Family: Their Role and Impact on Pain Management
How clinicians can counsel and guide both the patient and the caregiver through chronic pain.
By David Cosio, PhD, ABPP Pages 18-22
In the United States, approximately 100 million people suffer from chronic pain, and about 43% of households have at least one family member living with chronic pain.1,2 The effects of chronic pain are not independent to the patient, but also extend to their family and significant other. Intractable pain can demoralize and depress both the patient and their at-home caregivers, especially when there is no effective pain control or hope for relief.3 Conversely, there is an equally profound effect of family responses on their loved one’s pain,4 and family dynamics may contribute to the exacerbation or recovery of pain.5
There are two dimensions of life with chronic pain:
the loved one whose pain is invisible, and who may:
- fluctuate activity levels
- have unpredictable mood swings
- show signs of depression
- isolate themselves.
and the family who is unable to see the pain, and who may:
- take on more responsibility
- feel stressed, powerless, guilty, and/or anxious
- withdraw plans (for medical appointments or work disability evaluations)
- deal with emotional outbursts from the patient
- feel alienated.6,7
Thus, it is important for frontline practitioners to not only consider the person who is suffering in front of them, but also the people standing behind them who may need their own support and education about pain management.
The Spiraling Effects of Chronic Pain
Chronic pain may negatively impact the family system by intruding on every aspect of life, leading to significant consequences.2 For example, there may be a loss of sexual expression and intimacy in couples, which may lead to separation and divorce. There may be social isolation which then perpetuates further attention-seeking within the healthcare system.
Family members may experience changes in their thoughts and feelings, leading to depression or anxiety. They may engage in ongoing unexpressed family conflict and/or bring up childhood family issues. Family members may begin to believe that their loved one is attention-seeking or avoiding their responsibilities, which then negatively impacts their relationships.
Role reversals may begin to emerge between the pain sufferer and other family members. For example, one spouse may have led the household, from cooking to yardwork. If he or she begins to suffer from pain, they may be unable to maintain those tasks, leaving the partner or other family members to take them on.
Another individual may have served as the “social director” for a family, providing educational support and running errands. If this person is diagnosed with a chronic pain condition, their responsibilities may be subsumed by another family member or the duties may go unfulfilled. The struggle to recover lost functions and roles can be debilitating to a family, increasing stress, grief, and depression.
When Caregivers Reinforce Pain Behaviors
Chronic pain can also impact the family system with significant positive outcomes, although this is less common.6 For example, if a spouse was controlling before they developed a chronic pain condition, then the other family members may now have more freedom. Family members may feel good about helping a loved one if they have a strong need to help others. A decrease in intimacy may feel positive to the person who experiences intimacy, or even sex, with their loved one as unwanted. Some members of the household may get additional support or sympathy from other family members. These positive outcomes can lead to family members unintentionally trying to get the patient to maintain the “sick” role.
The presence of a familial caregiver may contribute to enhanced cohesion and resilience as everyone works together to adapt to the demands of chronic pain.5 However, the family may also be responsible, in part, for maintaining and perpetuating pain behaviors.2 Those who are nearest to the person manifesting pain behavior will almost always respond to them, for example, and their mere presence may come to serve as a cue for increased reports of pain.8 Reinforcements of maladaptive behavior may occur when family members unintentionally provide attention or react too caringly to pain complaints.9 This example is often seen in situations where the person in pain has an overprotective partner or spouse. While attention is certainly a form of love expression, it may also be a negative reinforcement if abused.
Family caregivers may also promote fear of harm; despite meaning well, they may begin taking over tasks or even speaking for their loved one who is suffering from pain in an effort to terminate the stressful impact of their pain complaints. This approach, however, may actually detract from their loved one’s independence and self-efficacy.10 It is important for the person suffering from pain to maintain their independence and that family members support them in this regard.
Some families also deal with emotional problems at a somatic level.11 In other words, they exhibit their emotional problems with physical complaints. The opposite may also be true. Those who suffer from pain may live alone and have no family nearby or support system in place. These individuals may feel ignored or express frustration because they do not have anyone to talk to about their problems.
How to Assess Family Functioning
If the family is involved in maintaining the patient’s pain, then they should also be included in the assessment and treatment of pain.12 Several self-report instruments have been developed to measure family functioning, which may be used with families of patients who suffer from chronic pain, including the:
- Family Adaptability and Cohesion Evaluation Scales (FACES II)13
- Family Environment Scale (FES)14
- McMaster Family Assessment Device (FAD).15
There are also observational measures that may be used to assess family interactions, including the:
- Revealed differences technique16
- Simulated Family Activity Measurement (SIMFAM) technique17
- Manual Interaction Coding System (MICS).18
More specifically, the practitioner should obtain a family history of pain, ideally at a first visit. In addition, information about familial interactions preceding exacerbations and the meaning or attributions ascribed to the pain are important to decipher. Self-report measures such as those listed below may be used to gather some of this information:
- Spouse’s Perception of Disease (SPOD) questionnaire19
- West Haven Yale Multidimensional Pain Inventory (WHYMPI)20
- a diary to relate pain to spouse or partner behavior.12
Finally, family members should be made to feel comfortable when asking for family or couples counseling if needed.
When to Refer Family and Couples Counseling
Frontline practitioners should refer a family or couple to counseling when there is evidence of stress, grief, anger or conflict in the relationship and when helpful to address specific issues. The family or couple may pursue family therapy along with other types of mental health or addiction treatments. Furthermore, counseling can be helpful to the patient and their family members to understand one another better and learn coping skills to bring them closer together.
Clinicians can also educate patients and their families about the benefits of counseling. For example, addressing emotions with support groups or therapy can help to strengthen the family and reduce the suffering of all involved. Research has shown that discussion groups for patients with chronic pain and their family helps to improve communication, support mutual relationships, and provide better coping strategies.21 However, reviews of randomized controlled trials have indicated that family-oriented psychotherapies used to treat chronic illnesses generally have small effects; more research is required.22 There are a number of treatment approaches involving family members that have been developed, including operant-behavioral, cognitive-behavioral, and others.
Operant-behavioral treatment is based on the operant conditioning model of chronic pain, which proposes that pain behaviors are influenced by social responses of family members. Over time, these responses may become rooted patterns which leads to increased dependency and disability.23-25 When using an operant-behavioral approach, family members are taught to validate their loved one’s pain but also disregard maladaptive behaviors and reinforce wellness behaviors.5 These interventions have been shown to be effective when combined with family support and education about coping skills.26,27
Cognitive-behavioral treatment (CBT) is based on the cognitive-behavioral transactional model.28,29 It proposes that the family develops a relatively stable set of beliefs about illness, pain, disability, and coping over time. The focus in CBT is to direct the family toward developing an adaptive problem-solving approach to pain management. This involves increasing the effective use of available family resources (time, energy, knowledge, skills/abilities), teaching family members new adaptive coping skills, and helping them draw upon available external resources (eg, schools, community centers, childcare programs, women’s centers, and other community networks). There has been empirical support for the effectiveness of CBT with spouses of chronic pain sufferers.26,30
There are three other family-oriented therapies that include the spouse or the family; these are structural, cognitive, and strategic. However, these family- oriented therapies have scant research to support their effectiveness.
Structural family therapy proposes that family system structures, such as enmeshment, roles and rules, poor communication, lack of conflict resolution, withholding feelings, and avoiding emotionally laden topics contribute to the evelopment and perpetuation of pain.12,31 Therefore, treatment concentrates on changing the structure of the family so that a new homeostasis may be reached without the patient taking on the “sick” role.
Cognitive theory focuses on self-disclosure in marriage and a resulting uptake in the couple’s closeness and intimacy.32 The couple is encouraged, for example, to share appraisals and thoughts about each other and openly express negative emotions.
Strategic perspectives, on the other hand, consist of interventions that are practical and problem-oriented; these may require a comprehensive assessment by a therapist.33
How to Encourage Family Self-Care
Members of the family should be encouraged to address their own pain and stress resulting from these circumstances.5 First and foremost, they should maintain a healthy lifestyle, including a healthy diet, exercise, relaxation, and proper sleep hygiene. These practices may not only help the family face the difficult times ahead, but may also serve as models to their loved one suffering from chronic pain. Familial caregivers should avoid coddling or being punitive toward their loved one suffering from pain and instead take on more facilitative roles.
Family caregivers can also work to acknowledge and overcome any special obstacles that may occur when communicating with a person suffering from chronic pain.34 Family members will want to learn as much as they can about their loved one’s condition and treatment options.6 However, family members need to keep in mind that when communicating with their loved one’s doctors, they must first obtain permission and consider HIPPA regulations.
Family members should be encouraged to allow the person in pain to speak directly to the doctor and to only provide additional information when specifically asked to do so. Family members may add insight into their loved one’s pain by sharing their perception using a pain score (0 to 10), describing it as it unfolds throughout the day, and helping their loved one complete a pain log or diary. They may also inquire further about the side effects and dosages of medications and/or the appropriate activity levels and limitations.
A good model may be to encourage family members to view the situation as “our fight” and not “their fight,” being careful not to take negative behaviors of the loved one too personally.6 Families and support systems work best when everyone is operating cohesively. (More on family communication for your patients.)
Frontline practitioners need to be aware of how chronic pain is associated with functional limitations due to the positive and negative reinforcements from the family dynamic in response to pain.35 It is important to include family members in pain education and treatment approaches, and to encourage communication between them, which has been shown to improve outcomes.36 •View SourcesLast updated on: December 12, 2019
CBT and ACT Therapy for Chronic Pain: How Does Psychotherapy Help?
Individuals with chronic pain share how Cognitive Behavioral Therapy and Acceptance and Commitment Therapy worked for them. By Rosemary Black Reviewed By Michael R. Clark, MD, MPH, MBA and Beth Dinoff, PhD
If you’re open to trying Cognitive Behavioral Therapy (CBT) or Acceptance and Commitment Therapy (ACT), you may not only get relief from your chronic pain, but you may find that you feel generally more content with your life as well. CBT is a practical, hands-on, goal-oriented psychotherapy treatment that aims to change whatever patterns of behavior and thinking are at the root of a person’s difficulties. ACT, which based on behavioral therapy, encourages mindful, values-guided action. Rather than focusing on symptom reduction, ACT encourages the person to take actions that are based on her own values to hopefully enrich her life. (See more detail on each therapy at the end of this article.)
“ACT is about accepting your distressing symptoms or situation and not trying to resist or suppress them,” explains Michael Clark, MD, chairman of psychiatry and director of the Behavioral Health Service Line at the Inova Health System in Falls Church, Virginia. “Once you’ve accepted it, it is focusing on what would you like to be different, which is generally informed by what you value and what your life goals are. CBT is more about cognitively reframing your distress that is a manifestation of cognitive distortions like ‘I’m a horrible person’ or ‘The world is a negative place.’ The patient is asked to think about the evidence for these cognitions as well as evidence to the contrary, that is, finding positive evidence. Then the patient is asked to “behave” as if that positive evidence is really true, even if their negative feelings and distorted thoughts would suggest otherwise to them.”
Both ACT and CBT are typically covered by insurance and offered in conjunction with other treatments, explains Beth Dinoff, PhD, a clinical psychologist at the University of Iowa Hospitals and Clinics. “Pain management is always best provided as a multidisciplinary treatment,” she says. “Pain impacts all domains of peoples’ lives so the more life domains that are addressed usually leads to improved outcomes.” Dr. Dinoff, who practices ACT, notes that psychotherapists are not required to have special certification to provide CBT and ACT, although all clinical psychologists must have either a PhD or a PsyD degree, which allows them to provide psychotherapy to patients.You may be interested in these related articles:
“For people who are in pain and feeling demoralized, CBT and ACT can help with chronic stress, managing symptoms, decreasing anxiety, and improving problem-solving,” says Dr. Clark, who is also a member of the PPM advisory board.
Many other forms of psychotherapy focus on trying to ignore or suppress symptoms, explains Dr. Clark, “but with newer forms like ACT and CBT, instead of ignoring or suppressing their symptoms, people are taught to focus on their goals and their values. They learn to make changes in their life and to move forward to regain life satisfaction.”
Of note, in a PPM online reader poll, 73% said they have not yet sought out a psychotherapist as part of managing their chronic pain and related symptoms. Below are stories of two individuals who have tried and found success with ACT and CBT for combatting their chronic pain.
Using Acceptance and Commitment Therapy (ACT) to Experience Pain Differently
Kelly Teuscher of Davenport, Iowa, has suffered from chronic pain since she was a teenager, but countless treatments over the years yielded her little relief. With migraine, back pain, arthritis, Crohn’s disease, and diabetic gastritis, rarely does a day go by for Kelly when one of these conditions doesn’t act up (Read more about pain flares.)
Her doctors have tried just about everything: various medications, injections, and water therapy, but the pain remained. On one of her visits to a pain clinic in Iowa City, not far from where she lives, Kelly’s doctor suggested that she make an appointment with a psychiatrist. “At first, I thought to myself, they must think I’m crazy,” she recalls. “I just couldn’t see how seeing a psychiatrist would help.”
But after a consultation with the psychiatrist, she was referred for pain psychotherapy (also known as “talk therapy”) with Dr. Dinoff, who practices ACT. Kelly began to see Dr. Dinoff in March 2019, and after just four visits, she began to feel better.
“I’m amazed,” Kelly says. “It’s weird, but I feel calm. I am learning how to deal with my pain and how to put it in perspective. I’m no longer focusing on it.”
She says that practicing ACT has enabled her to view her life differently. “Every day, situations arrive that are challenging,” she admits. “But I’ve learned how to deal with various situations and take them for what they are, and this has made my anxiety go down. For the first time, I’m using my mind to deal with my emotions and feelings.”
Dr. Dinoff is a pain psychologist and clinical associate professor in the department of anesthesia in the Pain Management Clinic at the University of Iowa Hospitals and Clinics in Iowa City. She says that ACT teaches her clients how to live a full life despite their pain. “With ACT, we accept our negative internal sensations, pain being one of them,” she says. “But we do this in terms of living in service of our values. We hope that our patients will embrace learning to live a full life in the context of pain.”
How ACT Works: Metaphors, Values, and Flexibility
In addition to the use of metaphors, ACT stresses psychological flexibility as well as “cognitive diffusion,” in which the therapist strives to help the person get unstuck from thoughts, emotions, and memories that he or she may be attached to. “The person may be used to thinking they will always be in pain and never walk again,” Dr. Dinoff says as an example. “But that may not be true.”
How an individual relates to pain is important, Dr. Dinoff adds. “Often, people tell me that they just want their pain to go away completely so they try to push it away as hard as they can,” she explains. “But using an ACT metaphor, I invite the person to imagine they’re at the beach, swimming in the ocean, and holding a beach ball that they try to shove under the waves.”
Next, Dr. Dinoff has the person think about how much energy that would take, and then asks the person to consider the following: What if you just let the ball float on the surface of the water instead?
“The person begins to see how much effort it is taking for them to suppress the negative sensation of pain,” Dr. Dinoff explains. “Once they have these images of the metaphor, they can apply this to their own lives.”
Another metaphor she likes to use involves thinking about using a garden hose to water flowers. “If you put your thumb on the hose, it sprays all over and is out of control,” she says. “Instead, what would happen if you just let the water flow? With the ACT approach, learning to let go of behaviors, memories, thoughts, and emotions creates space to explore new experiences, including acceptance of chronic pain sensations.”
In ACT, the therapist is not trying to decrease a person’s chronic pain but rather to help the person focus on how they can change their behavior. Dr. Dinoff helps the patient to make the transition from feeling like a sick person with a lot of symptoms to an individual who can enjoy a satisfying life, a life of value.
Dr. Clark says he also has discussions with his ACT patients about how they can manage the chronic pain together. “It’s like trying to climb to the top of the cliff,” he explains. “You get on the wall and start making handholds and footholds and as you go, other handholds and footholds become more obvious and, pretty soon, you’re at the top of the cliff.”
With Acceptance and Commitment Therapy, the patient learns how to be present and non-reactive to unwanted negative physical or emotional circumstances, adds Dr. Sara Davin, PsyD, of the Cleveland Clinic’s Neurological Institute. “We talk about the values people have in their life and how their current situation is interfering with their ability to reach their life potential. There is a focus on acceptance and being willing to experience things.”
For Kelly, practicing ACT has not made her pain-free, she says, but it has paved the way for her to deal with her pain. “Once you get your mind right and learn to deal with situations and take them for what they are and not out of context, your anxiety goes down,” she says.
Since she started ACT with Dr. Dinoff, she is not only able to handle the physical pain better but also the emotional pain of having lost her sister two years ago. “I’ve been having some good discussions with my parents,” she shares. “I am taking much less pain medication than I was, and I’m getting more exercise.”
In fact, Kelly, her father, and her boyfriend of eight years bought a house together in April 2019. She and her boyfriend have a dog, she’s working, and she says that life is good. “I don’t feel so blue,” she says. “It’s all about using your mind to deal with your emotions and your feelings. In just four sessions, I have learned so much.”
Using Cognitive Behavioral Therapy (CBT) to Reframe Negative Thoughts and Avoidance
For many years, CBT has been the gold standard for pain psychology. Many patients and pain psychologists have found the approach to be very effective. For example, Deborah Cook of Birmingham, Alabama, who suffers both from rheumatoid arthritis and fibromyalgia, has seen so many doctors for her pain that she’s lost count.The mother of two children (ages 12 and 13), she’s tried everything from muscle relaxants to a transcutaneous electrical nerve stimulation (TENS) unit, but nothing has worked. She had just started on prescription opioid pills when she was referred to Leanne Cianfrini, PhD, a Hoover-Alabama-based pain psychologist who utilizes Cognitive Behavioral Therapy. And while Deborah says that the past several months have been difficult, she says that practicing CBT over the past 5 years has kept things from getting worse. “I might have ended up being hospitalized otherwise,” she says. “It has saved me.”
Typically, CBT and ACT are offered either as individual or group psychotherapy and both involve attending sessions of 45 minutes to 60 minutes each either every week or every other week. Dr. Dinoff notes that “both are as or more effective as group psychotherapies.” The approach allows the patient and the therapist to be “co-investigators,” explains Dr. Davin, of the Cleveland Clinic. “The way someone interprets their physical pain can impact their emotional state and how they respond to the pain, so it can be a vicious cycle,” she says. “Patients respond to pain in a fearful or catastrophic manner and feel hopeless and powerless, which are negative emotions.”
Deborah’s doctor, Dr. Cianfrini, adds that the collaborative style of CBT guides the patient to discover ways to reframe unhelpful or negative thoughts that can maintain pain. “It’s a perspective shift,” she explains. “It involves counter-arguments to thoughts that provoke negative emotions. For example, patients can get locked into a thought habit like, ‘I should be able to do everything I used to do’ and then feel discouraged when their pain cues them to rest a bit or pace themselves.” In this case, the therapist would work with the patient to generate an alternative thought process, such as, “My body is different now. I accept that I will pace myself today and be proud of what I accomplish.”
Or, adds Dr. Cianfrini, a patient living with chronic pain might anticipate pain with a certain activity. She might think, “I can’t sit through church (or a movie, or the ballgame).” A CBT therapist would gently guide the patient toward phrases such as, “Well, I could, if…” and generate behavioral techniques to accomplish their functional goals, she explains.
CBT can help people to change their way of thinking and how they regulate their emotions. Those who practice CBT can be taught to retrain their brain in a way that helps them experience less pain over time, she says. In addition to being collaborative, Dr. Davin emphasizes that “CBT is present focused, so rather than spending a lot of time digging into their past, we help the person understand where the negative thinking comes from and show them how to respond to pain in a less threatening way so they can have a better quality of life.”
Deborah shares that her life is much better than it was before she began CBT. “Even on my hardest days, I feel so much relief and I can function with the daily pain,” she says. “I have the tools to help me through the really bad days and my worth is not determined by what I am physically able to do. Some days, my best is getting my kids to and from school. Some days, I can get chores done and some days I can’t. I own my pain, but it does not define who I am.”
For help finding a psychotherapist, consider searching the American Psychological Association’s provider directory. You can search by location and then filter the treatment methods to those that offer cognitive/behavioral therapy. https://locator.apa.org/
Read also about how CBT can help with insomnia, a condition many individuals living with chronic pain experience.
Learn More about CBT and ACT
Cognitive Behavioral Therapy (CBT)
CBT is a present-focused, short-term, psychotherapy approach that encourages patients to engage in an active coping process to change their maladaptive thoughts and behaviors that oftentimes maintain and even exacerbate the experience of chronic pain. The cognitive-behavioral model is grounded in the idea of pain as a complex experience that is influenced by a patient’s thoughts and their effects, as well as one’s overall behavior. The goals of CBT in pain management include reducing the impact pain has on one’s daily life, learning skills for better coping with pain, improving physical and emotional functioning and well-being, and reducing reliance on pain medication.
CBT was developed as “Cognitive Therapy” in the 1960s by Aaron T. Beck, based off of a previous therapy called Rational Emotive Behavior Therapy (REBT) developed by Albert Ellis in the 1950s. CBT is typically administered by psychotherapists such as psychiatrists, psychologists, licensed professional counselors, licensed social workers, licensed marriage and family therapists, psychiatric nurses, or other licensed professionals (such as pain specialists) with mental health training.
Acceptance & Commitment Therapy (ACT)
ACT, developed in 1982 by Steven C. Hayes, is a distinct form of mindfulness-based intervention in that it is a behavioral analysis that uses acceptance and mindfulness strategies mixed with commitment and behavior-change strategies. ACT encourages patients to shift their focus from reducing or eliminating pain to fully engaging in their lives, changing how they relate with their internal experiences and ultimately living a better life. Therapists aim for patients to become actively involved in what they care about and what matters most in their life, despite having and experiencing pain. ACT applies six core processes (willingness to accept, contact with the present moment, observing the self, cognitive defusion, values, and committed action) through different exercises; these interventions provide patients to become more open, present, and take action in their lives.
While there is no official ACT certification for physicians, the Association for Contextual Behavior Science (ACBS) has a registry of members who identify as ACT therapists. According to the ACBS, those seeking ACT therapy may also look to contact the psychology, social work, or psychiatry department at a nearby college or university for faculty members who are experts in behavior therapy or CBT.
-Sidebar reported by Steven AlianoUpdated on: 12/16/19
The pain-anxiety-depression connection
June 17, 2020
Everyone experiences pain at some point, but for those with depression or anxiety, pain can become particularly intense and hard to treat. People suffering from depression, for example, tend to experience more severe and long-lasting pain than other people.
The overlap of anxiety, depression, and pain is particularly evident in chronic and sometimes disabling pain syndromes such as fibromyalgia, irritable bowel syndrome, low back pain, headaches, and nerve pain. Psychiatric disorders not only contribute to pain intensity but also to increased risk of disability.
Researchers once thought the relationship between pain, anxiety, and depression resulted mainly from psychological rather than biological factors. Chronic pain is depressing, and likewise major depression may feel physically painful. But as researchers have learned more about how the brain works, and how the nervous system interacts with other parts of the body, they have discovered that pain shares some biological mechanisms with anxiety and depression.
Treatment is challenging when pain overlaps with anxiety or depression. Focus on pain can mask both the clinician’s and patient’s awareness that a psychiatric disorder is also present. Even when both types of problems are correctly diagnosed, they can be difficult to treat.
Treatment options when pain and anxiety or depression intersect
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In patients with depression or anxiety, various psychotherapies can be used on their own to treat pain or may be combined with drug treatment.
Cognitive behavioral therapy. Pain is demoralizing as well as hurtful. Cognitive behavioral therapy (CBT) is not only an established treatment for anxiety and depression, it is also the best studied psychotherapy for treating pain. CBT is based on the premise that thoughts, feelings, and sensations are all related. Therapists use CBT to help patients learn coping skills so that they can manage, rather than be victimized by, their pain.
Relaxation training. Various techniques can help people to relax and reduce the stress response. Stress tends to exacerbate pain as well as symptoms of anxiety and depression. Techniques include progressive muscle relaxation, yoga, and mindfulness training.
Hypnosis. During this therapy, a clinician helps a patient achieve a trance-like state and then provides positive suggestions — for instance, that pain will improve. Some patients can also learn self-hypnosis. One study showed that hypnosis training reduced both gastrointestinal distress and levels of depression and anxiety in 71% of those studied.
Exercise. There’s an abundance of research that regular physical activity boosts mood and alleviates anxiety, but less evidence about its impact on pain.
The Cochrane Collaboration reviewed 34 studies that compared exercise interventions with various control conditions in the treatment of fibromyalgia. The reviewers concluded that aerobic exercise, performed at the intensity recommended for maintaining heart and respiratory fitness, improved overall well-being and physical function in patients with fibromyalgia, and might alleviate pain. More limited evidence suggests that exercises designed to build muscle strength, such as lifting weights, might also improve pain, overall functioning, and mood.
Patients with anxiety or depression sometimes find that combining psychotherapy with medication offers the most complete relief. A randomized controlled trial, the Stepped Care for Affective Disorders and Musculoskeletal Pain (SCAMP) study, suggests that a combination approach might also work for people suffering pain in addition to a psychiatric disorder.
Some psychiatric medications also work as pain relievers, thereby addressing two problems at once. Just remember that pharmaceutical companies have a financial interest in promoting as many uses as possible for their products — so it is wise to check that evidence exists to support any “off label” (not FDA approved) uses for medications.
Patients may prefer to take one medication for the psychiatric disorder and another for pain. In this case, it’s important to avoid drug interactions that can increase side effects or reduce the effectiveness of either drug. Talk to your doctor if you are taking multiple medications.
Antidepressants. A variety of antidepressants are prescribed for both anxiety and depression. Some of these also help alleviate nerve pain. The research most strongly supports the use of serotonin and norepinephrine reuptake inhibitors (SNRIs) or tricyclic antidepressants (TCAs) as double-duty drugs that can treat both psychiatric disorders and pain. The findings are more mixed about the ability of selective serotonin reuptake inhibitors (SSRIs) to alleviate pain.
All drugs may cause unwanted effects. SSRIs, for example, may increase risk of gastrointestinal bleeding. TCAs can cause dizziness, constipation, blurred vision, and trouble urinating. Their most serious side effect is a dangerously abnormal heart rhythm, so these drugs may not be appropriate for people with heart disease.
Mood stabilizers. Anticonvulsants are also sometimes used to stabilize mood. These medications exert their effects by constraining aberrant electrical activity and hyper-responsiveness in the brain, which contributes to seizures. Because chronic pain in particular involves nerve hypersensitivity, some of these medications may provide relief.
When Chronic Pain Leads to Chronic Anger
Stress and frustration are common and expected emotions in individuals living with constant pain, but fueled anger can actually make chronic pain worse. Here are ways to combat the cycle. By Rosemary BlackReviewed By David Cosio, PhD, ABPP and Michael R. Clark, MD, MPH, MBA
Individuals living with pain can experience a range of emotions including anxiety, depression, sadness, and, last but not least, anger.
In fact, 70% of individuals living with chronic pain report feeling angry at themselves and at healthcare professionals,1 says David Cosio, PhD, ABPP, a psychologist in the Interdisciplinary Pain Program at the Jesse Brown VA Medical Center in Chicago and a member of the Practical Pain Management Editorial Board.
Unfortunately, anger is linked to greater pain severity, pain behavior, and muscle tension in people who live with chronic pain.2 In one study, researchers concluded that patients with headaches displayed a significant impairment of anger control and suggested that there is a connection between anger and how long a headache lasts.3You may be interested in these related articles:
Why Pain Fuels Anger and Other Emotions
“When someone suffers from pain for an extended period, this can affect their mood negatively,” Dr. Cosio explains. “These mood changes can negatively impact their levels of activity. People begin to engage in more unhealthy behaviors and less in healthy ones.”
Whether men or women are more likely to be angry is not certain. One study found that men (16.7%) were more likely than women (1.5%) to report anger.4 Yet when Dr. Cosio’s research team conducted a study in 2018 that looked at the prevalence rates of different psychological domains among veterans with chronic pain, they found that women (88%) reported anger more often than men (72%.) “Our findings suggest that anger may be a domain that all frontline providers should actively assess and make treatment recommendations for all their chronic pain patients,” he said.
Anger is a powerful, negative, and physiologically arousing emotion commonly experienced in response to acute pain,5 adds Gadi Gilam, PhD, a postdoctoral research fellow in the Stanford University School of Medicine’s Department of Anesthesiology, Perioperative and Pain Medicine in Palo Alto, California.
“Most studies indicate that patients with chronic pain tend to be angry,” says Dr. Gilam. “Understandably, they are dealing with a lot of challenges, frustrations, and with the feeling that their suffering is unjust and unfair. However, their anger and the way they express their anger can worsen their chronic pain.”
Anger as a Coping Mechanism
Anger can be a coping mechanism in response to pain but it’s actually counterproductive, agrees Germaine Rowe, MD, a pain management doctor at Healthcare Associates in Medicine on Staten Island, New York. “It puts the body into a state of stress, which causes the release of substances such as adrenaline, cortisol, and C reactive protein, and these chemical mediators cause a chain of events that end up worsening the pain,” she explains.
Individuals living with pain may become angry when they are unable to meet the demands of life and do the things they want to, adds Michael Clark, MD, MPH, MBA, chair of psychiatry and behavioral health at the Inova Health System in Falls Church, Virginia. The person may be struggling to answer the “Why me?” question, says Dr. Clark, who also serves on PPM’s editorial board.
“They have to figure out a way to process the loss of their former life and to reconnect with their world and realize there is still a path for quality of life to be achieved,” he says. “It’s a matter of doing an inventory of a person’s strengths and weaknesses and helping them to fit into something they can succeed at.”
Strategies to Combat Pain-Driven Anger
Fortunately, there are effective treatments for individuals whose pain may be accentuated by the anger they are feeling. The first step is to determine what you’re feeling, says Dr. Cosio. Fear, sadness, guilt, and shame are common emotions in a person who is in pain. “The person may be uncomfortable with these emotions, so they are quick to anger,” he says.
Cognitive behavioral therapy
“We teach our patients a 3-step process to address anger,” says Dr. Cosio. Using cognitive behavioral therapy (CBT), the person learns how to become aware of triggers for their anger. Next, they learn how to modify internal responses by using strategies such as relaxation exercises. “We also teach them to respond assertively when expressing an opinion and taking action,” Dr. Cosio explains. “This form of therapy helps the person recognize the self-defeating negative thoughts that lie behind anger flare-ups which in turn, can affect the perception of pain.”
Compassion cultivation training and mindfulness
Another effective strategy for helping to reduce anger is Compassion Cultivation Training, an 8-week program that Laurisa Dill, M.Ed, a Toronto-based registered psychotherapist who runs CCT workshops, says is typically taught for a couple of hours per week. CCT programs are offered around the United States.
CCT aims to help improve resilience, increase empathy and compassion, and cut back on anxiety and stress. Participants are guided to practice daily meditations and they learn techniques to help improve their mood, Dill says. The program has its roots in mindfulness-based programs, she says.
“You can change your outlook and your interpretation of pain and anger by cultivating compassion and mindfulness,” says Dill. “You can reduce stress and depression, increase self-compassion, and support your health and well-being.”
In CCT as well as other mindfulness-based programs, a person is taught that she has the capacity to regulate her nervous system and reduce the stress hormones that can worsen pain, Dill explains. “When we are in a state of caring and compassion, all our stress hormones go down a little bit, and we are less susceptible to the experience of pain,” she adds.Updated on: 05/11/20
So many of us get caught up in the rush to answer email or do other tasks on the computer that we forget or ignore many things that make life worth living. I found it refreshing to read the thoughts shared with me by Marian Griffey. Hope you will enjoy and appreciate her point of view.
In the Pursuit of Service
Malcolm Gladwell, author of “Outliers” and other insightful books, has unknowingly been one of my best “tools” in my personal toolbox for pain management. So often, I doubt my ability to endure the multifaceted causes of my chronic pain. Physical fatigue seems to hold a magnifying glass over the underlying causes, making even the smallest pain seem enormous, too big to handle. On those occasions when the body is weary from lack of healing sleep, and the barometric pressure reaches a level that wraps my entire body in its squeezing grip, and the daily news undermines my faith that “humane” has not been eliminated from humanity’s mind and willingness – such times give birth to limitless self-doubt.
doubt: (Latin) hesitation
Gladwell’s sensible approach to how things get to be the way they are helps me free myself from such hesitations in Life. His words remind me of the “how” I lost sight of goal (to be of service to others). More, he lays out the formula of “how” to help other like-minded people rediscover mutual benefits. For “service to others” becomes “mutual service” – a way of self-service (minus all self-serving aspects).
According to Gladwell, there are three qualities of work (service to others) that result in feeling fulfilled and producing a sense of meaningfulness.
- a sense of autonomy – that inner assurance that, not only can “it” be done, but more than that … assurance that “I can do it!” The “it” varies, of course, and the “I can” fluctuates by degrees according to the pain levels of the moment. A moment’s degree of hesitation in our self-confidence can provide an opportunity to reflect upon past times when we felt similar doubt and yet persevered. Within those brain-files of memories, we can find that sense of autonomy we need once again. By that act of kindness-to-self, we become empowered to return to being of service to others. The more we practice this, and the more of us who are practicing this, the more mutual our service becomes. Quality of work becomes more fulfilling, more meaningful.
- a degree of complexity – and what work could be more complex than that of being of mutual service to one another? As chronic pain touches all four aspects of our being (physical, mental, emotional, spiritual), every moment of pain represents a complexity of separate and interconnected elements, not only of who we are but also our personal history. From the date of our birth, to the geographic location, to the cultural and genetic inheritance in our genes – every person is so complex! An enigma of mysterious and wondrous proportions! Ergo, the work of service to others is one of the most complex kinds of work that could ever be undertaken. Each person is not a “simple” story. Every case of chronic pain is not a “simple” cause-n-solution event.
- a measurable reward in direct proportion to the amount of effort invested – In helping myself, I am rewarded with ability to help another. In helping others, I am rewarded by the evidence of their improved sense of autonomy, increased appreciation for the complexity of just being alive in this world, and the look on their face of inner “reward” of improved pain management, a return to being of service to others, and willingness to let hesitation (doubt) serve them as opportunity to rediscover their “I can!”
The secret to “mutual service” lies within this 3-point formula of how to make “service to others” fulfilling and meaningful. Like in most other forms of work, it begins with self. If the longest relationship that I will ever have is with my own self, then why not work toward making this the best relationship I will ever have? Relationships are by their very nature a work of mutual effort. By learning the three qualities necessary to make this (or any other type of work) both fulfilling and meaningful, I make myself beneficial to myself as well as to others. Thus, we learn to BE mutually beneficial.
(old proverb) Many hands make light work.
Mutual service does not have to be difficult, regardless of the challenges we encounter. My hands are willing to work in service to others. Bring your hands of similar willingness into that formula and we will find ourselves making light work together. (Double entendre intended.)
We will also discover that “pain management” need not feel like a prison sentence. Our individual toolbox can hold countless “tools” with which we continually learn, re-learn, and un-learn management principles.
management: from the same root-word for ‘manipulate’ – the skillful use of tools
My skills are not the same as yours. What works one day may not work the next. What one person feels to be a fulfilling and meaningful “tool” in their management program may not prove likewise in another. Becoming skillful with tools requires practice; lots and lots of practice. So too, pain management requires lots and lots of practice in remembering how to be your own best relationship. It is, as Gladwell would say, a most fulfilling and meaningful work of mutual service.
5 May 2021 © Marian Lovene Griffey
ACPA Pain Management Support Group facilitator;
Gainesville, FL chapter
The Mysteries of Multiple Chemical Sensitivity and Fibromyalgia Syndrome
Many people may not associate chronic pain conditions with MCS—but there is a connection, and gut health could be a culprit.
Reviewed By Gordon D. Ko, MD, FRCPC
For Starters, What Is Multiple Chemical Sensitivity?
People with multiple chemical sensitivity (MCS) have allergy-like reactions to low doses of common substances, such as chemicals found in carpeting, perfumes, and plastics.1 Symptoms may include skin, hearing, and breathing issues; pain in the head, muscles, or joints; nausea, fatigue, or immune challenges.2
Close to 13% of adults in the US have been diagnosed with MCS, which may sometimes be called multiple environmental chemical sensitivities, polyallergy, or environmental illness. Nearly 26% of the population reports chemical sensitivity. And when it comes to pain conditions, people with fibromyalgia syndrome (also known as chronic widespread pain syndrome) and chronic fatigue appear to be more likely to experience MCS.3,4
In fact, “Between 33 and 55% of fibromyalgia patients meet the criteria for MCS,” says Gordon Ko, MD, PhD. A specialist in physical medicine and rehabilitation with a sub-specialization in pain medicine, Dr. Ko is the medical director of the fibromyalgia clinics at the Sunnybrook Health Sciences Centre and Canadian Centre for Integrative Medicine in Markham, Ontario. “So all such patients should be screened accordingly.5
An Expert’s Approach
Dr. Ko regularly treats patients with fibromyalgia syndrome, many of whom also live with chronic fatigue syndrome and MCS. In a lot of these cases, he says, “traditional approaches—pills and surgeries—don’t work.”You may be interested in these related articles:
- Becky’s Journey: Integrative Pain Management Program Teaches Patient to Manage Chronic Pain
- How Fatigue Makes its Way Into Chronic Pain Conditions
- How Medical Marijuana Changed My Life
Dr. Ko explains, “When you see patients with fibromyalgia/multiple chemical sensitivity, you have to go beyond FDA-approved analgesics [eg, pain relievers, specifically pregabalin, duloxetine, and milnacipran] and find underlying root causes” before forming a treatment plan. “For MCS alone, the root cause should be biochemical,” says Dr. Ko. Biochemical causes can include food intolerances, nutritional deficiencies, stealth infections, and toxins like heavy metals, pesticides, solvents, and mold.
However, Dr. Ko also has to determine what may have caused his patients’ fibromyalgia. Possible origins include:
- structural causes, such as ligament laxity (looseness) sometimes caused by Ehlers-Danlos syndrome
- neurological causes, namely post-concussion syndrome from traumatic brain injury
- psychological causes, stemming from complex post-traumatic stress disorder (PTSD).
To find out what may be causing a patient’s symptoms, and possibly MCS, Dr. Ko starts patients off with his Food-Infection-Toxin (FIT) lab regimen, which includes blood tests and other diagnostic tools (such as MRIs), when indicated. For instance, a patient in need of a food-gut intervention may present as overweight/obese, and lab tests might show a high or high normal average blood sugar level over the past three months; high c-reactive protein (an indicator of inflammation); and/or suboptimal levels of vitamins like B12, D3, or minerals such as iron, Dr. Ko explains. He notes that more than 90% of his patients benefit from such an intervention.6,7
The reason is, he explains, “A poor diet contributes to an unhealthy microbiome (ie, bad bacteria in the gut), where 75% of the immune system is housed.8 Bad gut bacteria interfere with the body’s innate healing mechanisms.”
To help identify foods that may be triggering chronic pain or allergy-like symptoms, he often recommends to patients the Clean Gut Program crafted by Alejandro Junger, MD. “This is a 21-day elimination diet (gluten, dairy, processed sugar), combined with the use of probiotics and other supplements to repair the gut.” Dr. Ko has also seen positive effects in patients doing the Medical Medium Liver Rescue by Anthony William: “This is a simpler plant-based diet,” which cuts all fat intake for 9 days.
Dr. Ko also encourages patients to strive for the following optimal lifestyle habits, which he calls “TENSQ:”
- Toxin elimination, with normal daily bowel movements
- Exercise, including 150 minutes cardio a week and strength training
- Nutrition, with emphasis on a plant-based diet
- Sleep for 7 to 8 hours a night, and maintain
- Quality relationships with others (see also our guide to patient-caregiver communication).
If an individual maintains a good diet, healthy lifestyle habits, and shows optimal bloodwork but still struggles with symptoms of fibromyalgia, MCS, or chronic fatigue syndrome, then it’s “almost invariably a stealth infection,”—meaning a bacterial or viral infection—that’s causing pain, fatigue, or allergy-like reactions, Dr. Ko explains.
Stealth infections that can cause MCS-like reactions and fibromyalgia-like pain include Lyme disease and other tick-borne illnesses, as well as herpes DNA viruses (including herpes (type 3) zoster, which causes shingles; Epstein-Barr (type 4), cytomegalovirus (type 5), and others.9-11
Lyme disease can often be successfully treated with combination antibiotics, and antivirals can help make some infections, including shingles and cytomegalovirus, shorter and less severe.12-14
If Dr. Ko suspects exposure to toxins such as pesticides, heavy metals, or solvents are causing MCS symptoms, he often lets his colleague, Leigh Arseneau, HBSc, ND, FMP, guide the patient’s treatment. In addition to his work as the chief naturopathic physician at the Canadian Centre for Integrative Medicine, Dr. Arseneau is the medical director at the Centre for Advanced Medicineand a medical advisor at the Centre for Restorative Medicine. (Pain clinics often have doctors of differing specialties – read more about pain clinics.)
Eliminating harmful toxins from the body requires a personalized approach, Dr. Arseneau explains.“We want to know a lot about patients’ personal and family medical history,” as well as information about symptoms and exposures. This information allows Dr. Arseneau to conduct the right diagnostic test(s), which generally require blood, urine, and/or saliva samples.
Dr. Arseneau shares that she sometimes also does DNA testing in patients, which can seek out genetic variations that may be contributing to detoxification problems. For instance, a glutathione synthetase deficiency prevents the production of glutathione, which is crucial for healthy liver function, including the elimination of toxins.15,16 People whose detoxification processes are slower or less efficient tend to accumulate higher levels of toxins in their bodies, and are more likely to develop MCS, she adds.
Many of Dr. Arseneau’s patients take glutathione (often given via infusion) and supplements that boost glutathione activity, such as include N-acetyl cysteine, alpha lipoic acid, broccoli sprout seed extract (sulforaphane), dandelion root, curcumin, watercress, and EGCG, which is derived from green tea.17-19
In addition, B vitamins (especially folate, B6, and B12) and magnesium may be recommended, because, as Dr. Arsenau notes, “If you have really low levels of certain nutrients, you’re not going to detoxify properly. A protein deficiency will also impair detoxification abilities, so the amino acids methionine, glycine, and taurine” may also be recommended.
Finally, Dr. Arseneau may prescribe cholestyramine, a cholesterol-lowering medication that binds to toxins in the body. Cholestyramine is not absorbed, so the toxins can be excreted more easily.20
Cholestyramine, along with “antifungal medications (including nasal sprays) such as amphotericin and iconatrazole,” can also be used to treat mold toxicity, adds Dr. Ko.
The Final Piece of the Puzzle: Healthy Habits
In addition to the optimal lifestyle habits mentioned above, Dr. Ko recommends that patients with MCS limit their exposure to symptom triggers such as pet dander, cigarette smoke, perfumes, chemicals, solvents, dust, mold, and pesticides. He also encourages getting support from counselors, spiritual advisors, or loved ones, advice he attributes to the Environmental Health Clinic at Women’s College Hospital in Toronto, and the Blue Zones “Power of Nine” approach developed by Dan Buettner.21-23
If you live with fibromyalgia and MCS, it may be worth asking your doctor about whether your diet may be having an impact on symptoms.Updated on: 05/05/20