The experience of pain – anxiety about pain

The experience of pain – anxiety about pain

To effectively treat a chronic pain patient, we accept that all pain is real. This may appear like an observable statement, but persons with chronic pain are often treated as if their pain is either made-up or overstated. Some of this is perpetuated by the mind-body dualism inherent in the medical model. Unfortunately, this model continues to be alive and well in the medical community. Mind-body dualism espouses the old dichotomy of “functional vs. organic” when evaluating and diagnosing chronic pain. In the model, functional pain is conceptualized to be of purely psychological etiology. A patient is often given this label by the physician if a precise reason for the pain cannot be found (identification of a pain generator). In this scenario, the psychological etiology is a diagnosis by exclusion. Given this situation, it is not surprising that many chronic pain patients feel like they have to prove their pain to their friends, family, and doctors. There are countless patients with stories of being told by doctors that there is no “medical” reason for the pain and therefore “it cannot be that bad.” One of the first tasks for the pain management is to establish with the patient that his reports of pain will be believed. This is especially important since the patient may be hesitant about seeing a “shrink” in the first place. We will discuss this issue further under the initial interview section.

Pain is a personal experience and cannot be measured like other problems in medicine such as a broken leg or an infection. This causes a frustrating experience for the chronic pain patient in interacting with the healthcare system, family, and friends. Everyone knows that a broken leg can be confirmed by an x-ray and an infection by a blood test measuring the white blood cell count. Unfortunately, there is no medical test to measure pain levels. To make matters more challenging for the chronic pain patient, there may be no solid objective evidence or physical findings to explain the pain. Thus, chronic pain sufferers will go from one doctor to the next searching for medical explanations for their pain (and for a cure). This can lead to unnecessary evaluations and treatments, in addition to putting the patient at risk for actually being harmed or made worse by the interventions.

Emotions

The emotional aspect of pain is a person’s response to thoughts about the pain. If you believe the pain is a serious threat (thoughts), then emotional responses may include fear, depression, or anxiety. Conversely, if you believe the pain is not a threat, then the emotional response will be negligible. Consider again the previous example of a strenuous workout. The day afterward, the person may show grimacing, slow movements, and other "pain behaviors." Even so, the thoughts about the pain will be positive ("Boy, what a good workout that was last night") and the emotions will follow similarly (e.g., feeling good about having worked so hard). The thoughts and subsequent emotional response would be quite different in the case of a fibromyalgia flare-up even though the nociceptive input and pain behaviors are similar. We will discuss the emotional aspects of pain in more detail later in this chapter.

Chronic pain and depression

Comorbid psychiatric disorders commonly occur in chronic pain patients and, among these, depression is frequent. Chronic pain and depression are two of the most common problems that health professionals encounter, yet only a handful of studies have investigated the relationship between these conditions in the general population (Currie and Wang, 2004). For instance, major depression is thought to be four times greater in people with chronic back pain than in the general population (Sullivan, Reesor, Mikail & Fisher, 1992). In research studies on depression in chronic low back pain patients seeking treatment at pain clinics, prevalence rates are even higher. These range from 32 to 82 percent of patients showing some type of depressive problem, with an average of 62 percent (Sinel, Deardorff & Goldstein, 1996). In a recent study of chronic disabling occupational spinal disorders in a large tertiary referral center, the prevalence of major depressive disorder was 56% (Dersh, Gatchel, Mayer et al., 2006). In another study, it was found that the rate of major depression increased in a linear fashion with greater pain severity (Currie and Wang, 2004). It was also found that the combination of chronic back pain and depression was associated with greater disability than either condition alone.

Depression is more commonly seen in chronic back pain problems than in those pain problems of an acute, short-term nature. The development of depression in these cases can be understood by looking at the host of symptoms often experienced by the person with chronic spine pain. Explaining this process to the patient can be very useful since it demystifies the etiology of the depression and dispels the idea that being depressed is somehow related to a “weak will.” We will often tell patients that clinical depression goes beyond normal sadness, and is characterized by the following symptoms from the DSM-IV:

A predominant mood that is depressed, sad, blue, hopeless, low, or irritable, which may include periodic crying spells.

Poor appetite or significant weight loss, or increased appetite or weight gain.

Sleep problems of either too much (hypersomnia) or too little (hyposomnia) sleep.

Feeling agitated (restless) or sluggish (low energy or fatigue).

Loss of interest or pleasure in usual activities.

Decreased sex drive.

Feeling of worthlessness and/or guilt.

Problems with concentration or memory.

Thoughts of death, suicide, or wishing to be dead.

It is often quite impactful to go over this list with the chronic pain patient since it can help develop a therapeutic alliance in treating the depression.

Chronic pain often results in difficulty sleeping which leads to fatigue and irritability during the day. During the day, the chronic pain patient often has difficulty with most activities (moving slowly and carefully) as well as spending most of the time at home away from others. This leads to social isolation and a lack of enjoyable activities. Due to the inability to work, there may be financial difficulties that begin to affect the entire family. Beyond the pain itself, there may be gastrointestinal distress caused by anti-inflammatory medication and a general feeling of mental dullness from the pain medications. The pain is distracting, leading to memory and concentration difficulties. Sexual activity is often the last thing on the person’s mind; this causes more stress in the relationships. Understandably, these symptoms accompanying chronic pain may lead to feelings of despair, hopelessness, and other indicators of a major depression.

A recent study by Strunin and Boden (2004) investigated the family consequences of chronic back pain. Patients reported a wide range of limitations on family and social roles including physical limitations that hampered patients’ ability to do household chores, take care of the children, and engage in leisure activities with their spouses. Spouses and children often took over family responsibilities once carried out by the individual with back pain. These changes in the family often lead to depression and anger among the back pain patients, and to stress and strain in family relationships.

Several psychological theories about the development of depression in chronic back pain focus on the issue of control. As discussed previously, chronic back pain can lead to a diminished ability to engage in a variety of activities such as work, recreational pursuits, and interaction with family members and friends. This situation leads to a downward physical and emotional spiral that has been termed “physical and mental deconditioning” (as depicted in the previous Figure; see Gatchel and Turk, 1999). As the spiral continues, the person with chronic back pain feels more and more loss of control over his or her life. The individual ultimately feels totally controlled by the pain, leading to a major depression. Once in this depressed state, the person is generally unable to change the situation even if possible solutions to the situation exist.

Depression and chronic pain

The heading above is not a typo. We first discussed chronic pain leading to depression, and now we will now cover the idea that depression can predispose a patient to chronic pain.

For quite some time, clinical researchers have known that chronic back pain can lead to major depression (see Worz, 2003 for a review). Newer studies are now looking at how psychological variables such as depression and anxiety may be linked to the onset of a back and other pain problem. For example, Atkinson, Slater, Patterson, Grant, and Garfin (1991), in a systematic study of depressed male Veterans Administration chronic pain patients, found that 42% of patients experienced the onset of depression prior to the onset of pain, whereas 58% experienced depression after the pain began. Polatin et al. (1993) reported that 39% of the chronic low back pain patients they evaluated displayed symptoms of preexisting depression. More recently, in a review of research studies in this area, Linton (2000) found that ,in 14 of the 16 reviewed studies, depression was found to have increased the risk for developing back pain problems.

physical and mental reconditioning.

Anxiety

In most cases, anxiety about the pain is more likely in the subacute stage while depression prevails with chronification. The subacute phase occurs after the acute phase but before the chronic stage. It usually occurs at about the three- to six-month range. At the acute stage, the patient with pain generally feels a reasonable sense of hope that the pain will resolve within the near future. In the subacute phase and at the beginning of the chronic phase, one's thoughts and emotions about the pain begin to change. It is not uncommon for the person to begin to wonder, "Will this pain ever go away?" "This must be something serious," and "I'll never get better." These types of thoughts lead to anxiety.

Anxiety can occur at different intensities, all the way from nervousness to full panic attacks. We explain to patients that clinical anxiety is generally characterized by the following:

Muscle tension including shakiness, jitteriness, trembling, muscle aches, fatigue, restlessness, and inability to relax

Nervous system overactivity including sweaty palms, heart racing, dry mouth, upset stomach, diarrhea, lump in throat, and shortness of breath

Apprehensive expectations including anxiety, worry, fear, anticipation of misfortune

Trouble concentrating including distractibility, insomnia, feeling "on edge," irritability, and impatience

Although most patients believe that their anxiety will subside "when the pain goes away,” the anxiety is very often causing a significant increase in pain perception. This results in a vicious cycle of pain, anxiety, more pain, and more anxiety. As an example of this, this author recently evaluated and treated a seventy-two-year-old woman who had been scheduled to undergo spine surgery. She was clearly a good candidate for the surgery given all appropriate factors. As one part of her pain problem, she had a significant amount of generalized anxiety. She had been involved in a few sessions of psychological preparation for surgery, which we will often do with anxious or depressed patients. Approximately two weeks prior to the scheduled surgery, the patient's leg pain completely disappeared! Her findings on the MRI continued to be abnormal. The surgeon could only explain it under the category of "an act of nature one does not want to argue with." Given this experience, the patient expected that her anxiety and depression would also abate shortly thereafter. To her dismay, this did not occur. She continued to be emotional and began to address those issues in psychotherapy.

This is certainly an unusual and rare example, but it does illustrate that removal of the pain does not necessarily mean emotional issues will also then resolve. For the patient to wait until the chronic pain is gone before addressing an emotional issue is a trap that will prevent a return to a normal life.