Managing the Mental Health Impacts of Chronic Pain

This article was originally published at The Seattle Times here.

Maybe you had a bad fall and hurt your back, and recovery is taking longer than expected. Perhaps you’re recovering from a long-term illness like cancer, or an autoimmune disease. Or maybe you’re feeling constant discomfort without a clear cause.

As different as these situations are, they can all share a nagging challenge — chronic pain. 

Defined by the medical community as pain lasting three months or longer, chronic pain is closely linked to mental health, and can have an immense impact on a person’s psychological well-being.

Seattle-area doctors and therapists specializing in pain management say a key part of treatment is understanding pain better and learning to manage the emotional distress that comes with it.

“Having chronic pain, being upset about it and wanting to avoid doing things that make it worse is not a moral failing,” said Kaitlin Touza, a pain psychologist and assistant professor at UW Medicine. “It’s just an instinctual reaction to pain that we can retrain.”

What is chronic pain?

Unlike short-term, or acute, pain, chronic pain tends to last for months or years. 

While many people think pain may signal structural or tissue damage, that’s not always the case, said Hang Ruan, a Seattle-area clinical social worker and therapist who teaches classes about managing the mental health impacts of pain. Instead, pain functions as a warning signal to the brain, to protect the body.

Ruan likened pain in the body to a faulty fire alarm.

“You want the fire alarm to go off when there’s a fire,” Ruan said. “Unfortunately, the alarm can become oversensitive and overprotective. Then it can get really intrusive with your life. That’s what’s happening with chronic pain — from a nervous system level, the alarm system has become oversensitive over time.”

Yian Chen, a UW Medicine pain physician and anesthesiologist, said typically pain falls into three categories:

- Nociceptive: related to tissue damage

- Neuropathic: related to nerve damage

- Nociplastic: not necessarily related to either of the other two types. 

“This is the type of pain that’s probably being discussed more and more,” Chen said of the third category, pointing to conditions like fibromyalgia, chronic fatigue syndrome and even irritable bowel syndrome. “This is pain that arises from altered pain perception itself without any clear evidence of damage to the tissue or nervous system. So it’s kind of a disease of the processing of pain itself.”

Chen said pain types can overlap, and each have different risk factors for psychological challenges and treatment responses.

Mental health impacts

Seattle-area therapists say mental health ailments like anxiety and depression often accompany ongoing pain. People struggle with losing the ability to work, care for their homes or engage in activities that are important to them — plus the uncertainty of what the future holds.

“These things overlap,” said Touza. People with depression are more likely to experience chronic pain, and those with chronic pain are at much higher risk for depression, sleep disturbance and anxiety. Brain studies show similar patterns in both conditions, Touza said.

That doesn’t mean one guarantees the other. But, “it’s hard to separate these things because they’re all occurring within the same brain structure and influence each other,” Touza said. “Not everyone who has chronic pain has depression. But it’s really hard to get chronic pain under control without also managing mood and health behavior factors.”

Tucker Robinson, a therapist with Seattle-based Self Space, said chronic pain can trigger a “massive identity shift,” from losing physical ability to adjusting to a new reality of living with pain, he said. “A lot of the emotional pain in the beginning comes from grief and isolation.”

Trauma is another significant factor.

“We know that people with PTSD (post-traumatic stress disorder) have a kind of increased vigilance, being more sensitive to threats. That scanning for threats is going to bleed over to scanning for threats such as pain,” Ruan said. “This heightened sensitivity can also trigger more PTSD symptoms.”

Social stigma adds another layer. Touza said people with ailments that aren’t visible may feel invalidated — like being criticized for using a disabled parking permit while appearing outwardly fine — and that can add to the stress.

“It’s small, everyday things like that that add layers of internal conflict and shame,” Touza said. “And it’s hard to do anything about it because if you don’t have chronic pain you can’t really understand.”

What can help?

Robinson acknowledged stigma around seeking help but said therapy can be an important step. Pain reprocessing therapy, for example, helps the brain relearn how to respond to pain by focusing on the physical body and the sensations and automatic thoughts that come up with the pain.

“It’s reframing and changing our perspective of how we listen to our body,” Robinson said. “It’s common in the chronic pain world to feel like your body is the enemy, or you’re a prisoner of your body in some way.” Pain reprocessing therapy or somatic therapy can help people find little bits of freedom and help them relate to how they’re experiencing pain in a different way, he said.

Ruan teaches a class called “Pain in the Brain,” which helps patients with mindfulness — learning to be aware of sensations and feelings in the present moment without analyzing or judging them — as a way to ease pain’s psychological burden. 

Gentle movement can also help.

“With acute pain, rest is best. But with chronic pain, motion is lotion,” Ruan said. “We want to help people get into slow, gradual movement and activity, bit by bit.”

The most effective approach is one that combines a variety of treatments, said Chen, the UW doctor.

Medications don’t tend to cure the problem, he said, but can take the edge off symptoms enough for a patient to benefit from treatment, like physical therapy or pain counseling. 

While it’s rare to find a treatment that completely eliminates pain, Chen said even small reductions can bring people some relief.

“Even a 30 to 40% reduction can allow patients to be more active, allow them to do the things in life they were previously enjoying,” Chen said. “That’s the type of report we want. That is what is considered a success — allowing patients to go back to living their lives as well as they can.”