgery, physical therapy, relaxation exercises,anda variety of medications, such as antibiotics, anti-inflammatory or pain medicine, or oral contraceptives. Counseling can also help people cope with this form ofchronic pain.
8. Complex Regional Pain Syndrome (CRPS) is a rare condition that affects about 200,000 people in the U.S. each year, the majority of whom are of European descent.^{17, 18} It’s typically caused by a problem in the peripheral C-fiber nerve fibers and develops after a form of trauma, such as an injury or even a surgery. It can cause spontaneous or extreme pain, often in an arm or leg, as well as changes to skin’s temperature, color or texture, and swelling near the injury. It is common for people with CRPS to develop depression, anxiety, or PTSD. Treatment includes physical therapy, psychotherapy, graded motor imagery, and medications.

When Chronic Pain and Mental Health Collide: Symptoms, Causes, Diagnosis

A complicated series of reactions explains the connection between emotional and physical pain. For example, the cycle of pain and mental health issues changes your stress hormones and brain chemicals, including cortisol, serotonin, and norepinephrine. ¹⁹ As pain moves from being acute (short term) to chronic, the number of areas affected in the brain actually expands, Dr. Buday says.

Chronic pain can change how the brain processes pain signals, like wires that become crossed. Something similar happens in the brain with depression, Dr. Rajneesh adds.

Mental health issues and chronic pain are like a double-edged sword. Anxiety can make a person more sensitive to their feelings of pain or “catastrophize” their pain. Pain can be isolating, and isolation can worsen feelings of depression—there’s that double-edged sword again.

For people who are catastrophizing, there are three elements at work, according to Dr. Buday: Magnification, or a feeling of something being very overwhelming in a person’s life; rumination, or spending a lot of time thinking about the pain to the point of not being able to think about other things; and feeling unable to control the situation. Catastrophizing magnifies the distress and the physical limitations associated with chronic pain above and beyond what they should be.

When people experience both depression and chronic pain, they often will only share what is happening physically, which means they aren’t being treated for their mental health symptoms.² But it’s just as important to recognize and get help for symptoms that signal depression or anxiety.

Symptoms of depression include:²⁰

●       Feelings of sadness or hopelessness

●       Feelings of guilt or worthlessness

●       Losing interest in hobbies and activities

●       Gaining or losing weight

●       Being unable to sleep or sleeping excessively

●       A number of unexplained physical feelings, including pain, fatigue, and digestive issues

●       Recurrent thoughts of death or suicide¹⁹

Symptoms of anxiety include:²⁰

●       Feeling tense, restless, worried, or irritated

●       Having trouble focusing

●       Not being able to sleep

●       Experiencing physical changes like a rise in blood pressure¹⁹

Certain conditions are even more intertwined. For instance, people with CRPS are more likely to experience post-traumatic stress disorder (PTSD), a 2017 study reported.²¹ Psychiatric disorders, including PTSD, situational anxiety, and depression, can make pain more noticeable.²²

People living with fibromyalgia can experience a variety of psychiatric conditions, including borderline personality disorder, obsessive-compulsive personality disorder, other personality disorders, anxiety, depression, and PTSD.²³

People who are diagnosed with major depressive disorder have a significantly increased risk of experiencing migraines. Generalized anxiety disorder and migraines appear to have a strong link,²⁴ and migraine also has connections to a form of anxiety disorder that features panic attacks.²⁵

Back pain is linked with depression—and people with chronic low back pain who are also depressed have significantly more severe pain than those without depression.²⁶

Mental Health Treatment for Chronic Pain

Because there are so many different contributors to pain, it can take time to find what works for you. Sometimes, the pain just needs to be managed enough for you to take part in daily life and keep doing what makes you, well, you.

Finding a good provider is key. That means a doctor who believes in you and will work on treatment even if he or she is not able to see where your pain is coming from, Buday says. What matters is that if you say it’s there, it’s there.

Therapy. One answer is to find a pain psychologist, someone who specializes in treating people experiencing chronic pain, and then participating in either individual or group therapy.

Some evidence-based mental health solutions include:

●       Cognitive behavioral therapy (CBT), which helps you learn how to change negative thoughts and build coping skills to have more control over emotions, mood, and how you feel pain²⁷

●       Contextual cognitive behavioral therapy, also known as acceptance and commitment therapy (ACT), a type of talk therapy that focuses on accepting yourself, being present, freeing yourself of negative thoughts, identifying what’s meaningful to you, and using that to build a more satisfied life²⁸

●       Mindfulness training, which can include various types of meditation, as well as focusing on breathing and living in the moment²⁹

●       Clinical hypnosis

●       Supportive therapy

Medication. Though the opioid epidemic—their widespread abuse in the United States³⁰—has gotten deserved attention, these drugs still may be an option for short-term pain. Note that they’re not a good choice for long-term use because of a range of side effects, Dr. Rajneesh says. Here’s what we know to put their use into context.

Millions of Americans are prescribed opioids for chronic pain, with the CDC estimating that 20% of prescriptions go to people with acute or chronic pain symptoms unrelated to cancer (the more common reason for their use). Opioid misuse affects more than 11.5 million American preteens, teenagers, and adults on the drugs, according to available data from 2016.³¹

More than 165,000 people died from opioid-related overdose in the U.S. between 1999 and 2014, according to a CDC report.³² In 2018 alone, nearly 47,000 people died from an overdose where opioids were involved, according to the CDC.³³ It is important to note that the majority of opioid overdoses have been from illicit opioid use including manufactured or synthetic fentanyl, not prescribed use. Researchers of a 2017 study using national survey data did find that people who misused prescription opioids were 40 to 60% more likely to have suicidal thoughts.³⁴

Opioids aren’t the only cause for concern. Studies suggest that about 25% of adults with chronic pain self-medicate with alcohol, according to the National Institute on Alcohol Abuse and Alcoholism (NIAAA.).³⁵ Chronic pain on its own is estimated to double the risk of death by suicide, according to a factsheet from the U.S. Department of Veterans Affairs, which also noted the link between psychiatric disorders and chronic pain. And the presence of pain may impair needed treatment for depression.³⁶

There are other doctor-prescribed medications available that help with chronic pain, without the risks of opioids and self-medicating. They include nonsteroidal anti-inflammatory drugs (NSAIDs), antidepressants, anticonvulsants, sedatives, muscle relaxants, corticosteroids, anti-rheumatic/immunologic agents, and botulinum toxins, according to the Cleveland Clinic.²⁷

Surgical options.These include spinal cord stimulators³⁷ or DRG stimulators,³⁸ both of which are implanted devices that reduce pain by sending electrical signals.

Self-care and lifestyle strategies. Experts say it is also possible to make a big difference in how you feel physically and emotionally with these steps:

●       Find and participate in an activity that’s meaningful to you. Pace yourself. Take breaks when needed.

●       Stay socially engaged. Social isolation can worsen depression and chronic pain.

●       Find adaptations for activities that have the most value to you. Maybe you can’t play touch football with your youngster, but you can still enjoy time together in other ways that work for you.

●       Use a meditation app, such as Calm or Headspace, and try stress management techniques like yoga and deep breathing.

●       Followan anti-inflammation diet, which can help with chronic pain and fatigue. This involves limiting processed foods, cured and red meat, refined starches, sugars, and sodas. At the same time, up your intake of foods rich in antioxidants, mostly fruits and veggies, which can replenish the brain’s neurotransmitters.

●       Try low-impact aerobic exercise, which can boost endorphins, relieve pain, restore muscle tone, and increase your sense of well-being.

●       Get better sleep. Sleep plays an important role in modulating pain and recharging the body. Follow a sleep routine that includes taking a bath, doing yoga, or meditating before getting into bed. Keep bright lights out of your bedroom and turn off all screens at least an hour earlier.

●       Get a pet, if you can. Pet therapy provides companionship, and can also get you out of the house, helping with isolation.

What Can I Do RIGHT NOW?

All people living with chronic pain need emotional support. Here are some ways you can connect with others who are experiencing similar struggles:

Join a support group. It can help to join support groups and meet others who are living the same experience as you are. Start here:

American Chronic Pain Association (state-based)

Pain Connection Support Groups (state-based or national options)

Find the right doctor. Find a good medical specialist and/or a pain psychologist, depending on your specific symptoms.

The American Psychological Association has a Psychologist Locator tool to help you find a mental health provider in your area, including ones who specialize in areas like chronic illness and pain management.

The American Society of Regional Anesthesia and Pain Medicine has helpful information on what exactly pain management specialists do and what you can expect from your visits withthis type of expert.

Get ready for doctor visits. Put together a timeline for your condition and write down your answers to these questions:

●       When did the pain and the anxiety or depression start?

●       Were there any accidents or events that happened at this time?

●       What activities contribute to the pain, and what makes you feel better?

Advocacy can be empowering.You can volunteer, raise awareness, or participate in a clinical trial. Start here:

The Arthritis Foundation has ways that you can advocate for arthritis issues that are important to you, as well as volunteer opportunities too.

If you’re interested in participating in a clinical trial on chronic pain, Clinicaltrials.gov is a database of trials happening worldwide, including those recruiting participants.

How to Have Those Hard Conversations

You have a life outside of your pain, and it’s important to keep up with what’s important to you. Don’t withdraw because of the struggle. Instead, take clear action.

If you don’t want to open up with friends or coworkers, for instance, whether about why your pain persists or what you’re feeling on a given day, tell people that. Shift the conversation to your shared interests.

You might say something like, “I really appreciate that you care about how I feel. I just don’t always want that to be what people focus on, so when I see you, let’s not talk about it.”

In the workplace, you may be able to have a discussion with your employer, without revealing your full medical circumstances, but sharing that you might need some accommodations while you work through pain and other concerns.

FAQs

How does pain affect mental health?

Both pain and depression have a connection relating to pathways in the brain. Depression can cause or intensify feelings of pain. And pain can cause feelings of depression. They feed off each other, in a way, causing a vicious cycle.³⁹

What can long-term use of pain medications do to my mental health?

Some medications can improve mental health conditions like anxiety or depression, but others can make them worse. It’s important that your doctor tailor any prescribed medications to you as an individual. There are some medications that can improve more than one condition, including those that reduce pain and depression, Dr. Rajneesh says.

Can mental health issues cause back pain?

A lot of people have mild back pain. When they’re experiencing a mental health issue such as depression or anxiety, the thoughts running through their minds can include the mild back pain. By fixating on it, it can keep them from following good health habits as well as cause minor pain to become exaggerated.

How can I help someone with chronic pain and depression?

You can provide opportunities to reduce their social isolation. Also, offer to help do the things that can improve their condition over time. Drive your loved one to the doctor or physical therapy appointments. Remind them gently when certain lifestyle changes increase their pain (for example, too much coffee for someone who experiences migraines). Be aware that chronic pain may increase someone’s risk for suicide.⁴⁰Updated on: 03/30/21View Sources