Depression and physical chronic pain

Depression and physical chronic pain


What is depression?
People casually use the phrase, “I’m so depressed!” to say they are feeling down. But a temporary case of the blues – something we all experience has nothing to do with real depression. True depression is not the blues, sadness or even grief. It is an overwhelming despair so bleak that people who have experienced it say that it is the worst pain they have ever endured. Depression is a treatable mental illness. While there have been changes in people’s attitudes, the stigma associated with mental illnesses has meant that many people with depression never seek treatment. Yet, those who do have an excellent chance of recovery. Researchers estimate that people who receive treatment for depression respond well.

What Are the Symptoms Like?
There is no x-ray or blood test for depression. Instead, you, your family and friends will notice that your mood, functioning, attitude and thoughts have changed. Many of the symptoms of depression are a case of too much – or too little. For example, you may…

• Be sleeping too little or sleeping too much.
• Have gained or lost weight.
• Be highly agitated or sluggish and inert.
• Be extremely sad or very bad-tempered or both.
You may also feel….
• A loss of interest in the pleasures of life, as well as work, family and friends.
• Unable to concentrate and make decisions.
• Negative, anxious, trapped, unable to act.
• Despairing, guilty and unworthy.
• Fatigue and an overall loss of energy.
• Suicidal – expressing thoughts and sometimes, making plans.
• Numb – an awful feeling of emptiness.
• Unexplained aches and pains. A diagnosis of depression is arrived at when a person has been experiencing at least five of these symptoms for a period of two weeks or more.

What Causes Depression?
The causes of depression raise the old nature-nurture debate. Is it a result of family history (genes) or difficult life experiences? The experts say that we must consider nature and nurture: Family History – If close family members have experienced depression, you may have an inherited tendency yourself. Your inherited physiology is also involved in life changes such as the birth of a baby or menopause – both instances are associated with a greater risk of depression. Recent Events – a divorce, the death of a loved one, job loss, chronic illness, retirement, or attending a new school. Past History – experiences of childhood sexual, physical or emotional trauma, extreme neglect or abandonment. Also experiences of trauma in adulthood such as domestic abuse, living with drug or alcohol abuse, rape, robbery, war, kidnapping, or witnessing violence – to name only a few of the traumatic events that people can be exposed to.

What Is Chronic Pain?
Chronic pain lasts much longer than would be expected from the original problem or injury. When pain becomes chronic, you may have:
Unusually high levels of stress hormones
Low energy
Mood disorders
Muscle pain
Lower-than-normal mental and physical performance.
Chronic pain gets worse as changes in your body make you more sensitive to pain. You may start to hurt in places that used to feel fine. It can disrupt sleep and cause you to wake up at night. This can make you tired during and not as productive during the day. The ongoing pain can cause additional irritation and make it difficult for you to deal with others. If you have to care for children or work full-time, all this may make your life seem too challenging. These feelings can lead to irritability, depression, and even suicide.

What Happens?
Depression is one of the most common mental health problems facing people with chronic pain. It often makes someone’s other medical conditions and treatment more complicated. Consider these statistics:

According to the American Pain Foundation, about 32 million people in the U.S. report to have had pain lasting longer than a year. From one-quarter to more than half of the population that complains of pain to their doctors are depressed. On average, 65% of depressed people complain of pain. People whose pain limits their independence are more likely to get depressed. Because depression in people with chronic pain frequently goes diagnosed, it often goes untreated. Pain symptoms and complaints take center stage on most doctor visits. The result is depression — and sleep disturbances, loss of appetite, lack of energy, and decreased physical activity, which may make pain much worse.
Pain provokes an emotional response in everyone. If you have pain, you may also have anxiety, irritability, and agitation. These are normal feelings when you’re hurting. Usually, as pain subsides, so does the stressful response. But with chronic pain, you may feel constantly tense and stressed. Over time, stress can result in different emotional problems associated with depression. Some of the problems individuals with both chronic pain and depression have include:
Altered mood
Chronic anxiety
Confused thinking
Decreased self-esteem
Family stress
Fear of injury
Financial concerns
Legal issues
Physical reconditioning
Reduced sexual interest and activity
Sleep disturbances
Social isolation
Weight gain or loss
Work problems

The Association between Depression and Physical Pain
Researchers believe that there is a shared neural pathway for pain and depression with serotonin and norepinephrine involved in both mood and pain. People who are actually depressed may often talk to their physicians only about their physical pain. Research has shown that the higher the number of unexplained physical symptoms a person is experiencing, the more likely that they are suffering from depression. Depression is strongly suspected when physicians cannot find a physical source for the pain patients say they are experiencing. It is thought that depression may increase a person’s sensitivity to pain or may increase the suffering associated with pain. Studies have also shown that, of those reporting nine or more physical pain symptoms, 60% had a mood disorder. When only one physical symptom was reported, only 2% were found to have a mood disorder. A high number of physical pain symptoms are also predictive of further; people who experience chronic pain as part of their depression are more likely to also have suicidal thoughts. In addition, people with diagnosed physical illnesses such as stroke, diabetes, heart disease, or cancers (to name only a few) suffer depression in disproportionately higher numbers than the general population.

Descriptions of psychological therapies for pain
Operant-behavioural therapy: Treatment focuses on extinguishing maladaptive behavioural responses and fostering of adaptive behavioural responses to pain. Behavioural responses are altered through reinforcement and punishment contingencies and extinction of associations between the threat value of pain and physical behaviour.
Cognitive-behavioral therapy (CBT): Treatment applies a biopsychosocial approach to pain that targets behavioural and cognitive responses to pain. CBT protocols involve psychoeducation about pain, behaviour, and mood, strategies for relaxation, behavioural pacing, behavioural activation, positive event scheduling, effective communication, and cognitive restructuring for distorted and maladaptive thoughts about pain.
Mindfulness-based stress reduction: Treatment promotes a nonjudgmental approach to pain and uncoupling of physical and psychological aspects of pain; teaches “non-striving” responses to pain through experiential meditations and daily mindfulness practice intended to increase awareness of the body and proprioceptive signals, awareness of the breath, and development of mindful activities.
Acceptance and commitment therapy: Based on psychological flexibility model, treatment focuses on development of acceptance of mental events and pain and ceasing of maladaptive attempts to eliminate and control pain through avoidance and other problematic behaviours; emphasizes awareness, defusing, and acceptance of thoughts and emotions as well as behavioural engagement in pursuit of personal goals.

Gathering and compilation:
Marzieh Ahankoob, PhD (clinical psychologist)

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