Your chronic pain is relentless, you don’t want to rely on meds, and you’re anxious and depressed. Wisely, you’ve decided to learn about psychological interventions. Say no more…
Dr. Darnall submits that psychological treatments should be first-line, applied early, and not just recommended after meds and/or physical treatments don’t deliver.
The article detailed my induction into the chronic pain club. And we took a look at a new study that reviewed how folks with chronic pain can protect their mental wellbeing.
For yet more helpful info, let’s do part two…
”Psychological Interventions for the Treatment of Chronic Pain in Adults”
I found a fabulous article in the journal, Psychological Science in the Public Interest.
“Psychological Interventions for the Treatment of Chronic Pain in Adults,” published in September of 2021, was written by a high-powered team of psych researchers led by Dr. Mary Driscoll.
Highlights are in order…
What is chronic pain?
The team kick things off with the International Association for the Study of Pain’s definition of chronic pain: “…ongoing or recurrent pain that lasts beyond the usual course of acute illness or injury or for more than 3 to 6 months and adversely affects an individual’s well-being.”
They went on to make these observations…
Chronic pain is commonly viewed as a symptom, but can also be seen as a disease.
In many cases, the underlying biology of chronic pain are unknown, therefore medical interventions might not be beneficial.
People with chronic pain often report frustrations with health care systems and health insurance.
And perhaps the most important observation: the significant negative consequences of chronic pain go beyond physical suffering, affecting wellbeing, emotional functioning, and overall quality of life.
Those of us tussling with chronic pain know that all too well.
The biopsychosocial model of chronic pain
“The pain is excruciating. And my anxiety, depression, and social life aren’t much better.”
To explain its complexities, the team use the biopsychosocial model of chronic pain.
That’s significant because It emphasizes the interrelatedness of biological, psychological, and social factors.
And wouldn’t you know it, the biopsychosocial model is recognized as the foundation for the study of pain and the clinical practice of pain management.
Chronic pain and mental health: Psychological interventions
The team point out that a variety of psychological factors play a role in the onset, maintenance, and exacerbation of chronic pain. And a variety of psychological interventions are used to treat them.
Here are the interventions most widely accepted within the pain-care community…
Supportive psychotherapy: emphasizes unconditional acceptance and empathic understanding.
Relaxation training: uses breathing, muscle relaxation, and visual imagery to counteract the body’s stress response.
Biofeedback: uses biofeedback equipment to monitor physiological responses to stress and pain and teaches how to down-regulate the body’s physiological responses.
Hypnosis: involves a clinician’s hypnotic suggestion to reduce pain and incorporates relaxation training.
Operant-behavioral therapy: seeks to replace maladaptive behaviors consistent with the “sick” role with healthier “well” behaviors.
Cognitive behavioral therapy: identifies and seeks to change maladaptive thoughts about pain that cause distress and unhelpful behaviors, such as isolation and withdrawal; promotes the development of helpful behavioral coping strategies (e.g., relaxation).
Acceptance and commitment therapy: encourages acceptance of chronic pain and focuses on strategies for identifying and reinforcing behaviors consistent with the desired goals.
Mindfulness-based interventions: aim to disentangle physical pain from emotional pain via increased awareness of the body, the breath, and activity.
Emotional-awareness and expression therapy: highlights the interconnectivity of brain regions responsible for processing physical pain and emotions; encourages confronting avoided emotions to reduce the connection between emotions and pain.
Keep in mind, sex, gender, and sociocultural factors may present differences in risk for pain, suboptimal treatment, and poorer pain outcomes.
If it hasn’t already crossed your mind, I suggest that you use the list as a screening tool for current and future care providers.
It’s simple. If they have a profile available, look for your therapy of choice. No profile? Give them a call: “Are you qualified in _____?”
Integrated pain care
“Yeah, it still hurts. But having a care team on my side makes a huge difference.”
The team noted that in 2016 the U.S. Department of Health and Human Services published its National Pain Strategy (NPS).
The NPS calls for “integrated pain care” and defined it as “the systematic coordination of medical, psychological, and social aspects of health care.”
That’s right, the biopsychosocial model. Seems to be a lot of it going around. And that’s a good thing.
Critical role for psychology
According to the team, all models of pain-care delivery that comply with NPS recommendations suggest a critical role for psychology in treating chronic pain.
Now, there are bound to be issues with psychology being a major player. Well, barriers will have to be torn down.
Speaking of which: patients not recognizing the benefit of psychological treatments, stigma toward mental health treatments, providers misunderstanding the rationale and mechanisms of psychological treatments, inadequate insurance coverage to ensure timely and equitable access to treatments.
Time to rephrase
The team included an insightful commentary from Dr. Beth Darnall.
Dr. Darnall submits that psychological treatments should be first-line, applied early, and not just recommended after meds and/or physical treatments don’t deliver.
It gets even better. She believes describing psychological treatment as “pain coping skills” is often misinterpreted by patients as “learning to cope with pain.”
According to Darnall, that’s a problem and it’s time to rephrase. She says the most accurate description of psychological treatment is “…directly reducing the intensity of pain and favorably shaping the nervous system toward relief.”
A mouthful, but she’s spot on.
We all need support
None of us have to endure chronic pain alone – even if we live alone. I mean, we all need – deserve – support.
In addition to groups you may find on, say, Facebook, see what’s up in these neighborhoods…
Let’s see, relentless chronic pain, trying to go easy on meds, anxious and depressed, dicey social life. Absolutely, it’s time for psychological interventions.
Your hands were already full managing mood and anxiety symptoms. But chronic pain sunk its claws in and your emotional and mental health took a massive hit. Let’s see what we can do about it…
…the study showed pain interference was more problematic than pain intensity for people living with chronic pain.
I began to experience occasional pain in my hip last summer. No big, I’d shake it off and keep rolling.
Well, it worsened over time, so I finally checked in with an ortho six weeks ago. Thirty days and an MRI later: fractured femur, osteoarthritis, torn tendon – dang.
Chronic pain has sunk its claws in. And that’s a massive hit to my already, shall we say, “interesting” emotional and mental health.
Sharing is crucial
I’m learning all I can about what’s going on in my body and mind. And sharing is crucial because 20% of the world’s population – five billion people – are dealing with chronic pain.
And did you know depression and anxiety affect people with chronic pain three times as much as those who are pain free?
We have a lot of work to do and we’ll handle it in two parts. Let’s get part one, a discussion of a new study, underway…
“Protecting mental wellbeing in people with chronic pain”
Not long after I started my fact-finding I bumped into a helpful article. “Being flexible is key to protecting mental wellbeing in people with chronic pain” appeared on the Edith Cowan University (ECU) website.
The piece summarizes a new study, the work of ECUs Tara Swindells and Professor Joanne Dickson.
The details
Swindells and Dickson surveyed 300 people who were living with non-cancer-related chronic pain. The participants replied to questions about their mental wellbeing, the intensity of their pain, and how much pain interfered with their daily routines and activities they enjoy – pain interference.
Dickson observed that the study results suggested people might not have the psychological and/or physical capacity to participate in activities that help them reach their personal goals as a result of pain.
And, of course, that can have significant implications for mental wellbeing.
According to Dickson…
The good news is that this research showed personal goal flexibility (i.e., the ability to adapt and to adjust to life’s difficulties and obstacles) in how we strive to maintain or achieve the things that matter to us can provide a protective buffer in maintaining and promoting mental wellbeing.
Protection, then, comes with flexibility.
The mental health impact
“Man, those claws won’t let go – it’s chronic. I’m bummed, edgy, and really need help.”
Though Swindells predicted the opposite, the study showed pain interference was more problematic than pain intensity for people living with chronic pain.
Makes sense to me.
That being the case, in the presence of high intensity pain, people can amp up their mental wellbeing by findings ways to minimize interference with important aspects of their daily lives.
Don’t you think that calls for an intervention target adjustment?
The flexibility factor
The study investigated how goal tenacity – persistently pursuing valued goals – and goal flexibility – adjusting them in response to setbacks or obstacles – might help to explain how some people with chronic pain maintain a sense of mental wellbeing.
So the study, for the first time, determined that goal flexibility and goal tenacity appear to provide a defense against pain interference – flexibility more so than tenacity.
Swindells…
So if you’re able to adjust, adapt and find ways to still achieve what matters to you most in the face of life’s obstacles, that’s going to help protect your mental wellbeing.
That’s why working on flexibility has to be an ongoing priority.
Multi-faceted
Swindells emphasized that pain management and mental health are multi-faceted. She went on to note that previous pain-related research has shown that physical factors (e.g., sleep, injury, disease) and social factors (e.g., employment, social support, economic factors) play a significant role in pain management.
Swindells summarizes…
The findings from our study add to this body of knowledge. They indicate that variations in adaptive psychological processes provide another useful lens to understand the relationship between pain interference and mental wellbeing.
And there you have it.
All is not lost if…
Okay, chronic pain sunk its claws in you. And it’s a massive hit to your emotional and mental health. Just keep in mind, all is not lost…
You’re devastatingly fatigued. And you’re experiencing concentration and memory issues, lousy sleep, lightheadedness, and joint pain. “What the heck is going on? I mean, could I have chronic fatigue syndrome?” You deserve to know…
ME/CFS is characterized by extreme fatigue that’s often exacerbated by physical, emotional, and mental activity. And the thing is, the fatigue doesn’t resolve with rest.
We’ve been living in fatiguing times, so it’s understandable that many of us feel absolutely wiped-out. But if the fatigue won’t resolve, and a variety of other symptoms hit, we may be dealing with chronic fatigue syndrome.
Just like our frustrated, worn-out, and angry friend above, we deserve to know what’s going on.
Let’s see what we can figure-out…
What is chronic fatigue syndrome?
What has been traditionally known as chronic fatigue syndrome is now medically recognized as myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). In some circles it’s referred to as systemic exertion intolerance disease (SEID).
Though acceptance of ME/CFS in the medical world has greatly increased, and it’s garnering more research attention, it remains a mysterious load of misery.
ME/CFS is characterized by extreme fatigue that’s often exacerbated by physical, emotional, and mental activity. And the thing is, the fatigue doesn’t resolve with rest. A variety of unpleasant symptoms, which vary by case, are also involved.
Symptoms of ME/CFS may peak and stabilize early in its presentation, and may come and go over time. Complete recovery is a possibility; however, not to be counted upon.
Okay, the symptoms of ME/CFS can be all over the board and there isn’t a detectable pattern. Here are the biggies…
Fatigue that interferes with daily activities and doesn’t resolve with bed rest
Extreme fatigue lasting for more than 24 hours after physical, emotional, or mental exercise (post-exertional malaise – PEM)
Sleep problems: unrefreshing, insomnia, others
Concentration and memory problems
Frequent sore throat
Mildly enlarged and tender lymph nodes in the neck and armpits
Muscle and/or joint pain
Lightheadedness that worsens with moving from lying down or sitting to standing (orthostatic hypotension)
Pain that moves from one joint to another with no swelling or redness
Headaches
Keep in mind, ME/CFS symptoms may present in cycles. They may even disappear, only to come back down the road. Of course, with the exception of fatigue issues, one doesn’t have to have all of the symptoms to qualify for a diagnosis.
“And now I can’t even concentrate? Something’s up.”
Some 2.5 million Americans are believed to have ME/CFS. And I’m betting there are a significant number of undiagnosed cases.
ME/CFS can present at any age; however, it’s more likely to strike those in their 40s and 50s.
Although gender isn’t a proven risk factor for ME/CFS, the record shows that women are two to four times more likely to be diagnosed. A lot of that may have to do with the fact that women are typically more inclined to report symptoms and seek treatment.
What causes chronic fatigue syndrome?
As I said, ME/CFS research has ramped-up. Still, its cause remains a mystery. As we discuss cause, it’s really important to keep in mind that ME/CFS may well be an end-stage phenomenon of any number of conditions.
Here are the most widely recognized – suspected or researched – causes…
Genetic predisposition
Physical or emotional trauma
Viral infection (e.g., Epstein-Barr virus, human herpesvirus 6, Ross River virus, rubella virus)
Again, ME/CFS may be an end-stage phenomenon of a variety of conditions, especially viral and bacterial infections.
Is there a test for chronic fatigue syndrome?
There was a time when testing for ME/CFS was out of the question. However, these days, testing research is in the works.
The first bit of good news came in 2019 when Stanford University scientists identified a biomarker for ME/CFS. My understanding is they developed a blood-based test that accurately identified individuals with ME/CFS.
And just last year, researchers at CHU Sainte-Justine and Université de Montréal devised a unique two-step testing method.
Routine testing for ME/CFS isn’t available yet, but given recent developments, I wouldn’t be surprised if good news was announced sooner rather than later.
In the meantime, we’re going to have to continue to rely upon signs, symptoms, and rule-outs. Speaking of which, the most significant rule-outs are mononucleosis, Lyme disease, multiple sclerosis, systemic lupus erythematosus, hypothyroidism, fibromyalgia, major depressive disorder, sleep disorders, severe obesity, and drug and alcohol side effects.
How is chronic fatigue syndrome treated?
Most important in the treatment of ME/CFS is seeing a physician as soon as possible if you suspect you have it. Early diagnosis is the key to management and possible remission.
That said, there’s no specific treatment for CFS. Certainly no cure. So that means physicians and counselors typically recommend a combination of strategies and techniques to manage symptoms based upon individual presentation.
Given the significant role post-exertional malaise (PEM) plays in ME/CFS, pacing (activity management) is a significant treatment strategy. It helps to balance activity and rest in an effort to avoid ME/CFS flare-ups. In pacing, the individual determines their limits (“energy envelope”), plans activities, and rests to stay within those limits. A diary is kept.
Other common interventions…
Moderating physical, mental, and emotional stress
Counseling
The gradual onset of an exercise program or adjustments to a current regimen. Vigorous exercise could be a problem.
Maintaining healthy lifestyle habits
Limiting caffeine to help with sleep, as well as nicotine and alcohol
Establishing a sleep routine, while limiting napping
Acupuncture, massage, stretching, yoga, meditation, tai chi, breathing and relaxation exercises
Incidentally, there are no prescription drugs approved for the treatment of ME/CFS. However, they may be used to manage troubling symptoms.
It’s a wrap
Absolutely, we’ve been living in fatiguing times. And if the fatigue, and accompanying symptoms, match what we’ve discussed we may be dealing with ME/CFS.
“What the heck is going on? I mean, could I have chronic fatigue syndrome?” You deserve to know.
Don’t think twice about seeing your doc. It’s that important.
The nonstop ringing, buzzing, and pulsating in your ears. You’re beginning to think you’re going mad. Tinnitus, the gift that keeps on giving. Did you know there are psych connections?
In fact, exposure to high stress has the same incidence of tinnitus as exposure to occupational noise.
I’m guessing three-quarters of those trying to manage a mood or anxiety disorder have had a go with tinnitus.
It’s graced my head for the past two years.
I found an article, Psychopathology of Tinnitus, on Psychiatric Times that provides a ton of valuable information. It was written by neuropsychiatrist Zeina Chemali and psychiatrist Romy Nehme.
As we get into the material, keep in mind the high relief factor of gaining insight into that which ails us.
For me, it’s always been right up there with remedies.
One more thing – the way I handle article recaps. No “Drs. Chemali and Nehme said…” Just know the bulk of what you’re about to read comes from their work.
What is tinnitus?
Tinnitus is the perception of noise in the absence of any corresponding sound source. It typically presents with ringing, roaring, hissing, or pulsating in one or both ears, as well as the head.
There are two types of tinnitus: objective and subjective.
The very rare objective tinnitus consists of a sound heard by the patient and doctor. These can be abnormal sounds of blood flowing through the arteries (bruit), benign humming of blood flowing downward from the brain through the jugular veins (venous hum), or a brief and irregular twitching (myoclonus) of the soft palate or stapes bone in the middle ear. Pretty interesting, don’t you think?
The most common tinnitus, subjective, is only experienced by the patient.
Tens of millions of us are impacted by tinnitus. And .5-2% seek urgent medical assistance for an acute and unbearable presentation or worsening of an existing condition.
The numero uno cause of tinnitus is hearing loss. But, of course, having tinnitus doesn’t necessarily mean you’re losing your hearing.
Beyond the auditory system
Now, things get very interesting from our side of the fence when we come to learn that tinnitus plays with many brain areas beyond the auditory system and pathway.
For instance, electroencephalogram (EEG) studies have shown funny goings on in the anterior and posterior cingulate cortex, orbitofrontal cortex, and insula.
“This tinnitus is driving me nuts!”
But there’s more. PET scans and functional MRI have shown involvement in cortical and subcortical areas of the brain, as well as the amygdala and hippocampus – components of the limbic system.
All of the above are involved with the mood and anxiety disorders. However, the amygdala is likely the biggest player, with its role in processing emotional responses such as fear, anxiety, and aggression.
Tinnitus and psychiatric disorders
Let’s take a look at some psychiatric disorders of particular interest to us and their ties with tinnitus…
Affective Disorders: There’s a high prevalence of depressive disorders in tinnitus patients. Indeed, a decrease in depression has been associated with a decrease in tinnitus.
Anxiety Disorders: Anxiety is more prevalent among the tinnitus clinical population.
Personality Disorders: Tinnitus distress is associated with high neuroticism, high stress reaction, higher alienation, worse social closeness, worsened well-being, and externalized locus of control.
Stress: Emotional exhaustion is a huge predictor of tinnitus severity. In fact, exposure to high stress has the same incidence of tinnitus as exposure to occupational noise. Some have reported that their first awareness of tinnitus coincides with a significant stressful event.
Sleep Disorders: Insomnia is a common complaint of tinnitus patients, particularly trouble falling asleep. Screening for obstructive sleep apnea is a must-do when evaluating tinnitus. Bottom-line: achieving restorative sleep is a major player in tinnitus management.
Cognitive Impairment: Tinnitus affects executive function and attention. Tinnitus patients tend to have slower cognitive processing speed and longer reaction times on brain speed testing.
So it seems tinnitus causes poorer quality of life, especially in those with disabling hearing loss. But on the brighter side, reducing tinnitus intensity has a direct positive impact on quality of life.
How are we going to do that?
Tinnitus treatment
As with any other ailment, the best tinnitus treatment outcomes are generated by addressing the underlying cause.
Okay, so if someone is struggling with tinnitus that’s caused by, say, hearing loss, a drug, malformations of blood vessels, stroke, cervical spine and temporomandibular joint (TMJ) issues – they’re to be addressed with appropriate interventions.
When it comes to idiopathic (unknown cause or mechanism of origin) tinnitus, a comprehensive evaluation needs to be conducted to identify issues of relevance. These include depression, anxiety, substance use, and insomnia. Treating these issues, which may require medication, may well reduce the intensity of tinnitus.
Meds
Studies have shown that antidepressants such as nortriptyline (Pamelor), sertraline (Zoloft), and duloxetine (Cymbalta) can be helpful in treating tinnitus. Bupropion (Wellbutrin) and mirtazapine (Remeron) have been known to cause problems.
Benzodiazepines such as alprazolam (Xanax), clonazepam (Klonopin), and midazolam (Versed) have been reported to be effective. But you may regret opening that can of worms.
And there are a variety of supplements, as well as herbal and home remedies, touted to be beneficial. Be sure to do your research and check in with your doc.
Knowledge is power
Well, that’s going to do it. If you don’t know from personal experience, tinnitus can be a real piece of work. And important to us, it has very real connections with the mood and anxiety disorders.
Sorry to say, tinnitus isn’t a quick fixer-upper, but by learning all we can about it, we can manage. Knowledge is power (but useless without action).
Experiencing the coronavirus pandemic is stressful enough with standard brain wiring. But if that wiring kinks to a mood or anxiety disorder, this coronavirus business can absolutely mess with your head. If that’s you, here’s something to chew on…
It’s like we want to scream, ‘Stop!’ And, of course, we can’t make that happen.
Coronavirus disease 2019 (COVID-19) is dominating just about every aspect of our lives. Doesn’t matter where you live, your political persuasion, how much money you have, your astrological sign, or what you were in a previous life – there’s no running from this baby, and its impact upon how things were.
A Personal Message
If you’re enduring a mood or anxiety disorder, this something to chew on is exclusively for you.
My guess is you’re pretty spooked by what’s going-on. Geez, the changes, lack of order, uncertainty, interruption of freedom, desertedness, helplessness, and hopelessness. And let’s not forget the mortality factor.
It all can be so powerfully anxiety-provoking and depressing. Heck, you thought you were already under the influence of some dark stuff. And now donning this opaque veil? Give me a break.
Now, this isn’t where I hit you with a cold “10 Things to Do…” But it is where I make my point…
I absolutely, positively believe we’re going to be okay when the waves finally head back to sea. Now, I didn’t say we’ll all come out unscathed. And we can’t be naive about mortality.
But, you know, I’m not so sure potentially losing one’s life to COVID-19 is really the primary issue for most mood or anxiety disorder sufferers. At least it isn’t for me. No, I think it’s more about those changes, lack of order, uncertainty, etc. I just mentioned.
It’s like we want to scream, “Stop!” And, of course, we can’t make that happen.
In closing, it’s important to monitor disease updates, pay heed to recommendations and mandates, and play it smart.
It’s also incredibly important to check-in with self on occasion and make the necessary adjustments. For instance, keep in mind how we typically receive, interpret, and react to incoming stimuli. You know as well as I that we’re the champions of cognitive distortion. To name a few: catastrophizing, overgeneralization, and polarized thinking.
Cognitive distortions exponentially increase fear and overall discomfort. I mean, who the heck needs that? So let’s remain aware of how we emotionally and mentally operate.
Thinking of You and Wishing You the Best
As we part company, I want to emphasize that I understand – I know – where you likely are in your head and heart just now. I also understand – I know – we’re going to make it through this.
And I deeply believe we’ll be stronger and more positively self-aware, with better coping resources, by virtue of our determination and success. You wait and see.
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