Pain and Mental Health

It May Not Be Your Fault, But It Is Your Problem

2011-07-28T11:23:00.000-07:00

Facts first: Therapy (physical or psychological) requires that you do a large portion of the work (probably 75%) at home, continuously. Doctors cannot fix you (in most instances of pain complaint) without your participation in the healing process. We professionals can only take you so far – you are with you many many more hours a day than we are with you…so, it is largely in your hands. Even with the right medications, the best physical therapy and wise advice from your favorite psychologist, none of it matters if you don’t take the pills, do the exercises or change your thoughts as prescribed.

This means that, even if you feel better with treatment or therapy, you have to keep doing it (e.g., taking your medications, going to physical therapy [PT] or psychotherapy, etc). If it works, why stop? Think about brushing your teeth – you don’t say “I brushed my teeth, they’re clean, I can stop now” (your four year old says this, not you). You are a work in progress, never quite finished or done.

Maintenance, effort, upkeep – these are the buzzwords I want you to take away here. Even more importantly, control and responsibility. These two, fortunately or frustratingly, go hand in hand – if you give over total control to your medical team and take a passive role, well, you can always blame someone else when things don’t improve, but you also can’t really say you are in control of your own destiny either. Some people like the backseat and don’t want to drive, but that can be debilitating in the long run, mentally and physically. What may feel like a burden or another thing on your shoulders really is an invitation to be your own best treatment source, to heal thyself!

(You see, this post is meant to inspire action, not despair and frustration).

There may be another layer here as to why people tend to stop doing what is good for them – often, doing “it,” whatever it is, can be a reminder of illness, injury, or vulnerability.

“I don’t need a cane, that’s only for old people.”

“I don’t need to see a shrink, I’m not crazy.”

Phrases like this have been said by you or someone in your family, I’d bet. Or my favorite,

“I don’t want to go to the doctor, she’ll just tell me something’s wrong.”

We often cling to the irrational belief that, if you ignore it, it’ll go away. Good luck with that…

Being told you have pain or illness, or being given medicine or treatment can be (frighteningly) seen as evidence that you have something wrong with you. Alternatively, (and the view I prefer) these things can give you the tools to take control and be part of the team that is getting you back to life. Do you want the backseat, or the driver’s seat? Do you want control and responsibility or would you rather sit back and complain? You may not like the circumstances, it may not be your fault that things are the way they are, but it is your problem, and you are the one who has to live like this every day.

Wouldn’t you like to live a better life? Well, in many ways, it’s up to you…

Question: Is the Pain Physical, Mental or Emotional? Answer: Yes

2011-05-02T10:50:00.000-07:00

Let me start with this disclaimer – this post is not meant to convince you that the “pain is all in your head.” I hope the Blog thus far has shown that mental impacts physical and vice versa, and that I am not a professional who believes pain patients are “faking it” or “drug seeking.”

However, some interesting research of late suggests that the overlap of physical, mental and emotional is much more significant than we thought. Two studies recently showed that, at the brain’s chemical level, looking at photos of loved ones (in the early stages of romantic relationships) eased perceived pain levels, and that holding the hand of or thinking about a loved one reduced perceived pain experience. We’ve talked before about the benefits of distraction through pleasant experience as a means of reducing pain – sure, if you think about your kids instead of the pain then your reduced focus on the pain should lessen its impact. However, these studies are showing something more than just distraction from the pain – the pain, in direct focus, is either felt emotionally as less painful, or at the chemical level in the brain is perceived and interpreted as less painful. And take note, this is pain relief (even if minor) brought on by thoughts and touch, not pills and needles.

To further make this point, functional MRI scans of the brain’s activity showed patients felt the laboratory equivalent of 8 out of 10 pain in their brain when looking at photos of ex-lovers who dumped the patient recently. This study elaborates upon the idea of an overlap, at the neural level, in physical and emotional pain. The areas of the brain that were activated/stimulated by these emotional memories were areas of the brain typically only noted for physical pain sensations. Many past studies (too many to cite but including the Journal of the American Medical Association) show similar but less definitive results – that the pain of social rejection mirrors, or feels like, physical pain.

None of this news should be all that surprising, given the recent push by drug manufacturers to market medications with taglines like “depression hurts” and so on. We are finding more and more in the medical and scientific pursuit of treating pain that pain and mood are strongly interrelated. Again, this is an obvious statement and something we clinicians have treated psychologically for the longest, even at times using antidepressants as an additional treatment aid. But these studies show in greater visual, hard detail the why and how of this overlap. It is not just that being in pain is depressing, or that being depressed makes you focus on your negative lot in life. The wires are actually crossed in the brain – pain hurts, no matter what caused it.

The take away point here is that, whether it is depression, personal loss, chronic low back pain or fibromyalgia, the end result may FEEL the same – and when you have more than one, well, you see where this is going…

So, while the statement “the pain is all in your head” is usually meant to demean pain patients as “fakers or exaggerators,” these studies show otherwise – pain is ALWAYS in your head, whether mental, physical, or emotional. All the more reason to tend to hurt feelings, and cultivate positive relationships…heartache hurts just like headaches, and sometimes one is easier to fix than the other.

Exercise: Try thinking about someone or something special to you when that breakthrough pain comes.

REFERENCES:

Kross, E., Berman, M., Mischel, W., Smith, E., & Wager, T. (March 2011). Social rejection shares somatosensory representations with physical pain. PNAS, published online before print March 28, 2011 doi: 10.1073/pnas.1102693108 http://www.pnas.org/content/early/2011/03/22/1102693108.full.pdf+html

Master, S., Eisenberger, N., Taylor, S., Naliboff, B., Shirinyan, D., & Lieberman, M. (November 2009). A Picture's Worth: Partner Photographs Reduce Experimentally Induced Pain. Psychological Science, 20 (11), 1316 – 1318. http://psycnet.apa.org/?&fa=main.doiLanding&uid=2009-21312-003

Younger, J., Aron, A., Parke, S., Chatterjee, N., & Mackey, S. (2010). Viewing pictures of a romantic partner reduces experimental pain: involvement of neural reward systems. PLoS ONE 5(10): e13309. doi:10.1371/journal.pone.0013309 http://www.plosone.org/article/info:doi%2F10.1371%2Fjournal.pone.0013309

Out With the Outliers!

2011-04-04T14:48:00.000-07:00

In statistics (the basis of all good scientific research) we talk about outliers. There are the pieces of information that fall way outside of expectations – imagine that you ordered a slice of pepperoni pizza and the waiter brought you Chinese food, that’s an outlier. It’s when all the data, all the people in a study look the same, have similar outcomes, and then one or two people have VERY bad or good results compared to the rest.

Why am I telling you about statistics? Because so often, patients come to me talking about the latest pain treatment they read about online, or something the person in the waiting room mentioned – and so very often I hear how absolutely terrible the experience was and someone nearly died, or how amazing it worked and after one pill or treatment all the pain was gone!

What people hear about (or talk about) are the outliers. These are the most extreme (and thus the most interesting) cases. The 98% that have normal, expected results from treatment don’t tell their stories – or if they do, the stories don’t get repeated. This is because no one thinks it’s interesting that you ordered pepperoni pizza and got pepperoni pizza. That story has no big emotional component, no twist, no surprise.

For better or worse, I think the Internet makes outliers even more prominent these days. (How else could some of these “celebrities” ever become famous?!) The average Joe or Jane isn’t interesting. The person who has a nerve block and the outcome is just as predicted – some relief, not total, it was a “little better for a while” – that’s just boring. The person who had a terrible reaction to anesthetic and almost went into a coma! The person who went back to work and the gym the next month! Those stories stir up strong emotions – the first because we have a protective reaction and want to avoid such negative outcomes; the second because we all want hope (pain patients crave it like water), and we WANT to believe.

The problem is this – there is research to support the idea that we remember stories with strong emotional components better than those stories that are typical and bland. Furthermore, we have a tendency to remember the story later on, but not where we heard it; so, information from doctors and studies get lumped in the same category as anecdotes in the waiting room – we end up confusing the facts and the fairytales.

Now, all that I have just said here doesn’t discount the fact that outliers do exist – some people (unfortunately) do die from surgery gone wrong, and some people do (thankfully) find the “miracle cure.” The thing to remember is that they are literally the exception to the rule. They are interesting because they are highly unlikely and improbable. What are the odds?!

The take home point should be this – I am not trying to steal your hope, just as I am not trying to convince you to try every treatment regardless of the risk. I am telling you to think with your brain and not your gut or emotions. “Wanting” something to work or being “scared it will go wrong” rarely impact the outcome – most of us don’t have superpowers like that. (The small caveat here is that some studies show that pain improves/worsens based on emotional expectations, but this is also more the exception than the rule.)

The numbers don’t lie – play the odds – do your research based on the data, not on the stories. Trust the professionals (or at least the masses) more than the person next to you in line. And be careful – talking about outliers (or believing those stories wholeheartedly) may make a liar out of you…

Becoming the Butterfly

2011-01-21T14:02:00.000-08:00

Death and Rebirth – this is what happens with chronic pain.

When most people think of death, it is not uncommon to think of the famous stages of grief: Denial, Anger, Bargaining, Depression, Acceptance. In truth, the five stages of grief have actually been largely debunked, showing there is no order to grief (though you do usually hit all five stages somewhere). But the reality is that the first four stages happen without any effort, just naturally. The last part, the acceptance, that takes effort, that is necessary before rebirth.

Keep this in mind as you look at the image just below.

What you should notice is that there is an old self (before pain - Part A), and a new self (with pain - Part B). But, the important part of the diagram is the overlap (the grey area); this is the you before pain that continues to be, even after pain set in. You don’t lose (all) of who you are with pain…you retain much of who you are and then can (and must) integrate the old with the new. For instance, the old you might have been able to run fast and play piano – the new you might still be able to play piano (the overlap), you can no longer run fast (the lost, old self), but you might have discovered a skill at crossword puzzles (the entirely new self).

I can easily digress into the “when the universe closes a door, it opens a window” and other such phrases, but those do not clearly make the point. The point is not that this chapter of your life is over and a new one has begun – it is that you (YOU) continue moving forward, developing the new but still retaining parts of the old. We’re not “throwing the baby out with the bathwater” here…the idiom or saying that really fits here is this – the caterpillar, with change, develops into the butterfly.

Now, before you can fully embrace this concept, I believe that you must properly grieve and let go of the old self (the parts that are lost). So, back to the stages of grief (but in terms of your pain) - first you can't believe this is your life; then you are angry at how unfair the situation is; then you start talking to doctors, witchdoctors, anyone who might help; then you see little hope for beating the pain and depression sets in; and finally (hopefully), you can reach a place of acceptance - but getting to this last piece is the hardest part. And until you achieve a level of acceptance, you won't be able to truly grow in a positive direction. The rest of the process will happen naturally, but this last piece, acceptance, is both the most necessary and the one needing the most effort.

Not the same as chronic pain, but here's my example. When I moved from Buffalo, NY to New York City I learned to walk everywhere or use the buses/subways – but, if you had told me that I had to abandon my car while I was still living in Buffalo, I would have said “heck no” and kept on driving. I wasn’t going to try to learn a new way of doing things until life forced me to completely let go of the old way. Until you accept that the old way is completely gone (sad as that may be), you will have trouble embracing the new approach. (The butterfly cannot become the butterfly until it relinquishes the identity of the caterpillar…and moves forward).

Let me reiteriate - you MUST grieve the loss of the old. How you do this is up to you (tears, shouts, getting rid of objects/mementos, talking through it, and so on). Nevertheless, it is my belief that without some form of emotional release, you can't properly make the transition and start anew. So, go into your cocoon in whatever way you need to, allow yourself the time (and ask for patience from loved ones) and let the change take its course in the timeframe needed.

The acceptance process (ideally) should look something like this:
1) Accept that pain is a chronic and lasting part of your life
2) Accept that pain limits what you can do and how you can be “the old me” - this is letting go of the left half of the diagram, the A circle
3) Grieve the loss of those skills, activities, habits - by raging, crying, talking, and so on
4) Take stock of what skills/strengths you retain (in part or in total) - this is the overlap of the circles, the grey area
5) Consider what you can continue to do (even if in modified form) or what new jobs, hobbies, activities you might engage in with your current strengths and assets - this is still the grey/overlap
6) Develop the entirely new self, integrating new and old - the right half of the diagram, the B circle

Death and rebirth. Grief and loss. Begin by accepting that the whole whirlwind of emotions is reasonable and expected with chronic pain. Then you can start with exploring your emotions about the parts of you that are gone. From there you will hopefully find a place where you can see that, despite the losses, there is a "you" that continues to exist, live, even thrive and enjoy life. With restrictions. With a new outlook. With hope. As the butterfly - because the caterpillar, the old you, is gone.

What's In a Name?

2010-11-29T12:04:00.000-08:00

I’m a big believer in the impact words, labels, and language have upon on how we think of ourselves. (This should be obvious from my prior post). So let’s start this discussion with a thought experiment: What do you call yourself (in light of your chronic pain condition)? Disabled person? Pain patient? Person living with pain? Trauma survivor? Still just Joe or Jane? How do you explain to people (in a brief version) why you wear a brace, take pain pills, don’t work, etc?

Starting from this label or identifier can impact your outlook – the simple application of a label can speak to your level of acceptance of your condition. (And this varies person to person – for some people, saying “I’m disabled” is a sign of growth, but for others this descriptor leads to depressive and negative behavior.) Labels can indicate adjustment or “stuckness,” they may be self-appointed or assigned by those around you, and they can transition over time.

Labels can also be something you remove, not something you add - are you still an athlete, a plumber, a nurse? Can you still be the father, aunt, brother you were…and still are…? (I would argue, as a professional, that you don’t have to lose parts of yourself because you have chronic pain, but you certainly must learn how to serve these roles in a new and different way).

Of course, sometimes labels that might be seen as objectionable (e.g., “disabled) may serve a benefit. Have you had the experience of people asking “How are you? You don’t look sick/hurt/in pain?” This can be a complicated explanation (for others and for yourself), often hearing the comment “if you can have fun with friends, you can go back to work, right?” I’ve had many patients say they would almost rather be missing a limb or be confined to a wheelchair, so that it would be clearer to others (and themselves) where the line was drawn. It is much more complicated to think (and sometimes, to act) in a way that reflects some but not all limitations. (And, the reverse is also true – so often my patients point out that while their bodies may be in wheelchairs and have limitations, mentally they may feel, as one patient so poignantly put it, “like survivors on a sinking ship.”) The labels you apply can be ways of describing your strengths/weaknesses, or they may end up defining and shaping your behavior – holding you back, so to speak.

So, can a pain patient return to work? If you are a trauma survivor, does that mean you are supposed to feel down and depressed all the time? Do you even need or want a label, or are you still the same old Joe/Jane?

Do you need or want others to acknowledge your limitations or health conditions, or would you rather they treat you like you were “normal”?

Regardless of any label or title you take on, I ask you to consider two things after reading this post:

First - Whether you want/need a label, others will likely assign one to you, so consider doing your own P.R. and choosing for yourself how you want to be seen (and why you are labeling yourself that way).

Second - It is vital to acknowledge that, regardless of the words you use when talking about yourself, you are no longer the Joe/Jane that you were – there is necessarily a change that takes place once pain sets in. This doesn’t have to be a disabling mental or physical adjustment, but just as you can’t overcome racism by pretending you don’t see people’s skin tone, you can’t overcome pain by pretending it doesn’t change you.

Who are you (now)?

Healing Words

2010-09-30T08:07:00.000-07:00

Call it self-talk, cheerleading, meditation, improving the moment, finding your happy place, even prayer. These are all variations on a theme that at its core may amount to focusing on words or phrases that inspire you, that make you feel good. I’ll offer some of my favorites in a bit, but let’s begin by helping you find (or define) for yourself what your inspiring words might be.

Self-talk is the most basic version of these techniques, and can take the form of an internal dialogue, a way of talking to yourself like a best friend would, and ultimately a means of keeping yourself focused: “You’re seeing only bad and ignoring all the good in front of you.” One of the skills I often work on with patients is teaching you how to argue with yourself – if you can (in your mind) argue for both sides of a feeling or belief, you may be able to avoid certain negative feelings or the “playing the broken record” phenomenon. Consider this one: “I know it feels like the pain is debilitating, but am I really totally disabled, maybe I can still do some things…”

Cheerleading is my way of describing the overly positive voice you hear in your head (often a loved one’s voice internalized) that pushes you forward during tough times. This is the louder more hopeful version of self-talk: “You can do it, I believe in you, don’t give up!” This is the idea of the little engine that could, the “I think I can! I think I can!” approach.

Meditation takes many forms and typically involves variations on posture and breathing as well. Most often, meditation focuses on a word, phrase, or intention used to focus the mind: “Calm” or “See the light within yourself.” Meditation often involves a spiritual phrase or statement, especially when tied to yoga or certain religious rituals.

Improving the moment is a phrase taken from the mindfulness literature, and it refers to finding the silver lining on the clouds – refocusing your thoughts, emotions, and attention through some internal cue: “I may be in pain, but that pain means I’m alive another day with my family around me” or “My pain doesn’t negate the pleasant experience I am having at this meal.” Sometimes we need to be our own best friend by using such phrases as internal cues to stay on a positive or hopeful track, and avoid placing a negative spin on everything.

Finding your happy place is the classic psychology cliché, but it’s a cliché for a reason – sometimes the use of imagery, fantasy, or pleasant escape is a great coping mechanism: “Mmm, an all chocolate buffet” or “I’ll always have that memory of traveling to Tuscany, I can picture the hills and vineyards.” You can use words to paint a picture or tell a story that brings you comfort or calm. (Remember, in an earlier post I noted the proven benefits of fantasizing about chocolate.)

Prayer can come in many forms and I don’t claim to be an expert. However, most people’s approach to prayer involves “talking” to a higher power or repeating a phrase or mantra over and over, any of which can be soothing: “Peace, peace, peace” or “I trust in Your will.”

So you see, words can be more than just words. They can serve as a motivator, an escape, a source of peace and comfort, a rallying cry, an emotional outlet, or a guide for living. There is a growing body of research supporting the use of many of the above methods for relief of pain and pain-related distress. (Don’t forget that the mind and body interact, and lessening emotional distress can reduce the intensity of your pain experience.)

My own means of finding a moment’s peace combines many of the techniques discussed here. I keep a collection of quotes, some famous, some spiritual, some from literature, and some from friends and patients. If I need inspiration or comfort I can scan this list where I find there is often a phrase in there to provide direction.

Some of my favorites include:
”I am only one but still I am one. I cannot do everything, but still I can do something. I will not neglect that something I can do.”
Helen Keller
(This statement speaks to me about overwhelming strength and courage, and keeps me focused – a version of cheerleading).

“To enjoy, to love a thing for its own sake and for no other reason.”
Leonardo da Vinci
(This one for me is about improving the moment and mindfulness – just being in that moment, whatever it is.)

“We can't all be heroes because somebody has to sit on the curb and clap as they go by.” Will Rogers
(Quotes by Will Rogers have certain personal memories tied to them, and they start a trickle down of images and stories that can serve as my happy place.)

"The great art of life is the sensation, to feel that we exist, even in pain."
Lord Byron
(Again, improving the moment, as well as a version of the arguing with yourself in self-talk.)

“Pain is inevitable, suffering is optional.”
(This quote tells me that, while we can’t always escape our circumstances, we can alter our attitudes and interpretations. This acts as cheerleading and a mantra-like meditation.)

"If you saw Atlas, the giant who holds the world on his shoulders, if you saw that he stood, blood running down his chest, his knees buckling, his arms trembling but still trying to hold the world aloft with the last of his strength, and the greater the effort the heavier the world bore down upon his shoulders—what would you tell him to do?"
"I…don’t know. What…could he do? What would you tell him?"
"To shrug."
Ayn Rand, Atlas Shrugged
(This one means to me that, even if not always apparent, we have choices and options. This is part of a happy place for me, remembering when and why I read this book, but also a personal belief system that is like meditation or cheerleading as well.)

The idea behind this posting is to encourage your own self-sufficiency – any of these techniques can be done solo, without any tools, people, or in any environment. When dealing with pain and its related psychological baggage, it is useful to have portable skills that you can draw upon anytime, anywhere. Use these brief descriptions as a way of picking a technique to explore further, to learn more about it and practice.

What words will inspire you? Do you believe that words can change your thoughts and feelings? What does the little voice in your head say?

It Isn’t Funny, But It’s Okay to Laugh…

2010-08-31T12:53:00.000-07:00

When we (psychologists) are evaluating a person, we take note of their affect. Affect is, loosely defined, the way your mood looks to the rest of the world. So, it is worrisome if you say your mood is “fine,” but your affect says you are very angry or sad. We take note of such incongruity, and question why you say one thing and do another. However, the ideal situation is where we can say a patient has a “full range of affect.” This means that, no matter your circumstances, you are able to feel/show emotions of a varied range – happy, sad, angry, anxious, etc. It is a sign of a healthy and well-adjusted person who experiences all of the feelings, at least some of the time.

Laughter and humor have some documented positive benefits:
-Relationship strengthening
-Physical and mental health
-Stress and pain relief

What I ask you to consider is this: even though pain and the issues that come with it are far from funny, sometimes it is okay, even good, to have a laugh. Sometimes it’s not even wrong – it’s just right.

I remember Saturday Night Live had its season premiere just two weeks after September 11th, 2001. The show’s creative director got in front of the camera with Mayor Giuliani, with firefighters and police in the background, and he asked the Mayor – “Is it okay for us to be funny?” And the Mayor said something like “you haven’t been funny in years, why should that change now?” And the point (that I remember) was that 9/11 was far from being something to laugh at…but you can’t be mad or sad all the time. Sometimes, even if you don’t want to laugh, or think it’s wrong – that’s when it’s right.

I used to work in cancer and end of life care and, in that field especially, sometimes you had to find the humor (for the professionals and the patients). Someone showed me this guy’s blog, where he had some laughs at his own expense and made inappropriate (but funny) cartoons, like this one and this one Now, there are usually only two reactions to these – “that’s pretty funny” or “cancer isn’t funny at all.” And they’re both right – cancer is very un-funny, but sometimes the situations we face are so absurd, so upsettingly bizarre and unexpected, that they are sort of comical.

Think about it – is there anything about your situation that is funny? Not desirable – but funny because it’s so absurd? Like, isn’t it ridiculous that you get prescribed pain medications that constipate you so you then need medications to help you move your bowels…you fix one problem, and something else breaks. Isn’t it absurd that a person your age has these limitations like an older man or woman? (Not funny, but sort of ridiculous?) Now take note, I’m not advocating for mean-spirited mockery – like most sensitive subjects, if you are the person in pain, you may have to set the rules for when jokes are funny or desired and when they may be rude or too off-color.

Or, apart from your own experience, when’s the last time you saw a comedy, or laughed with your friends, or told a joke? You can be in pain and still have a laugh (even if it hurts). Leading a full life means focusing on other people, things, and feelings besides yourself. This doesn’t mean negating your experience or pretending you’re okay. It just means that people in pain can still laugh.

A good laugh and a long sleep are the best cures in the doctor's book. ~Irish Proverb

Why Me?

2010-08-03T14:17:00.000-07:00

This is a question most pain patients ask themselves at some point. Rarely does this question result in a satisfactory answer – the truth is, the only good answer would be if it were not you.

While asking “why me?” is often a bad idea, knowing the answer to “why” as it relates to your pain can have some benefit. There may be positive outcomes that grow from knowledge of the cause, source, or origin of your pain. Knowledge of why can guide treatment, including psychological approaches taken, and can guide the course of your rehabilitation and overall well-being. Let’s explore three common answers to “Why?” – injury, illness, or unknown.

If your pain is the result of a physical injury (such as a slip and fall or car accident) then there may be some associated psychological trauma. Some people may suffer from anxiety and worry, even posttraumatic stress (PTSD). You may begin to fear that such an event could occur again in the future. Certain behaviors or events may be avoided, even to the point of phobia. What is called “guarding” can occur, leading to pain sufferers holding their limbs in odd positions, even padding them to avoid re-injury, or avoiding physical contact with people. Obviously it makes sense to try to avoid worsening your situation or “making the same mistake twice,” so to speak. However, if such psychological tension or behavioral change is unconscious (and even if not), these reactions to your pain onset can be unnecessarily troubling. (For instance, if a traumatic event caused the pain, then every time you feel a twinge of pain you are reminded of that traumatic event – this pattern only makes the physical and emotional pain that much harder to endure.) Studies have shown that a history of trauma (even long before your injury or pain onset) predisposes people to experiencing worse pain, as the physical and psychological issues intertwine, and your psyche is made somewhat more vulnerable to negative feelings. Additionally, research has proven that posttraumatic stress (as a result of a physical trauma) exacerbates pain and disability by way of increased depression – meaning, trauma leads to PTSD which leads to depression, which impacts pain and functional status (Roth, Geisser, & Bates, 2008). By treating the PTSD, we can treat the depression, and thus reduce or better manage the pain. This becomes a true example of what is called (in mental health) a pain disorder, where pain leads to psychological issues, and psychological issues lead to pain – there is an interplay between both sides of the coin. The good news is, if we intervene on one side, it can positively affect the other.

Another aspect of trauma or accident as the onset of pain is that there can be an outlet for blame – anger and frustration can be directed at the other driver, the building owner and so on. This is good and bad – nice to have a target, bad because then we can get “stuck” on trying to find remediation, financial or otherwise. Such belief structures also guide treatment in the way I might encourage or discourage such outward, externalization of your anger or distress – for some people this behavior may help, for others it is quite harmful, but either way it is an important piece of information.

If illness (whether chronic or brief) is the cause of your pain, the implications for your outlook may be a bit different than if there were an injury. For example, pain related to diabetes may lead patients to experience guilt for not catching or controlling symptoms. Questions like “could I have done something different” and second guessing can occur. Periods of overcorrection may result – “I ate that dessert and my neuropathy got worse, from now on, only broccoli for me!”. And the reverse can occur – beliefs may arise wherein any increase in pain levels can lead to fears of worsening health or illness (“pain was the first sign of my cancer, does this pain mean the cancer’s back!?”). These flare-ups of pain, and thus anxiety, can be PTSD-like in that the traumatic experience of a cancer scare or a heart attack or a diabetic event may be re-lived every time the pain gets worse. And, there are psychological implications for the behavioral reaction you choose – some people find extremes of either reporting to doctors even the most minute changes in pain, for fear of illness recurrence; others fear that telling of the pain will bring on such bad news, so they avoid telling the doctor to avoid any potentially unpleasant truths. Obviously, both extremes can be detrimental to your physical and mental health, and moderation is key. (And this issue is complicated, as reporting increased pain to your treating physician can be important to track disease progress, even if pain does not always tie back to the illness.)

So with pain tied to an illness, the risk may seem ever present, always waiting for a symptom flare-up to lead to worse pain (or for the pain to signal a symptom of illness). With an illness-related pain, the course may be more gradual and hidden, not knowing when or where symptom changes will lead to anxiety, whereas in accident-related pain, you may be able to more easily and actively avoid certain situations – it is more overt and externalized. There is also more a component of self-blame that may occur (versus outward or other blame with an accident). And the biggest difference with illness-related onset may be my reaction as a psychologist – knowing that your negative mood is not just a result of a bad pain day, but tied to fears of illness – this changes my approach to your therapy.

Finally, not knowing the origin of your pain can present a host of other issues. Where the other two causes can result in all the emotions and behaviors noted, at least those cases allow people to direct their concern at a specific cause. With no known source of the pain, anxiety can spiral to an even greater degree. Fear and paranoia even. And consider this – if you know that a car accident or a poor diet led to your pain, you can at least try to avoid these triggers. However, with no clear cause there may be no clear coping mechanism – that can be very scary and debilitating. Your worldview may go from “bad things happen only to bad people” to “the world is dangerous and unfair.” Without a known cause, many patients begin to lose their faith in medicine and doctors – “why can’t you figure out what’s wrong, it’s your job!?” And the reaction from the medical profession often is negative in itself – some professionals will question patients’ pain and wonder if it is real at all, coming from the perspective that if it cannot be diagnosed then one of the solutions is to label it as fiction. The psychological implications for you as the patient are obvious in this scenario.

Regardless of the reason for your pain (the why), what we are really talking about here is a consideration of how – how your pain began, how your worldview is impacted by your beliefs about your pain, and how this belief structure can impact you thoughts, emotions, behaviors, every aspect of your life. What this means is that there can be a trickle down effect, even a cyclical effect (in that greater emotional distress and poor coping can actually worsen pain). To give a simple visual, consider this:

PAIN CAUSE -> PAIN BELIEFS -> EMOTIONS -> BEHAVIORS -> FUNCTIONING

…for instance…

CAR CRASH -> CARS HURT -> FEAR -> AVOID CARS ->ISOLATE/DON’T GO OUT

…which of course means you stay home alone and focus on your pain, which makes the pain feel worse, and around and around you go…

Or, consider this quote a patient shared with me: Watch your thoughts, for they become your words. Choose your words, for they become actions. Understand your actions, for they become habits. Study your habits, for they will become your character. Develop your character, for it becomes your destiny.

The point of this post is not to increase your distress, or to oversimplify your experience. What is meant is to direct you regarding the questions you might want to ask, or issues you might want to raise. It is vital that you discuss your feelings and beliefs about the pain onset with a medical or psychological professional. Knowing this answer to “why” (or how) can impact where we professionals intervene, and how we do so (as treating anxiety is different from treating depression, or we may need to address your anger at others versus anger at yourself). Working through your beliefs can then have a positive cascading effect on the pattern drawn above. Studies have shown that such therapeutic exploration can reduce posttraumatic stress, anxiety, negative behaviors, and so on.

You don’t want to build further assumptions atop the old ones – our feelings are often correct, but can be misguided if not challenged from time to time. If you start with the belief that all pain is a sign of terrible illness, or that car accidents can occur at any minute, you have taken your negative experience and magnified it, stretched it, and made it something bigger (and less true) than how it began. On that unsteady and faulty base, whatever you build atop it is sure to lead to distress. One of the best interventions we can provide is to help you separate out faulty or illogical beliefs from the facts – your emotions may tell you that the world is filled with danger, and while the emotion is valid, the belief is skewed – psychology can help you think more clearly. Techniques like cognitive therapy and rational emotive therapy can help you to see what beliefs are important (e.g., always report increased pain to your physician, always wear a seatbelt) and distinguish which beliefs you can alter or relinquish (e.g., not every car ride will end in an accident, it is unlikely that one meal off of your diabetic diet caused your pain).

So while you may not like the answer to “why me?,” you should do your best to learn of the origin of your pain and share that information with providers – knowing the “why” can help you (and me) answer the “how” to improve your quality of life. We can’t take away your pain or change the past, but we can reduce your distress going forward by helping you re-evaluate your belief and start from a solid base.

Reference
Roth, R. S., Geisser, M. E., & Bates, R. (2008). The relation of post-traumatic stress symptoms to depression and pain in patients with accident-related chronic pain. The Journal of Pain, 9, 588-596.

Come On, It Can’t Hurt That Bad?!

2010-06-17T10:50:00.000-07:00

Remember that old slogan, “What would you do for a Klondike bar?” Well, I’ll up the stakes – what would you do to get your pain treated? A woman in Michigan was willing to shoot herself to get doctors to address her shoulder pain. (Now, I know the crux of this story really centers on access to healthcare and the poor economy, neither of which will I address here.) What I find truly striking is the way this story speaks to the issue of pain’s potential impact on people’s mood and behavior. Regardless of good sense, finances, or circumstances – pain can impair your logic, the resulting depressed mood can harm your perspective, and combined you can make rash or poor choices out of desperation. This story shows loud and clear how much suffering chronic pain patients endure – this woman had not yet even met criteria for chronic pain, having suffered only one month so far. One month! So, as you try to communicate to friends, family, and providers how you suffer, day in and out, for years at a time, you can point to this story – one month in pain was enough for a woman to grow distressed enough to shoot herself. (Obvious disclaimer – I am not encouraging shooting oneself as a means to address your need for treatment – this is a terrible and dangerous idea and should not be repeated.)

The other moral of this story (apart from saying that chronic pain can really hurt that bad) is that communicating your emotional distress (in appropriate ways) is an important skill to learn. This communication is very unique to the person and to the people in his/her life, and so your methods may vary. However, the key is finding methods that work. For instance, some pain patients attempt a passive, or passive-aggressive, approach – behaving or speaking in ways that they hope spouses recognize their pain, or growing angry and vengeful if the “right” response to pain flare-ups is not given. Such approaches usually fail, because the message gets muddled in translation. (The woman in the story could be said to have taken a passive approach – though she took strong action, she only hoped that the treatment of her gunshot would lead to incidental treatment of her shoulder pain/injury – this in fact did not happen and she is still suffering from her original injury. Passive or passive-aggressive approaches may get you attention, but it may not be what you hoped for.)

I encourage direct or indirect communication that has a clear message and asserts your needs in that moment. For a direct, assertive communication example, consider this: “Hey sis, my back pain is flaring up today and has me really down. Would you mind if we cancelled dinner and I just stayed home on the couch? Actually, could you grab some take-out and come sit with me awhile?” This message communicates three important pieces of information: 1) what is your pain level (very bad), 2) how it is affecting your mood/behavior/needs (can’t leave the house), and 3) what the people in your support network can do or not do to make things more tolerable (visit me and bring food).

And such communication can be indirect also – consider a man saying to his wife “Dear, I’ll be in the back room watching tv.” This statement says nothing directly about pain – but, let’s say that this couple had previously agreed that the husband got angry and frustrated when talking about his pain. Let’s also say that they needed an indirect way for him to communicate his distress without talking about it – so they agreed upon a phrase and behavior (watching tv in the back room) to let the wife know that her husband’s pain was flaring. They also have learned that the husband’s pain flare-ups are best handled by allowing him time alone, and that he would emerge from the tv room when his mood or pain would be less likely to lead to a fight between them. Of course, somewhere in this story you see that direct discussion has to occur, but it may only need to be said once, and henceforth the communication can be indirect but still have a clear message with all three components noted above. In this example, the phrase means pain is very bad today, thus my mood is angry and I am likely to snap at people, so please let me isolate for a few hours and use tv as a distraction.

These are just a few oversimplified examples of communication styles. I encourage you to find your own healthy way to share with people in your life, to let them know how your pain affects you. Be sure to include those three components: 1) pain level, 2) how it impacts your mood/behavior, and 3) what people can do to help. Use this news story as a jumping off point to explain how bad the pain feels, and how you sometimes may act bizarrely because of the pain. But also let this story be a cautionary tale – better to find an effective communication method (through trial and error) than to wait until things become intolerable and you are left without a way to ask for help.

Another Avenue for Advocacy and Education

2010-06-02T10:26:00.001-07:00

I recently learned of a new website called In the Face of Pain which serves to educate professionals and the public on gaps in pain management. It is specifically designed to aid you in composing advocacy messages to spread in your community, to providers, or to your politicians.
I have posted on such websites in the past here and here and I hope you find such sites helpful.
If nothing else, they can be a route to greater self-awareness and self-education about your own pain condition, as well as treatment options.

Pain Action Website

2010-04-27T11:04:00.000-07:00

I wanted to briefly note for patients and readers that this resource, PainAction, appears to have some nice information. I haven't reviewed every aspect of the site as yet, but what I have seen consists of varied videos, links, and information, all geared toward empowering patients to better cope with their pain. It seems you can even personalize your information to be tailored by pain type, and receive email updates as well as utilize the online pain diary they provide.
Please take advantage of this unique resource, and feel free to offer any feedback (positive or negative) you have while using the site.

Who Would Want to Feel this Way?

2010-04-14T09:01:00.000-07:00

The answer is, you’d be surprised….

Let’s begin this month with a vocabulary lesson. Sometimes people who presumably want medical treatment (which is the stated or “primary gain”) actually want disability benefits, money, time off work, attention, or any number of other less obvious results from treatment. This is called “secondary gain,” and is largely the reason that pain patients (especially those with more obscure disorders or less visible injuries) are so often looked at sideways by the medical community. We have all heard the stories of the “fakers,” looking for pills or a quick buck, or to avoid some responsibility.

However, this issue is important to you, too – the person with actual pain. Whether you realize it or not, you may at times use or exaggerate your pain to garner attention from loved ones, sympathy from strangers, or because some days you simply do not feel like getting out of the house. This doesn’t mean you’re faking, or manipulative, or even lying. Often times, such behavior is unconscious – but that doesn’t mean it is not occurring.

Think about it this way. No one wants to be in a wheelchair, right? Given the choice, everyone would pass. BUT, if you had to be in wheelchair due to illness or injury, why not get some benefit from it. So, you skip ahead in the line at Disney, or you ask your friend to spend extra time with you that day, and so on. Again, you didn’t want to be in the wheelchair in the first place, but why does it all have to be negative?

Now, I don’t mean to encourage people to cry out in pain in hopes of getting discounts at the car dealer or to simply cause a scene. I simply am asking you to consider two questions: a) Have all the changes from my pain/condition been negative? and b) Do I exaggerate or hold onto my pain some days, for some reason? The most telling tale I’ve experienced of “secondary gain” was a woman who found that her husband, who had been loving but not in an affectionate or outward fashion, became much more attentive and “into the relationship” once she needed greater caregiving assistance.

And this, while a nice end to a bad story, can also lead to what we call “tertiary gain.” (To reiterate, primary gain is getting what you asked for, secondary gain is getting what you wanted but didn’t ask for, and tertiary gain is when someone else benefits from your situation, without them asking for it.) Example: Consider the disgruntled older man whose family is not so fond of his bossiness and demanding nature. After pain onset and subsequent disability, his bark remains but his bite is gone. The family is thrilled (inwardly) to see that granddad has mellowed, or is more pliable. Do you think they want to see him get back to his old self again? Now, again, they didn’t cause the initial injury, or ask for harm to befall him. However, since it already happened, why shouldn’t they benefit from it? (And, yes, you may have heard of this as Munchausen’s by proxy, or secondary gain as Munchausen’s syndrome – these are not necessarily correct terms but they are similar enough.)

Just like secondary gain, tertiary gain may largely be unconscious or unstated. And, like secondary gain, those who benefit from tertiary gain (typically family, friends, caretakers) may at times exaggerate or maintain the illness or injury to maintain the benefits. So, sometimes family members may not push the patient toward physical therapy, may be happy to see the patient overmedicated or may not encourage attempts at returning to independent functioning.

You can choose to see these levels of secondary and tertiary gain as lies, or evil deeds, or manipulation. And they certainly can be. But they can also be the unintended positive result of a negative situation – family grows closer, we begin to appreciate our strengths, take time to “smell the roses,” and what have you.

In addition, I don’t mean this information to lead to questioning or resentment of family members. They may not be engaging in tertiary gain, or if they are it may be out of love and concern. Many people have the fantasy of wishing a loved one would open up more emotionally, ask you to be more involved in their life, or wish for a greater commitment. These aren’t uncommon or awful thoughts, and it doesn’t make them wrong for feeling that way. They are just making lemonade out of lemons.

Lastly, consider that these levels of gain may be occurring in or around you without your knowledge, and that is the point I wish to drive home here. Most pain specialists and physicians (and even we psychologists) have moments when we question the underlying thoughts or motives of people in our office. We have to ask “why?” sometimes. And, you should too. Rather than take offense at the nature of such questioning, consider that knowing the answer for yourself may change how you interact in relationships or how others perceive you. And, if you are more aware of how you or others are maintaining your pain status, you are more well-equipped to combat such issues and find greater improvement. So, though you’d love to be healthy and fit by tomorrow morning, do you or your family members get any benefit from your situation? Is there any reason to say that this bad set of symptoms has led to some positive outcomes (no matter how small or transient)?

Why the Olympics May Have Depressed You….

2010-03-19T11:00:00.000-07:00

Watching the Olympics, and Lindsey Vonn’s recovery from pre-competition injury and return to glory on the slopes, I was inspired. What a bounce back, both physically and mentally. How impressive, the way the human body can recuperate and then sustain such a pounding.

However, thinking of my pain patients, I worried there were a lot of resentful people in front of their televisions at the end of February. Now, not all people look at someone more fortunate than them and instantly grow frustrated or angered. But, even the most well-intentioned of people can be inclined to compare themselves to others and think, “why can’t I do that?”

So, why is Lindsey Vonn able to come back from injury so quickly, and you suffer with chronic pain for years? The answers vary and are not clear, but consider the following:

-She is a world-class, Olympic athlete, in better shape physically than all but probably 1% of the population. So, she is at a different starting point before the injury compared to most people. More in shape to start, better odds of rehabilitation (in most cases).

-She is 25 years old, so she is younger than a majority of the population (about 70% of U.S. citizens), and thus, at a different starting point, with better odds of returning to pre-injury levels of functioning. And, the older a person is, the greater the odds that they’d have sustained additional injuries, possibly even to that same body part. So, youth is a factor.

-Her injury might have looked scary on film, but the actual physical result involved (based on media reports) damage to the muscle more so than nerve or other tissue. These latter issues are largely to blame for chronic pain (not because muscle injury is not as painful, but because nerve or tissue damage can be harder to adjust to, treat, repair, or rehabilitate). So, the type of injury makes a difference. (beyond saying she hurt her leg).

-She has a team of professionals (and loads of financing) supporting her efforts to a speedy recovery; most people, even with the best medical and support team, do not have the time pressure and world-class efficiency she likely had behind her (or the money).

-The long-term effects aren’t yet clear; she may have been able to ski downhill again weeks after her injury, but the toll that takes on the knees/legs and how she suffers in the future are yet to be seen. The take home message is that short-term results do not always equal long-term gain. (There is growing press coverage addressing the long-term disability resulting from playing in the NFL, at times caused by a focus on being ready for the Sunday game rather than for a lifetime of health.)

-She had a goal; now, yes, we all have a goal to be pain and injury free, but her goal had an immediacy and passion that is hard to contest. I’ve seen patients of mine endure pain through a child’s wedding or graduation, as these events are brief, with set time parameters, and of emotional importance. However, the Wednesday after finds the patient struggling yet again.

-Though unclear (because I haven’t met her), it seems Lindsay’s confidence (or ability to throw caution to the wind) was quite high before the injury. I so often counsel patients on going slow and steady, planning for pain flare-ups following vigorous activity, and so on – she may not have considered or cared about any of that (short-term versus long-term). Also, there is less risk involved, because even if this was her last competition, sponsorship money and advertising dollars and so on will probably have her set for life, whereas the rest of us have to plan for years of working while in pain or surviving on meager disability benefits.

-What looked impressive on television is also what she does every day, it is her best skill and one she works at many hours every day. Many pain patients might be able to continue to do X task with some proficiency if they went for rehab 8 hours a day, 6 days a week, with a goal of doing only that one skill for three minutes at a time. So, the big factor here is not only innate and learned skill, but also lots and lots of effort and focus – lots of effort. So let’s not forget to give credit its due – the girl did indeed make an impressive recovery!

The reason I mention all this is not to make you angry that you’re not Lindsey Vonn. The take home message is that we all have a tendency to compare our situation to those around us. However, these are rarely apples to apples comparisons. Even if you are looking at the other patient in the waiting room (and not Lindsey Vonn), there are opportunities to be frustrated or depressed because “she has back pain like me but she can walk with less pain.” But if you can keep in mind all the factors that may differ between you two, you may better accept these differences in functionality. Someone else’s circumstances or injury, or pain, may seem the same, may even come with the same diagnostic label but that does not mean you should be like “her.”

Making assumptions and cognitive leaps so often lead to negative emotions or let downs. Awareness of your thought patterns, and how they tie to your mood, is the psychological portion of this article. If we can pause, take a breath, and evaluate the facts (beyond the smoke and mirrors and gut reaction), we might find that those urges to throw something at the television, or to silently hate the other patient in the waiting room, are unnecessary.

So, you’re not Lindsey Vonn, and that’s okay. I’m not Brad Pitt, and while that can be depressing some days, I need to remember that he may not be as happy as me, or it’s very likely that he is much happier because he has multiple assets that I don’t. But I’m not in competition with either of these celebrities; I’m in competition with my own mind to find logic, contentment, and peace. And you can too – just don’t forget to look at all the facts, the whole picture, and to avoid unrealistic or unfavorable comparisons.

A Massage for Your Brain

2010-02-09T07:33:00.000-08:00

Most people have had the experience of banging your shin against the dresser or bedpost in the middle of the night. The pain hits immediately, and before we even have time to have a thought our hands reach down and begin rubbing that leg. This massaging is what is called a counterirritant. The reason we do is that our brains instinctively know it works as a quick pain reduction technique.

In brief, studies have found that our brains and bodies are self-protecting, and while initial news of an injury is useful information, pain beyond that is often unnecessary. What can happen is that, when provided with a counterirritant, the brain (unconsciously) can choose to close the “gateway” to the pain sensation and only allow in the sensation produced by the counterirritant (rubbing your shin). So, while you still often feel some degree of pain, it is dulled to more of a background noise, with the counterirritant taking the main focus. And while this is partly an element of simple distraction of your attention, there is also a biochemical action at play. (This is one of the reasons that treatments such as menthol, capsaicin, “icy hot,” massage, TENS, and acupuncture are typical pain treatments).

So if you picture an actual gate, you can consider that the brain only lets in the visitors it likes, or finds helpful, and the rest can be turned away (so to speak). The reason this is of interest to a psychologist is that the research suggests that emotional experiences can also serve as counterirritants. So, consider the same injury (banging your shin) but picture this happening in the context of you walking down the street holding hands with your spouse, or while playing soccer with your niece. In that situation, when presumably your emotions are more primed to be strongly positive, your brain may choose to focus more attention to the pleasant sensation (emotion) rather than the unpleasant sensation (your shin).

There is evidence that negative emotions can also close the gate to pain (if the negative emotion or experience is strong enough). The catch, of course, is that now your emotions take a negative turn, and much research indicates that negative moods lead to negative interpretations of events, and thus, worse pain sensations. So with negative emotions the counterirritant effect is a bit more complex and complicated.

I recommend pleasant/positive emotions serve as your emotional counterirritant, or a good massage. Seek out pleasant experiences, even if you are in pain, because you are in pain. Rather than the pain spoiling the day, a nice day with loved ones may actually lessen your pain. Try tasty foods, good theater, joyful music, quiet sunsets – eventually you will find a successful counterirritant, and along the way the search will be enjoyable.

P.S. As a native New Orleanian, the current Mardi Gras season and recent Saints Superbowl win are serving as my pleasant counterirritant!

Cold Enough For You?!

2010-01-07T11:37:00.000-08:00

I hear patients talk about being “human barometers” – everything hurts worse if it is rainy or humid, or they dread the winter months when temperatures begin to drop.
The question is this – is there any science to support such reports?

The answer is that it may depend on the pain condition you have. A review of the literature suggests that rheumatologic, neurologic and vascular issues (e.g., arthritis, RSD, Fibromyalgia, headaches) may be more impacted by weather conditions than other types of pain (e.g., muscle injuries, visceral pain, etc). Though, I did come across several reports of back pain being affected by the weather (and it was unclear if this pain was muscular or neurologic.) Many of the studies contradicted each other, and the majority were based on self-report, meaning that patients said “yes, the cold makes my pain worse” but their reports were not verified or tested in any meaningful way.

Also, many of the studies I read seemed to say the same thing – patients say their pain is affected by the weather, but we don’t know why or how. So I offer two thoughts: a) who cares about the mechanism, just accept that for THAT PATIENT it’s a real phenomenon and b) maybe the pain gets worse because of how the weather affects the whole person, not just their pain. Consider the possibility that measurable physiologic changes may not occur (e.g., neurochemicals, blood flow) as a result of the weather, but people may REACT to the weather physically (e.g., muscle tension, shivering, pulling shoulder up, less activity) or psychologically (recall that pain is subjective, and regardless of objective physical factors, your mood and perception largely determine your pain). Therefore, cold weather = sour mood = pain feels worse? Seems like a recipe for disaster to me.

For those who believe in (or live) this association between pain and weather, you can take an active role in preparing and coping by looking at this website. Remember, it is important to accept that certain factors are out of your control, but taking a helpless stance will only worsen your mood, your pain, and your life. Any area of control that you can take back is important. In an earlier post I made this point loudly – your body may be out of control but your behavior and your lifestyle choices are still in your hands – and these factors affect your quality of life.

In closing, the jury is out on whether the weather will make your pain unbearable. However, if it feels real (and worse) to you, that’s all that matters. Pain is an individual phenomenon and very relative and subjective in how we all react to the same stimulus. You need to know how YOUR body and pain react to temperature, weather, noise, activity, medication, and so on. Keep records, update your doctor, and make changes in your schedule where you can to avoid unnecessary pain flare-ups. And, of course, don’t neglect your mood in all this either. If cold weather = sour mood = pain feels worse, then maybe if we change your mood we can avoid the part where the pain intensifies…

Happy New Year, But Be Careful What You Wish For

2009-12-10T07:33:00.000-08:00

While most people look to January as a time to make positive change, often by cutting back on vices, I caution you to consider all possible outcomes of change. A common new year’s resolution is quitting smoking. This is an excellent recommendation for pain sufferers – studies have generally shown that smoking can have negative effects on pain onset, severity, and interference. However, for some people, vices like smoking serve as coping mechanisms, as means to relieve stress and avenues of distraction from pain. (There have even been studies showing that nicotine may reduce some types of brief and acute pain, in certain people; but note, the long-term effects of smoking outweigh such benefits.)

So, while cutting out smoking may improve your physical ability to cope with pain, for some people this behavior change may lessen their psychological/emotional ability to manage the anxiety and distress caused by pain. From another perspective, consider that cutting out smoking will improve your ability to exercise for longer periods (a positive coping skill for pain patients), but many smokers begin to eat and gain weight after quitting smoking, and increased weight inhibits exercise (and can worsen pain). And these are just a few possible scenarios…

Now, I’m not intending to dissuade you from making change, losing bad habits, and so on. However, if you get rid of a coping mechanism, you need to have another to put in its place. Behavior change, positive or negative, has consequences. Behavior is like a pyramid of soup cans or a stack of blocks (like Jenga). Remove a behavior from your repertoire (e.g., smoking) and, without a replacement behavior (or can or block) the whole stack can crumble. Take smoking out of your routine and you will likely see many benefits, but you may also have removed your main coping mechanism – and you may fall apart without a new means of coping. While pain can lead to anxiety, increased emotional distress can also worsen your pain.

So what can you do instead of smoking to reduce pain-related anxiety and life stress? Try deep breathing and meditation. Consider prescription medications (e.g., Xanax) in moderation. Explore the benefits of psychotherapy, spiritual counseling, or venting to peers as a means of relieving distress. Take up a new hobby to fill the idle time when you would “take a smoke break” to distract you from negative thoughts.

Happy holidays, and may you have a good start to the new year!

PS – I endorse the benefits of stopping smoking. This article is actually meant to aid you in your pursuit of removing nicotine from your life. It has been found that people have difficulty staying smoke-free if the costs outweigh the benefits. However, if you can foresee the negative effects of stopping smoking and plan for them, maintaining your positive behavior change is easier. Plan for the worst, hope for the best is my motto.

Looking Outside of the Box

2009-11-05T13:58:00.000-08:00

Recent news reports have noted the benefits of Tai Chi for arthritis knee pain as well as the mental and physical health benefits of yoga. What is noteworthy about these studies is the message that there are benefits to looking outside the box – outside of Western medicine or what Americans typically think of when considering healthcare. So often we want pills, or at least quick fixes that require little effort or change on our part.

If you’ve been following this blog, it should be no surprise that treatments such as yoga and Tai Chi appeal to me – I champion the idea that patients feel better about results that they bring upon themselves. I use variations of many Eastern medicine techniques in my practice (e.g., mindfulness) and have referred many for Reiki therapy, Tai Chi, acupuncture, and so on. (I actually hope to have an article written by a local Traditional Chinese Medicine provider to post to this site – outlining the utility of herbal remedies, acupuncture, and the like.)

Let me state for the record that my philosophy on pain management is this: if it doesn’t hurt you physically, financially, or emotionally, why not give it a shot? Pain is a multifaceted and individualistic experience, and I so rarely see patients find total pain relief via one treatment avenue (e.g., just medicine alone). So, as long as you are not shelling out money on obvious scams or picking up new and dangerous habits, then the more diverse the treatments, the better (most times). Almost any major publication addressing pain treatment will note the need multidisciplinary care – including physicians, pharmacists, psychologists, physical therapists, and more. I often include spiritual guides and psychiatrists in this mix, and also practitioners of Eastern medicine or movement therapy (e.g., Tai Chi, yoga, etc). Just remember to tell all of your providers about one another - if your psychiatrist doesn't know what herbal treatments you are using, dangerous drug interactions can result.

Another important factor to remember, regardless of the treatment avenue taken, is that pain is largely a function of perception – meaning, the physical injury is a fact, but the pain experienced is affected by your mood, your level of activity, your degree of attention to the pain, and so on. So it should be clear that your interpretation of events plays a big role. Add to that the idea of placebo effects – that our minds can cause physical or psychological changes beyond what the physical medicine can account for – and you have to factor in a person’s belief in the treatment they are receiving. Whether Western or Eastern, spiritual or physical, treatments work better when patients think they will work, or at least have faith in the provider that s/he has confidence that the treatment will be effective.

Note that, religious views aside, I use the word faith in the prior paragraph intentionally. While I have blogged earlier about the pros and cons of scientifically validated treatments, the bottom line is that proof of effectiveness is always desirable. However, that proof may not be gotten in a lab or through rigorous testing – it needs to be proof that you improve with treatment. Whether it was prayer, herbs, opiates, psychotherapy, or physical therapy that lessened your pain isn’t the issue – so long as you get better. So reaching outside of your comfort zone (within reason) is worth some consideration. The key is to know when to have faith, and when to accept that your faith was unfounded and move on to another treatment avenue. I try to be up front and honest with patients in saying that I want to help, I know ways to help, but if what I provide isn’t effective, I need to know so we can try a different approach or I can refer you elsewhere. You shouldn’t be afraid of saying the following to any professional treating you – “Sorry, but I tried the BLANK you suggested and I don’t feel any better. Can we try something else?”

The take home message here should be this – don’t be afraid of seeking pain remedies outside of mainstream Western medicine, or exploring treatments/activities such as Tai Chi. I hate to think that the answer to your pain problem is out there and you wouldn’t take advantage of it because it seems “weird” or outside of the norm. Consider this - talk therapy seems fringe to some people, even though the idea of confession or seeking advice is quite common in all parts of the world. Like your pain, treatment is all a matter of perception – what is tolerable to one person may be too much for another to handle. However, if there is a chance you’ll see even a slight improvement in your well-being, I say have a little faith, keep an open mind, and look outside of the box.

One Size Does Not Fit All

2009-10-06T09:45:00.000-07:00

When considering treatments (both psychological and medical), we must remember that people vary, and so the treatment of choice (in general) may not be the treatment of choice (for you). While this is less often the case in the medical arena, where bodies are more consistent (as compared to minds and personalities), there are variations even between people in terms of how one's body may reject or react to a certain treatment. (Anyone who watches the television show "House" has a front-row seat to this exception proves the rule type of issue.)

I mention this issue of "fit" when it comes to treatments after reading a recent study which examined the benefits of expressive writing (a generally well-proven treatment) among military veterans. Adler and colleagues found that, despite the benefits of this writing style for civilians, among a veteran population it actually hurt more than helped. The take away point from this is that: a) science and research are important to confirm our ideas, but also that b) just because a treatment works with one group of people doesn't mean it will work for all people.

Similarly, a recent Newsweek article blasts psychologists for not adhering to "proven" treatments, instead favoring personal preference and opinion as guidelines for treatment. Now, you should certainly question your doctor if s/he asks you to engage in any treatment you feel is too fringe or odd. That being said, what the Newsweek article fails to address is the theme of this post - that there is an art that is involved in the application of science, and psychology (and pain management) falls into that category more than many other medical pursuits. There is a "fit" that is necessary for treatments to work, and despite the mounds of evidence that certain treatments should work, that doesn't mean they always will work. There are always exceptions to the rule - often in psychology, to make for a good study, certain patients are excluded because they don't fit certain criteria. Well, you may not fit the criteria either, so the treatment may have been proven to work on most people, but the people most like you might not have been included in the study. An important point to remember as a patient is that this cuts both ways - you may not be receiving the treatment that helped your friend because your doctor knows that you and your friend have different issues/backgrounds, and you may not fit the patient profile that the treatment was proven to work on.

Now, this doesn't mean that some research supporting your doctor's choices isn't warranted - many good clinicians collect their own internal data, monitor trends, and keep up on the latest research to be sure that the art doesn't stray too far from the science. With this post I am not promoting bizarre treatments for the sake of being different - clinicians should almost always start with the standard treatment and move to other ideas only if the standard treatment fails. However, there is a finesse that cannot be learned in school, books, or research articles. In psychology especially, we as a profession are easy targets for comedians, with people saying how "anyone can do what you do." And while it may look that way, a good clinician (though not all clinicians), will be considering the science, the person, the artistic application of the science, and the timing all before saying "tell me how that makes you feel."

I have found myself in some weeks proposing the same solutions and coping mechanisms to multiple patients - and I admit that as a sign of failure. Even if all their symptoms and issues matched up, they are different people who should receive tailored treatments, not cookie cutter application of the same speech from the same psychologist. And pain patients know this better than most - you compare with fellow patients and determine that Dr X always gives her patients Vicodin first, or that Dr Y tells all his patients that better stress management is the key to coping with pain. This doesn't mean Doctor X or Y are wrong - but it makes you wonder if you are getting the right treatment for you.

So question your doctors, ask what else then can do for you, tell them when treatments have side effects or feel like they aren't working. Don't play doctor or quote the Internet as your legitimate source - trust that medical and graduate school have taught us something - but remember you are the expert on you, and we need to fit the treatment to the patient, not the other way around.

More Opportunity for Action!

2009-09-16T12:37:00.001-07:00

September is Pain Awareness Month and with that declaration the American Pain Foundation (APF) encourages patients and caregivers to speak out about their needs and concerns. In conjunction with the APF theme of "Conquering Pain Together" are local events and activities, information on how to be vocal on this issue, and even some useful information for military veterans - see the APF website here.

>>If you haven't noticed by now, the theme of most of the posts on this blog is one of empowerment, action, and independence. In my clinical experience, patients who find strength, resolve, and determination in themselves (in whatever fashion) are the ones who overcome/tolerate pain best. Such personal initiative and sense of ability to effect change is also excellent at combating the depressive symptoms that often accompany chronic pain.<<

So get educated, get active, get loud and make sure your government, community, support network and medical team are helping you fight your fight!

Let Your Voice Be Heard

2009-08-25T13:13:00.000-07:00

Click this link to learn more about Naomi Judd’s commitment to support “Partners Against Pain® - a resource that serves patients, caregivers, and healthcare professionals to help alleviate unnecessary suffering by advancing standards of pain care through education and advocacy.” (quoted text from partnersagainstpain.com) This website is a nice source of general information, including some coping tools for patients and those in their lives. What I find interesting, though, is their pain advocacy page, which educates patients about avenues to speak up for themselves and their needs.

In my experience with pain patients (and their caregivers), feelings of helplessness and worthlessness are both common and debilitating. Empowerment, in all forms, is vital in learning to live with chronic pain. Now empowerment and independence come in many forms, from managing normal daily activities on your own to writing to Congress to ensure that your healthcare needs are met. This latter approach, while “bigger” in some ways, may actually be easier and more fruitful (practically and psychologically)…and certainly worth a try. This process can lead to greater understanding of your own pain condition, a better means of speaking to others about your needs (including your pain physician), and a new sense of usefulness and meaning in the world.

Let your voices be heard!

10 Ways To Reduce Pain Without Pills

2009-08-12T14:51:00.000-07:00

Practice deep breathing (emphasizing slow and steady breaths deep into your stomach and diaphragm)
Seek out distraction (such as engaging in hobbies or spending time with friends)
Allow time for emotional venting (either talking to a professional, loved one, spiritual leader, or even to yourself in a diary)
Reduce your stress (studies show that greater psychological stress leads to greater pain; consider reducing your commitments, asking for help, or improving your time management)
Find meaning in the pain (many patients find that understanding the “why” makes pain more tolerable – your meaning may involve spiritual growth, improved communication of your needs, a closer connection to others socially, etc.)
Discover your happy place (this sounds like a bad therapy joke, but the use of imagery - a type of daydream or fantasy - can allow you to take a mental vacation from your pain momentarily)
Plan for the pain (if you know the rhythms of your body or the activities/events that trigger your pain, you can use this knowledge to structure your life in a way that avoids unnecessary pain flare-ups; in some cases, you might start this by monitoring your pain and behavior patterns, as discussed in a prior post)
Engage in mindfulness (this is an Eastern practice that involves increasing your awareness of all of your senses – so, yes, you notice the pain more, but you also notice the pleasant or distracting sounds, sights, smells, and sensations that you may have missed because the pain seemed so “loud”)
Plan activities (many pain patients have nothing to look forward to but more pain, but if you can anticipate a trip to the mall, a dinner with friends, an upcoming trip, etc, you can look past the pain to the next thing on your schedule – many people without pain do this to get through the work week!)
Argue with yourself (sounds odd, right? – but, instead of just saying “I can’t do this,” say also “yes, but you can do that”; don’t say “I am worthless,” but say “I may be limited physically and out of work, but I am still a mother, spouse, friend, whatever” – this is a means of avoiding only focusing on one [negative] side of things)

An Already Proven Treatment, Now With Research Support

2009-07-15T12:47:00.000-07:00

This will not be news to most pain patients, but interesting to see it verified scientifically: Click Here

Also, check out this interesting bit of research (chocolate is the cure all, it seems): Click Here

You Can Take Control of Your Pain!

2009-07-08T14:18:00.000-07:00

Why is pain a psychological issue? Well, let me clarify that – why is pain a behavioral medicine issue? (And what the heck is behavioral medicine??)

Behavioral medicine is a subset of psychology and other medical disciplines that addresses the impact of behavior (and thoughts) on physical health. And, yes, pain is a behavioral issue.

Consider this – regardless of the type of pain a person suffers from, physical activity will (almost without exception) worsen that pain. Now, sometimes light exercise can be beneficial, as can physical therapy (the exceptions). However, all too often I see patients who have “good days and bad days” – and on the good days they overexert themselves, and that leads to the bad days, when they are sore, achy, fatigued, irritable, and so on.
The good news in this is that pain patients can influence their pain, and avoid flare ups, by increasing awareness of what activities or behaviors worsen their pain (in the moment or in the next day “hangover effect”).

So, how do you do this? For instance, keep a journal or diary – a brief record for a week or two of daily activities, medication use, and pain scores (e.g., Monday – took oxycodone in morning, walked through the grocery for one hour, argued with spouse). This will allow the person in pain (and his/her caregivers) to monitor the cause and effect process, and pinpoint patterns of behavior that consistently help/hurt when it comes to pain. This record keeping can be important because most people don’t remember what they had for breakfast yesterday, let alone what they did 48 hours ago to lead to pain today. This delay is what I call the “hangover effect” – that gap between the behavior that seemed like a good idea at the time, and the negative symptoms one experiences in the moment – and because of this gap, we don’t always put two and two together. However, the things you did (your behavior) in the past affects how you feel in the present – without recognizing this, you are left confused or fearful of where the pain is coming from, left wondering why it’s getting worse? (Consider the idea of a hangover from alcohol here – if you wake up feeling awful and don’t know why, the thought most of us have is some sort of illness; but, if you remember drinking a lot of booze the day before, now that changes the diagnosis, and that information changes the treatment.)

Now, behavior doesn’t just mean “the stuff I did yesterday,” like going to the doctor or doing the laundry. Other behavioral factors to be aware of include: medication use (to be discussed in future posts), sleep habits, diet, substance use (including tobacco and alcohol), social/occupational stressors, and so on. All of these are factors that patients often have some say in, but that are not always associated with pain management issues. Such behaviors should be included in your record keeping to aid in finding the pattern of behaviors that help/hurt, specific to you.

If I have one goal with this Blog (and in my work with patients), it is empowerment – pain and the psychological symptoms that come along with pain do enough to take away a person’s sense of independence. I aim to give some of that feeling of control of your life back – to give patients more of a say in their lives. The flip side of this, of course, is that recognizing you have control means you have the responsibility to do something about it. I don’t think this is a bad thing, but it is a choice – being a victim or being a survivor. Sometimes, being a survivor takes more energy, and can be more frustrating, because you learn to blame yourself for behavioral decisions that negatively affect your well-being.

For me, though, I’d rather blame myself than feel helpless. So consider this idea of behavioral medicine as a means of learning from professionals how you can re-gain control over your life, and prevent pain flare-ups.

As always, feel free to contact me to set up an appointment to receive further information and treatment similar to what I Blog about here. Though I have a limited number of appointment slots available, I will do my best to accommodate.

Pain and Depression

2009-06-08T12:31:00.000-07:00

Do you suffer from chronic pain? Doesn’t it get frustrating, feeling like you have these new limitations? Do you find that, since the pain started, you don’t feel like yourself? Are you finding yourself more emotional, depressed, even hopeless when you consider your situation.

These are very normal (though unfortunate) results of living with chronic pain. But don’t give up yet…there are treatments you may not have considered. For instance, did you know that a large number of people living with chronic pain develop depressive symptoms? And, these depressive symptoms can make the pain and coping with it that much worse?

It’s true. So, don’t give up hope. Seeking psychotherapy (or psychiatric medication treatment) for your symptoms may actually reduce some of the pain sensations. And in talking about how you are adjusting, coping, and living you might find better ways of functioning. Now, this doesn’t mean that the pain is “all in your head,” just that the way we feel physically can be affected by our mood and emotions. And, this also doesn’t mean that psychotherapy can make your physical pain go away…just that it can ease the pain, help you develop new coping skills, aid you in managing your emotional distress, and show you ways of adjusting to the lifestyle that chronic pain has imposed. When people get married, have kids, retire, or go through over life changes there are expected periods of adjustment…and adjusting to chronic pain is no different. It’s just harder…because you didn’t ask for it, look forward to it, or have an easy way of explaining why the pain has made your life better.

To learn more about techniques to manage pain and its effects on your mood and lifestyle, contact Dr. Giardina at 954-340-0888 to set up an appointment (or refer to http://bhifl.com/).