Pain, Anxiety and Depression -- A Challenging Trio to Treat
June 23, 2011
By Michael Craig Miller, M.D.
Anxiety, depression and pain often go together. This is true for people with chronic and sometimes disabling pain syndromes, such as fibromyalgia, irritable bowel syndrome, low back pain, headaches and nerve pain. After all, chronic pain is depressing.
For people with depression or anxiety, physical pain can be more severe and last longer compared with what other people experience. And some people with major depression experience it as physically painful.
Researchers once thought that pain, anxiety and depression were related due to psychological factors. But researchers now know 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. Focusing on the pain can mask the presence of a psychiatric disorder. Even when both types of problems are correctly diagnosed, they can be difficult to treat.
Pain is demoralizing as well as hurtful. Psychotherapy isn't just for treating depression or anxiety. It can also help treat pain alone or in combination with drug treatment.
Cognitive behavioral therapy (CBT) is a well-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. For example, patients might try to participate in activities in order to improve function and distract themselves from focusing on the pain.
Various relaxation techniques can help reduce the stress response, which tends to make pain worse. Stress can also intensify the symptoms of anxiety and depression. Techniques include progressive muscle relaxation, yoga and mindfulness training.
Hypnosis is another helpful therapy. During hypnosis, a clinician helps a patient enter a trance-like state and then provides positive suggestions. This might include the direct and simple idea that pain will improve. Some patients can also learn self-hypnosis and use it when pain is at its worst.
Don't forget exercise. There's a wealth of research showing that regular physical activity boosts mood and alleviates anxiety. But there is less evidence about its impact on pain. Experts believe that regular moderate-intensity exercise might also alleviate pain in some conditions.
Some psychiatric medicines can relieve pain symptoms, too. There is no way to predict, however, which people will benefit most from them.
Antidepressants. Several antidepressants are prescribed for both anxiety and depression. Some of these also help alleviate nerve pain. (The evidence is less convincing about their ability to treat other types of pain, such as backaches, which are usually of muscle rather than nerve origin.)
The best choices are:
Mood stabilizers. Anti-seizure medications, which may also be used to stabilize mood, work by regulating the abnormal electrical activity and hyper-responsiveness in the brain that can contribute to seizures. Because chronic pain in particular involves nerve hypersensitivity, some of these medications may provide relief. For example, pregabalin (Lyrica) is FDA-approved for treating diabetic neuropathy, postherpetic neuralgia and fibromyalgia. Research also suggests Lyrica can treat generalized anxiety disorder.
Patients with pain often find a combination of psychotherapy and medication to be the most helpful. This approach is reminiscent of treatments for anxiety and depression.
Depression, anxiety and pain share this in common: They have a wide variety of causes and we don't yet have the tools to figure out what is at the root of any person's suffering. Good treatment, therefore, usually depends on working with your doctor to carefully try different options and find the one that is best for you.
Michael Craig Miller, M.D. is editor-in-chief of the Harvard Mental Health Letter and an assistant professor of psychiatry at Harvard Medical School. Dr. Miller has an active clinical practice and has been on staff at Beth Israel Deaconess Medical Center for more than 25 years.