When Pain and Mental Illness Collide

People living with pain are at far greater risk of developing mental health issues. Equally, people living with mental health issues are at greater risk of experiencing chronic pain. The intricate connection between the mind and body truly comes to light when exploring the connection between chronic pain and mental illness. More importantly, it raises the question: how can I cope when pain and mental illness collide?

Why are pain and mental illness so intertwined?

Some researchers believe the relationship between pain and mental illness could result from neurotransmitters (chemicals in the brain) that are commonly affected in both pain and psychosocial disorders. This is particularly the case for the neurotransmitters dopamine (which influences reward-motivated behavior) and serotonin (which helps regulate functions such as mood, digestion and sleep).

Others believe a genetic link may exist. In 2017, a team of researchers from the Icahn School of Medicine at Mount Sinai in New York conducted a study on mice with peripheral nervous system damage. They discovered that pain can trigger gene changes in the brain. These gene changes can, in turn, lead to mental illnesses like depression and anxiety.

Whatever the cause of the connection, the evidence does indicate a direct link between pain and mental illness.

Evidence of a link between pain and mental illness

• In a sample of people with chronic pain, more than 60 percent also experienced depression.

• According to official statistics in the U.S., close to 7 percent of the population suffers from depression, while about 35 percent of pain patients experience that illness.

• In a UK study, about 30 percent of rheumatoid arthritis patients developed depression within the first five years of their diagnosis.

• A global study of almost 200,000 pain sufferers revealed that people with severe back pain are far more likely to experience a range of mental health issues such as anxiety, stress, depression and psychosis.

• Shared pathophysiology (disordered physiological processes) has been found between fibromyalgia and bipolar disorder.

The relationship between pain and mental illness can lead to a vicious cycle of exacerbation. It is, therefore, imperative to gain a better understanding of how you can better self-manage when contending with these two conditions.

Managing comorbid pain and mental illness

1. Get physical (when possible).

While it is tempting to avoid physical activity due to pain or lethargy, exercise really does benefit both the mind and body. So why wouldn’t you use it as part of a self-management plan for pain and mental illness? Indeed, research has even shown that, for some, exercise is comparable to antidepressants. Mental illnesses lock the brain into a negative loop and limit neurotransmitters from performing their normal, mood-regulating functions. Exercise counteracts this by boosting the production of brain-derived neurotrophic factor (a protein), which enables neurotransmitters to resume their functioning. Exercise is beneficial not merely in the short term, but in the long term because it can prevent symptoms from resurfacing.

Start with walking. You may experience some initial pain, but listen to your body. Push it a little, but not too far, and you will gradually build up your tolerance to physical activity. Develop a walking plan, slowly increasing your time. When ready, you could also indulge in yoga, aqua therapy or riding a stationary bike, depending on your pain condition. The more enjoyable you find the activity, the more likely you are to repeat it, so experiment to see what works best for you and your body.

Putting one foot in front of the other
Susan was extremely resistant to starting a walking regimen. She had severe arthritis and felt walking would increase her pain. She was also suffering from clinical depression and fatigue, which was making it difficult to motivate herself. Her doctor helped her understand how tight muscles, reduced stamina, fatigue and increased weight associated with continued bedrest would make it harder for her to get back to routine life. Susan also learned that the feeling of fatigue would be replaced by energy only once she initiated physical activity. She gradually added walking to her schedule, which helped her increase her physical strength. Eventually, she began feeling less pain while moving, and her depressive symptoms lessened. Later, she even invited a friend along and started to look forward to the company. This social interaction acted as another mood-boosting tool.

2. Don’t believe everything you think.

Pain and mental illness can weigh you down and color your thinking. You may start to lose your rose-tinted glasses and, before you know it, everything looks bleak. You may find dark thoughts entering your mind such as, “This pain has taken over my life, and I can’t do anything about it” or “It’s not worth trying anymore.” Not only do such thoughts have the power to increase pain and mental distress, but they can become a self-fulfilling prophecy.

Before you accept a thought without question, why not challenge it? You can’t lose anything by asking yourself, “Would I be thinking this if I was having a pain-free day or if I didn’t feel so low or tired?”

Mind control
Kathy has lower back pain and told herself that her spine was “disintegrating” after the MRI showed damage. This thought understandably made her panic, and she was afraid to do anything because of the fear of further “disintegration” of the spine. Her anxiety about her condition further increased her blood pressure and heart rate. With support from a cognitive-behavior therapist, she started to concentrate on more realistic thoughts like, “There is some damage to my spine that cannot be fixed with surgery. However, some muscle strengthening exercises will help.” Controlling her thoughts helped alleviate her physical reactions and calmed her down considerably. She felt more in control of her life—and her mind and body.

3.Take a deep breath and . . . relax.

When you experience pain, your body reacts with a fight-or-flight response. This is critical to survival in the face of a dangerous situation, but in the case of chronic pain, this response is not adaptive because it prolongs stress and creates wear and tear on the brain and body. This condition of persistent stress caused by pain can also exacerbate mental illness. Relaxation techniques can lower physical arousal and calm the body and mind to reduce the perception of pain.

In the case of anxiety disorders, which are common in people with pain, relaxation training helps ease worry and decreases the distress it causes. Once the anxiety is reduced, it becomes possible to deal with the negative thoughts underlying that anxiety. Relaxation is also helpful in treating fatigue and sleep problems caused by depression.

Technique to try: Diaphragmatic breathing
Try this deep breathing mini-session when you aren’t stressed, anxious or in pain. This will help relaxation become a habit and something you can call upon automatically when you are stressed or in pain.

•  Sit in a relaxed posture, close your eyes, and place one hand on your chest and the other on your abdomen.

•  Make sure you are breathing using your diaphragm.

•  Inhale slowly through the nose, letting your abdomen expand.

•  Slowly exhale through the mouth, letting your abdomen sink back down.

•  Continue for 3 to 5 minutes.

4. Don’t run away from the problem.

When you are struggling within, it is natural to look for ways to feel better—and, often, this involves avoiding the problem. This is known as “maladaptive coping”—it may help in the short term, but it won’t do you any long-term favors. Instead, the best action you can take is to tackle your problems head on.

Mind over matter
Mark Lumley, PhD, director of clinical psychology training at Wayne State University Department of Psychology, shares his experience of a woman with fibromyalgia who lost her teaching job unjustly: “She was greatly disturbed by this, but had been avoiding dealing with her feelings and memories. She avoided driving by the school and stayed away from anyone who brought back memories of this experience. In a brief therapy session, she was encouraged to remember, talk about and express her feelings about this experience, including intense anger, fear, guilt and relief. With the support of her therapist, she then started encountering school-related stimuli in everyday life, including entering the school again. After this experience, she said, ‘A great burden has been lifted, and I feel 50 pounds lighter.’ Her pain dropped by about 75 percent and remained much decreased over subsequent months.”

Approaching a problem head-on doesn’t necessarily require counseling. You could write about the problem, draw a picture of the problem, research the problem or discuss it with a friend. Choose what works best for you, but don’t run away from it. Repressed problems will find a way to make themselves known, and all too often this can be through physical pain or mental distress. “A key to treating pain and mental illness is to stop avoiding experiences that are difficult—emotions, memories, people, places and activities,” says Mark Lumley, PhD. “The avoidance of healthy things due to fear or discomfort leads people to have both mental health problems and chronic pain, and one needs to shift from being ‘stuck’ and avoidant, to start ‘approaching’ and ‘engaging’ in those scary, difficult or painful things.”

5. Get social.

Pain and mental illness can both lead to social withdrawal. Fatigue, one symptom of depression, decreases the energy required to engage with others. Pain conditions can lead people to stay at home due to fear of pain or sometimes even embarrassment that they may need to rest while with others. You may even have developed a specific mental health issue in the form of social anxiety or social phobia, which isn’t uncommon in those who initially start to find social activities difficult for other reasons, such as pain or fatigue. However, humans are social beings. Even the most introverted among us needs a certain level of social contact. If you find socializing an effort, put something in place that ensures you are not completely isolated. Think back to Susan, who now has a friend join her on her walks.

6. Be prepared for obstacles.

It is all well and good for someone to recommend these self-management tools, but how do you overcome the obstacles that might crop up along the way? We can have good intentions that simply don’t come to fruition because of the inevitable ups and downs of life. However, if you are prepared for these obstacles, you can arm yourself with tools to overcome them.

Rainy day tools
Richard wanted to do more walking, but admitted that a cold or rainy day was always a good excuse to stay in instead. When asked to come up with an alternative for such days, he realized he could go swimming at the local pool instead. He had addressed one barrier, but still had another—the immediate impulse to skip the walk. So he prepared some statements that would remind him of why he was planning the walk in the first place, such as, “Walking always makes me feel better” or “I use walking as time to clear my thoughts.” Richard now had tools in place to stop both practicalities (such as rain) and thoughts from getting in the way of his physical activity.

Whether you plan to self-manage your comorbid pain and mental health issues through physical activity, challenging your thoughts or another method, take some time out to think about the potential obstacles. For every potential obstacle, have a plan of action. If an obstacle arises that you weren’t prepared for, make sure you are armed next time it rears its head.

Developing your toolbox

Living with pain or mental health issues is a challenge, and when you combine the two, this challenge can seem insurmountable. That is why it is important to develop your own toolbox, which you can access whenever you need it. The best toolbox will include a range of tools that are good for both the mind and body, such as physical activity, social support and relaxation. The tools you need may vary on a given day, so don’t limit yourself—your best tool is variety.

Want to learn more about techniques such as cognitive-behavorial therapy and relaxation exercises? Read “Using Cognitive-Behavioral Therapy to Control Pain,” “Managing Stress Before It Manages You,” and “Relax: Three Stress-Busting Methods.”

Nicola Davies, PhD, is a health psychologist. She last wrote for Pain-Free Living about Rational Emotive Behavior Therapy.

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