This paper examines the nature of the relationship between chronic pain and depression. Using information gathered from published research studies and books, the link between chronic pain and depression was found to be important, but not directly causal.
Chronic pain has psychological implications which commonly result in depression; at the same
time, depression poses a significant risk factor for chronic pain. The intimate link between the two conditions is discussed at length, and examined through the prism of several theoretical models which the therapist may
employ in designing treatment. These include the somatic model, the Gate Control Model (Philips, 1988) and the psychodynamics model.
The nature of the relationship between chronic pain and depression
has long
been of interest to health care providers and patients. Chronic
pain
sufferers are far more likely than healthy individuals to
experience
depressive symptomology; similarly, patients seeking help for
depression are
more liable to have chronic pain problems than their
non-depressed
counterparts. The two conditions are so commonly associated that
some have
suggested a causative link. Others maintain that certain patients
are at
high risk for both chronic pain and depression, although the two
conditions
present themselves independently of one another. The issue is of
particular
relevance to mental health professionals and pain specialists,
whose
treatment success and methods rest in part on developing a
fuller
understanding of the link between the conditions.
This paper hypothesizes that chronic pain and depression are
intimately
linked phenomena. It seeks to answer several related questions:
How does the
experience of chronic pain contribute to depression? Is the
relationship
direct, or are there intermediate steps separating chronic pain
sensation
and the development of depressive feelings? What psychological
transformations brought about by chronic pain suffering can lead
to
depression? Why are depressed individuals so susceptible to
chronic pain?
The paper also examines several theoretical models for
understanding chronic
pain and its relationship to depression, and reviews possible
treatment
methods.
Pain and Chronic Pain
As a preface to the discussion of the relationship between
depression and
chronic pain, a brief discussion of "pain" itself is useful. The
experience
of pain is a necessary part of life. It is common to all
neurologically
normal individuals, and is fundamentally a protective system. Pain
warns an
organism of potential or actual harm to the body, both internal
and
external. With time, one develops a pattern of experience which
helps one
sense and identify dangerous circumstances. An illustrative
example is the
pain one suffers from burning. It quickly sensitizes one to the
dangers of
touching fire or other hot objects. The sensory experience of beat
can
elicit a reflex-like response, as it is associated with burning.
Similarly,
intense stomach pain may warn of damage or dysfunction in the
digestive
system or other organs. Even in the absence of a clear injury, it
is well
understood that acute pain is indicative of a problem, a danger.
Pain may
warn against the intake of certain foods, or participation in
particular
activities.
But pain is not a simple warning device; it often persists beyond
the "need"
to warn. After providing immediate protection, it can persist for
an
extended period of time, or may even increase in severity as
tissue is
repaired and returns to normal function. The exact nature of
this
"persistent" pain is difficult to define. Is it an extended
warning, a
punishment used to reinforce a lesson and warn of future dangers?
Or is it a
way of forcing the organism to be careful with damaged, vulnerable
tissue?
These questions are particularly confusing when viewed within the
context of
"chronic pain," the focus of this paper.
Pain is typically divided into two broad categories: acute pain
and chronic
pain. Acute pain is "nociceptively driven pain; it is pain for
which there
is a readily available biological explanation. It is associated
with trauma,
illness, or disease... acute pain points the physician in the
direction of
proper diagnosis and treatment" (Grzesiak & Ciccone, 1994, p.
2). In
contrast, "Chronic pain has none of the utility of acute pain.
Chronic pain
continues long after tissue damage should have healed, is
frequently
associated with depression... and frequently must be managed
because it is
not amenable to relief' (Grzesiak 8z Ciccone, 1994, p. 4). Often
no organic
cause can be identified.
These two general forms of pain expression are often difficult
to
distinguish from one another, though their implications are
vastly
different. Acute pain may become chronic with time even as the
body
successfully eliminates the initial source of pain. It is fairly
well
accepted that this shift from acute to chronic, and the
persistence of
chronic pain in general, is influenced by psychological factors.
It also has
numerous psychological implications.
The Biological Link
A number of physicians, particularly in the field of psychiatry,
have
investigated the biological link between chronic pain and
depression.
Research has attempted to identify a basic biological substrate
shared by
the two conditions. This approach was taken by Blumer and
Heilbroun (1982)
in a study that examined biological markers of depression in
chronic pain
patients. They found such biological markers in one-half of the
patient
group, and "noted that antidepressant response was associated with
the
presence of these biological markers" (as cited in Bellissimo
& Tunks, 1984,
p. 6). Other work as well has contributed to the body of
circumstantial
evidence suggesting a biological factor linking depression and
chronic pain.
"Abnormalities in the amount and action of certain central nervous
system
biogenic amines (e.g., serotonin and norepinephrine) have been
repeatedly
documented in affective disorders and are also implicated in the
modulation
of pain perception" (Herr & Mobily, 1992, p. 9). Of course,
the association
of common biological markers is not solid evidence of a
causative
relationship between those substrates and either condition. But it
does
provide a basis for further research.
Another biological link between chronic pain and depression may
develop as a
result of drug treatments for pain. Narcotic analgesics like
codeine, for
example, can directly decrease the intensity of pain. However,
such drugs do
have common side-effects, including central nervous system
depression. The
drugs "act on the brain to decrease sensation, thus causing
drowsiness and
lethargy" (Philips & Rachman, 1996, p. 29). In the case of
chronic pain
patients, tolerance of the drugs may develop over time, resulting
in a need
for increasingly larger doses, with potentially stronger
side-effects. Of
course, the dependence on narcotic analgesics is itself a cause
for concern,
for it can lead to depression or other withdrawal related symptoms
(Philips
& Rachman, 1996).
The link between chronic pain and depression is so intimate that
some
researchers argue chronic pain syndrome is really a form of
depression. But
while chronic pain syndrome may indeed be a potential
manifestation of
depression, or may share with it similar neurochemical mechanisms,
the
relationship between the two conditions extends far beyond the
scope of
simple biology. A host of psychological variables influence
the
relationship.
The Psychological Implications of Chronic Pain
The vast majority of research indicates that the relationship
between
chronic pain and depression is important, yet indirect. Chronic
pain
contributes to a depressive affect in some individuals by changing
routines
of behavior, self-perception, and interaction with others.
"Normal" life is
disrupted by the experience of constant or frequent pain, and
gradually an
individual's function is impaired. Often, frustrating feelings of
impotence,
helplessness, and alienation develop as daily activity decreases,
and life
becomes unmanageable. It is these factors which ultimately
contribute to
depressive feelings, and can even result in long-term depression.
Thus, the
relationship between chronic pain and depression appears to
involve an
intermediate stage: chronic pain affects physical function,
self-perception,
and interaction with others, which in turn can lead to depressive
symptoms.
In this section I will identify a number of the psychological
reactions one
may experience as a result of chronic pain. The effects of chronic
pain may
be viewed in three broad contexts:
1. Chronic pain as it affects physical function, routine activity,
and
functional independence.
2. The impact of chronic pain and reduced activity on
self-perception.
3. The social/interpersonal implications of chronic pain in
redefining
relationships and interaction with others.
The physical, tangible implications of chronic pain are varied in
form and
severity, but they do often share a common denominator:
impairment. Lower
back pain, joint pain, and persistent chest pain all limit an
individual's
ability to go on with life as in the past. Chronic pain keeps one
from
pursuing the activities that give to life its meaning. Everyday
experience
becomes a struggle to continue functioning despite the
debilitating effects
of pain. When walking, stretching, or simply getting out of bed is
a
challenge, and such basic needs as using a restroom or making food
are
burdens, life itself is burdensome.
Patients often find that efforts to distract their attention by
engaging in
activities which once gave them pleasure-such as athletics,
hobbies, or
entertainment outside the home-actually enhance pain sensation.
Disuse and
inactivity weaken the body and make it difficult to resume normal
activity
even after the repair of damaged tissue or muscle groups. Over
time, chronic
pain (real or perceived) can lead to severe physical limitations
as a direct
result of inactivity. It has been estimated that a muscle loses
one-third of
its size and power after only one week of total immobility, and
that 30%
demineralization of the bone occurs after only two weeks of bed
rest.
(Philips, 1988) Thus disuse compounds functional impairment over
time, a
particularly relevant concern in the case of inactive long-term
chronic pain
sufferers. With potential "distraction" activities increasingly
limited by
physical inactivity, feelings of depression build and expand.
The difficulties of managing chronic pain often bring an
individual to a
state of dependence on others to fulfill basic needs. This loss
of
independence has grave psychological consequences" The frustration
of
needing others to perform routine household chores and errands is
compounded
over time. A sense of helplessness and desperation develops. This
is
especially common when the physical cause of the pain is elusive.
Chronic
pain sufferers are left to continually wonder when and if the pain
will ever
subside.
Self-perception is framed by the dependence and disability brought
about by
chronic pain. Loss of independence and mobility often lead to
feelings of
impotence. Those who suffer debilitating pain over time may find
that they
contribute less to their families and at work, which lessens their
sense of
self-worth. A parent may find him/herself unable to change a
baby's diaper
or participate in any physical aspect of a young child's rearing.
Cooking
dinner for a spouse, washing dishes, or ironing clothing can
become
impossible tasks, which require others' help. Those working in
physical
labor may find themselves unemployed, or unable to attend to their
duties in
a competent manner. Individuals commonly feel "useless",
"irrelevant", or
simply "burdensome". It is no surprise that depression often
follows. Over
time, psychological barriers to function may emerge, even in the
absence of
physical limitation. Sufferers develop a perception of themselves
as
"helpless" and unable to perform basic tasks. As they focus on
their pain,
they reinforce these feelings, which, however real or imagined,
begin to
define the range of patient function. Even after tissue has
healed, and the
patient can slowly resume a pre-injury routine, chronic pain may
reinforce
purely psychological limitations to physical activity.
In their 1992 study of pain, activity restriction and depression
in elderly
adults, Williamson and Schulz draw a clear connection between
functional
disability and depression. In their words,"functional disability
means loss
of independence, control, and rewarding pastimes...it may be the
relatively
early signs of loss of mobility and independence that contribute
to the
association between pain and depression...pain is a constant
reminder that
their lives are constrained by physical limitations" (p. 37 1).
The large
number of participants studied-288-lends credence to the
author's
association of pain, activity restriction, and depression. But
one
limitation must be noted: the age of the patients. The mean age of
the
participants was 72.0 years, and all participants were at least 55
years of
age. Even absent chronic pain symptoms, members of this age group
would
likely find their levels of activity decreasing as they advance in
age. In
any event they would probably find themselves increasingly
physically
limited.
A more recent study by Herr, Mobily and Smith (1993) addresses
these
limitations and other potential skepticism about the diversity of
the
patient group studied by Williamson and Schulz. Herr et al.
examined 128
participants of various ages and found, "When combining both the
elderly and
the nonelderly in dysphoric and nondepressed groups, tests of
significant
associations between age, education, gender and marital status
were all
insignificant..."(p. 110). The figures reported by this study
were
relatively high compared with other studies: ". ..the prevalence
of
significant levels of depressed mood among chronic pain patients
was present
in 58% of the elderly and 66% of the non-elderly of our sample"
(p. 110).
This perhaps may be attributed to the fact that the participants
studied all
had sought intervention through a specialty pain clinic, and, as
the authors
concede, "patients referred to pain clinics often have a long
history of
pain and are more likely to have significant problems with
depression" (p.
112).
Goldberg, Kerns and Rosenberg (1993) further support the
connection between
physical impairment and depression. The study of 105 married males
measured
how much patients engaged in each of 18 activities, including (1)
Activities
away from home, (2) Social activities, (3) Outdoor work, and (4)
Household
chores. It was found that "patients reporting relatively low
levels of
instrumental activity or a relatively high degree of perceived
interference
of pain in their lives also reported a relatively high degree of
depression"
(p. 38). As in the Herr et al. study, age was not a good predictor
of
depressive symptoms.
Chronic pain can also affect interpersonal relationships by
redefining
social interaction. As chronic pain becomes a central focus of
an
individual's experience, it often comes to dominate the
individual's
relations with others. The sufferer will often focus attention on
his/her
problem in an attempt to get reassurance. This is particularly
common when
the patient has limited interaction with others. Similarly, family
and
friends tend to feel an obligation to provide assurance and
support, even if
the patient does not need or want it. With time, "mutual"
relationships may
develop into "dependency" relationships, wherein the pain sufferer
becomes
dependant (and expectant) of constant encouragement. In the
absence of that
support, feelings of helplessness and abandonment commonly
manifest
themselves in depressed affect and anxiety regarding one's place
in the
family or community.
Research shows that in some cases social support serves as a
buffer against
pain related depression, particularly in patients experiencing low
levels of
activity. Goldberg et al. (1993) summarize that, "it appears from
these data
that spousal support for pain may exert a positive buffering
influence in
the face of a vulnerability to depression among chronic pain
patients..."
(p. 38). The role of spouses is particularly important, for
spouses tend to
provide a durable framework of support not found in other, less
committed
relationships. Living in the same home, a spouse is in a position
to give
constant reassurance, while friends and extended family likely
have less
contact with the patient.
Despite the positive influence of social support, the redefinition
of
relationships within the context of chronic pain can become a
source of
insecurity and concern to the pain sufferer. Friends and family
may become
alienated by a real or perceived need to continually give
reassurance. This
is particularly the case if the pain persists over a long period
of time,
and if no clear cause is identified. The nature of the
relationship itself
may change as well. Friendships based on common experience or
mutual hobbies
will likely suffer if pain limits activity and range of
function.
Relationships at work may suffer if one's workload is shifted to
others, or
as the result of frequent absence. To the chronic pain sufferer,
already
preoccupied with pain management, these adverse effects on
social
interaction can be another impetus for depressive symptomology.
They
contribute to feelings of isolation, rejection, and
loneliness.
Mood and Susceptibility to Chronic Pain
It is widely accepted today that pain, and chronic pain in
particular, is
influenced by non-physical factors, like depression, anxiety,
past
experiences, and a variety of psychological elements. Mood in
particular is
a powerful influence on pain perception. Anxiety and depression
are both
recognized as increasing pain perception, especially in chronic
cases. It
follows that diminishing anxiety and depressive thoughts may help
ameliorate
pain experience.
Sternbach (1986) cites two studies demonstrating the high
incidence of pain
in psychiatric patients. One reported that 61% of patients in a
psychiatric
outpatient clinic had pain; another indicated that 65.5% of
psychiatric
outpatients admitted to pain during psychiatric observation. This
does not
necessarily indicate causation, but there are a number of models
which do
explain the connection between depression, anxiety and chronic
pain.
According to Merskey (as cited in Sternbach, 1986), "There is
recurring
evidence that some pain appears with depression and goes away with
it, the
depression being a psychiatric illness, which responds to
psychiatric
treatment. In such cases it is customary and reasonable to regard
the
depression as being the cause of the pain" (p. 109). Merskey
discusses four
mechanisms to explain this relationship: The most straightforward
suggests
that anxiety and depression give rise to muscle tension, which in
turn leads
to tension pain in some form. There is strong evidence to support
this
hypothesis. A second possible mechanism is that delusional ideas
related to
severe depression cause hallucinatory pain. Third, pain found
with
depression may possibly develop as a hysterical conversion
symptom. And
fourth, pain and depression may share a common physiological
pathway.
Beyond the notion of depression as a direct cause of chronic
pain-which is a
relatively extreme characterization of the link between the
two
conditions-there is evidence that depression poses a risk of
susceptibility
to chronic pain. "When someone is depressed, the ability to battle
a pain
problem reduces, and their tolerance of the experience of pain is
much
lower. The pain will feel worse...it is hard for the person to
differentiate
the feelings of pain from the psychological feelings of defeat
and
unhappiness." (Philips & Rachman, 1996, p. 50) This
predisposition or
susceptibility is suggested by a wide range of researchers,
physicians, and
mental health specialists. Pain and depression interact in a
vicious cycle
of reinforcement, where chronic pain leads to depression, which in
turn
exacerbates pain experience. Depression or anxiety thus pose risk
factors
for chronic pain suffering and heightened sensitivity to pain.
The issue of susceptibility is better understood in the light of
several
theoretical explanations of the link between chronic pain and
mood
disorders, especially depression. The somatic model, the Gate
Control Model,
and the psychodynamic model are all helpful analytical tools in
this regard.
Somatization
The somatic model provides an alternative framework for
understanding
chronic pain and the psychological symptoms with which it is
often
accompanied. Somatization can be described as the following:
. ..the presentation of physical symptoms, most frequently pain,
for which
there is: (A) no readily apparent cause and no physical diagnosis
can be
discerned; (B) symptom complaint that is not commensurate with
physical
pathology, if present; (C) denial of psychological illness;
and/or(D)
psychological distress accompanying the physical complaints that
is apparent
as some measurable form of anxiety or depression (Grzesiak &
Ciccone, 1994,
p.28).
In short, somatizers experience physical symptoms which are not
consistent
with physical findings.
Within the context of this work, the most relevant manifestation
of
somatization is the condition as a "psychological defense". This
involves
experiencing chronic pain instead of depression or anxiety. Though
the
patient "masks" depression or other psychological problems behind
chronic
pain, the pain sensation may seem absolutely real to the sufferer.
It should
be noted that the process of somatization discussed here is
different in its
extent and intensity from Somatization Disorder, the much rarer
psychiatric
condition described in the DSM-IV, which is "a pattern of
recurring
multiple, clinically significant somatic complaints" (American
Psychiatric
Association, 1994, p. 446).
Treating somatizers requires addressing emotional and
psychological factors
in order to reduce the manifestation of physical symptoms. In
addition to
improving the patient's mental health and eliminating pain, the
objectives
of such treatment include preventing "unnecessary diagnostic,
invasive or
pharmacological medical interventions" (p. 46), which can foster
further
reporting of symptoms and ultimately increase the intensity of
chronic pain.
It is the caretaker's job to modify the patient's explanatory
model of his
pain experience, and to decrease behaviors which encourage
somatic
preoccupation and promote the "patient role", both of which
increase the
likelihood of depression (Grzesiak & Ciccone, 1994- see
discussion above).
Dworkin, Wilson, and Massoth note a number of cognitive
behavioral
interventions aimed at decreasing the patient's somatic
symptomology. They
involve: (1) decreasing anxiety about symptoms and their effects
by
educating the patient and providing an alternate explanatory
model; (2)
shifting the patient's attribution of illness; and (3) modifying
behavior by
facilitating a return to normal activity and social interaction.
It is also
recommended to involve somatizers as active participants in their
health
care (Grzesiak & Ciccone, 1994).
While all chronic pain patients are not somatizers, as many as 50%
of
patients with depression and anxiety have somatic complaints as
well
(Grzesiak & Ciccone, 1994). This suggests the importance of
understanding
and considering somatization as a factor in the association of
chronic pain
and depression. Particularly when no pathological explanation is
available,
somatization may indicate the presence of depressive symptomology
or
anxiety, masked behind perceived physical sensation.
The Gate Control Model and Self-Management Approach
In The Psychological Management of Chronic Pain-A Treatment
Manual, Philips
(1988) develops a treatment "plan" or "approach" to assist in
"the
management of pain problems that persist after tissue has healed"
(p. 5).
Philips' program of treatment is derived largely from "The Gate
Control
Model" of pain formulated by Melzack and Wall (1982). The Gate
Control Model
"acknowledges chronic pain as a complex phenomenon entailing not
just
aversive sensory and affective experience, but also behavioral
changes and
adjustments in motivation, in mood, and in cognitions. Thus, the
importance
of psychological factors in mediating pain experience, in
exacerbating pain
problems, and in influencing pain behavior is highlighted"
(Philips, 1988,
p. 5). These psychological factors, discussed at length above, are
the
target of Philips' "self-management approach."
The self-management approach endeavors to help patients gain
control over
their chronic pain using "an entirely psychologically directed
perspective"
(p. 6) which is introduced over a series of training sessions.
According to
Philips, the results of this psychological approach-to a
problem
traditionally within the realm of physical medicine-are at least
as positive
as those achieved by programs which make use of other
professionals in the
treatment regime. Philips notes that "The crucial emphasis of this
method is
the importance it places on the patient's participation in
learning
management techniques that will help him or her control and,
therefore,
minimize pain...Patients are persuaded to become the active
directors of
their own improvement, rather than the passive recipients of
medical
treatments...A sense of control develops, and remarkable shifts in
attitude
often occur" (Philips, 1988, p. 6).
Philips' treatment program, which is designed to take at least
three months,
appears to be an effective framework for targeting the
psychological
symptoms of chronic pain that can lead to feelings of depression.
Several of
her strategies are particularly appropriate for the chronic pain
patient who
demonstrates no physical pathogen, yet whose pain endures. The
nine
strategies she describes are: relaxation, increased
activity/fitness,
independence from drugs, diffusing/reducing emotional over
reactivity,
external focusing (distraction), assertion, reappraisal of pain,
activity
pacing/nonavoidance, and cue-controlled relaxation (Philips,
1988).
Relaxation is an effective tool in controlling chronic pain
sensation and
breaking the vicious cycle which links pain, muscular tension,
anxiety, and
ultimately depression. Philips writes, "The most common reactions
to
continuing pain are increasing muscle tension, guarding and
disuse, anxiety,
anger, depression..." (p. 53). She suggests closing the "gate" of
pain
through a relaxation regime which integrates deep diaphragmatic
breathing
and progressive relaxation of muscle groups. The intention is to
stop or
reduce the pain and at the same time restore a sense of control to
the
individual. With practice, the patient is taught to break habitual
responses
to pain-including frustration, anxiety and ensuing depressive
feelings-by
cue-controlled relaxation (Philips, 1988).
Increasing physical activity is also an important strategy in
combating the
negative psychological symptoms of chronic pain, such as feelings
of
dependence, impotence, helplessness, and a lack of control. As
noted above,
these emotional reactions can lead to depression as they change
perceptions
of self and the nature of interaction with others. Physical
activity may
help to restore confidence and one's sense of independence.
Furthermore,
exercise appears to be critical to the body's production of
endorphin, which
is manufactured in the brain and "acts to block the transmission
of
electrical signals between the nerve cells carrying pain messages.
It
appears that when endorphin levels are high, pain experience is
reduced" (p.
74). Athletes have been found to have high levels of endorphin,
while
chronic pain sufferers typically have low levels of endorphin.
Physical
activity may thus play a significant role in breaking the cycle of
chronic
pain-induced depression by diminishing the pain (Philips,
1988).
The potential psychological side-effects of pain control
medications-mood
disturbances and central nervous system depression, for
example-indicate the
desirability of limiting their use, particularly in the case of
chronic pain
patients who may use such analgesics over long periods of time. A
graded
program of drug reduction and elimination may prove helpful to
chronic pain
sufferers who experience depression and other psychological
disorders.
Philips observes that "emotional reactions to pain itself can
contribute to
an individual's intolerance of pain" (p. 99). In response, she
suggests a
strategy of diffusing or reducing emotional reactions such as
anxiety,
anger, or tension. This involves self-monitoring by the patient to
identify
changes in mood. Relaxation techniques and pacing activities are
then
employed to restore a sense of control and calm, thereby
minimizing tension
and subsequent pain, or the onset of depressive feelings (Philips,
1988).
Among the most useful cognitive techniques outlined by Philips is
"external
focusing" or distraction. Chronic pain sufferers tend to focus
increasingly
on their pain sensations as they persist over time. Not only does
this
preoccupation serve to increase the pain sensation, it has
potential
psychological/behavioral effects as well. Philips writes, "Talking
and
complaining of pain may become an indirect way of controlling
others and
fulfilling needs. Seen in this way, complaining to friends and
relations may
in fact be an unassertive method of achieving other goals" (p.
105). Philips
suggests that the therapist discuss with the patient ( 1) the
effect that
focusing on pain may have on perceived pain level (2) the effect
on
interaction with others, and (3) how focusing on pain may serve to
fulfill
an individual's need for attention, reassurance or sympathy. Such
attention
focus is pivotal in redefining dependency relationships and
patient
self-understanding (see discussion above). To combat this,
Philips
introduces a cognitive technique designed to shift the focus from
pain to
events outside the individual. Patients are first asked to relax
and focus
exclusively on their pain for 30 seconds. They are then asked to
shift and
focus exclusively on their external environment-sounds, sights,
images,
colors, and so on. It is expected that the patient will experience
different
pain levels during the two focus episodes, and will understand
the
importance of external focusing in limiting pain sensation. The
patient can
later utilize this method of pain control to attenuate pain at its
onset, or
to achieve a short period of relief from chronic discomfort.
Refocusing
attention may also be used as a method for escaping the cycle of
depressive
thinking associated with chronic physical pain. This relatively
simple
cognitive tool can be very beneficial in both the psychological
and
physiological realms (Philips, 1988).
Philips' integrated approach to pain management is a cognitive
program aimed
at closing the "Gate" of pain experience by conditioning the
patient to
reevaluate and transform pain sensation, while engaging in
pleasurable
activities and exercise to attenuate the negative psychological
and physical
effects of long-term suffering. Her approach is particularly
suited to
patients who are able and motivated to selfmonitor their
condition. They are
encouraged to develop exercise routines and set goals for
themselves in
learning how to deal with chronic pain, rather than allowing that
pain to
run its destructive course through their lives.
Psychodynamic and Chronic Pain
The psychodynamic model of chronic pain takes into account
pain's
interaction with the total personality. It suggests that pain
experience is
associated with the gratification or frustration of an
individual's innate
drives, including sexuality, aggression and dependency (Sternbach,
1986).
Pain may become integral to an individual's defensive structure.
Freud
(1924) emphasized that this defensive use of pain serves to
maintain an
individual's psychological equilibrium, and relinquishing the pain
poses a
threat to that equilibrium. Engel (in France & Krishnan, 1988)
postulated
that pain is associated with the experience of guilt resulting
from overt
hostility, and suggested that patients may have excessive guilt
feelings for
which the experience of pain serves as a form of punishment. He
identified a
number of situations in which pain may be unconsciously initiated
in such
patients: (1) lack of external stimuli to satisfy the need to
suffer; (2)
response to a real, fantasized or threatened loss; and (3) guilt
related to
sexual feelings. In these cases, he states, patients turn their
anger
inward, feel great guilt, and appear depressed or pessimistic.
Even if there
is no physical basis for the pain, the patient usually assigns it
a
location. The location is determined according to whether pain has
been
previously experienced, it is identification with pain felt by
others, or it
is pain that the patient wishes another person had (France &
Krishnan,
1988).
Psychodynamic thinking holds that pain is a common "conversion
reaction".
Viewed narrowly, it is seen as a "transformation into physical
symptoms of
repressed sexual drives as a consequence of unresolved Oedipal
conflicts"
(p. 187). The pain may function ". ..as an expression of hostile
dependency
and allow the punishment of parental figures (such as doctors) for
not
gratifying dependency and sexual needs. At the same time, the
attention
derived from doctors...allows covert gratification of sexual
needs..."
(Stembach, 1986, p. 187). Patients in such situations typically
report
anxiety or depression as a consequence of their pain.
Chronic pain may also occur as part of a psychotic depression. In
this case,
the depressed individual who is preoccupied with pain is less
depressed and
less likely to feel guilt. As Pilowsky has noted, "pain can serve
to
neutralize guilt and also (possibly by allowing the discharge of
aggression
through complaint behavior) cause an amelioration of
depression."
(Sternbach, 1986, p, 188).
It is a difficult task to investigate and demonstrate the validity
of the
psychodynamic approach to chronic pain, perhaps because
psychodynamics
indicate a host of subconscious factors which influence pain
perception.
Studies have in the past made use of small sample groups, which do
provide
some support for psychodynamic models. The evidence, however, is
by no means
conclusive.
The Cultural Influence
The impact of culture in defining and relating to pain experience
cannot be
understated. Although most literature attends to cultural factors
only in
passing, they are important nonetheless as determinants of how
patients
perceive and react to their chronic pain condition. Most important
in this
regard is a person's understanding of the "sick role". In poorer
sectors of
society, for example, where individuals are often forced to work
regardless
of their health, chronic pain may be ignored, or consciously
subordinated to
the need to continue functioning. The "sick role" may be rejected.
The case
of so-called "blue collar" workers involved in stressful physical
labor is
illustrative. Farm workers, builders, gardeners, and others
involved in
heavy lifting and uncomfortable bending likely experience back and
joint
pain on a regular basis, but continuing their work despite the
discomfort is
a necessity. As such, the vast psychological implications of
inactivity may
be minimized, the sufferer not seeing him/herself as a
"patient".
Furthermore, in cultures where strong family units dominate, and a
holistic
sense of group responsibility is embraced, chronic pain patients
who are
unable to function normally tend to feel less marginalized than
in
communities which stress the role of the "individual" over the
"group". When
the individual stands fundamentally alone, his/her physical state
has
painful implications for financial stability, self-perception,
and
acceptance by friends and family. In contrast, when the individual
feels
him/ herself part of a cohesive group involving mutual
responsibility and
shared resources, the effects of functional disability-temporary
or
permanent-are less severe. Community support and understanding can
thus help
to counter the destructive psychological processes which may
ultimately
result in depression, or at least reduced self-esteem.
IMPLICATIONS FOR TREATMENT
The challenge of treating chronic pain is complicated by the
inseparable
psychological elements of pain experience. Chronic pain has a wide
impact
not only on a patient's physical function, but also on
self-perception and
relationships with others. This is in part due to the "nature" of
pain. Most
can understand visible pain: a pain which results from readily
apparent
tissue damage or observable physical trauma. But the invisibility
of chronic
pain makes it difficult to explain, nearly impossible for
healthy
individuals to understand, and frustrating to justify in terms of
its effect
on one's life. Patients often report that the most painful
consequence of
long-term chronic pain is the frustration involved in convincing
others of
why it takes such a great toll on their lives. It is really no
surprise that
depressive feelings often develop over time, and that treating
depression is
an integral component of treating chronic pain.
Theoretical models for understanding and modulating chronic pain
experience,
along with its attendant psychological elements, are helpful
analytical
tools. They enable the therapist and health care provider to
examine chronic
pain and depression from different perspectives, and to design
an
appropriate strategy for treating both conditions.
CONCLUSION
The relationship between chronic pain
and depression is more complex than
it may seem upon first examination.
The link between the two conditions
is not directly causal- it involves a
number of intermediate psychological
stages. Chronic pain has
well-documented psychological
implications, which often result in
depressive symptomology; similarly,
depression poses a significant risk
factor for chronic pain. Neither
condition can be considered without
regard for the other, as illustrated
by the arrows in the following
diagram (see Figure 1, page 52). For
example, anxiety as a result of
chronic pain, may cause depression,
and anxiety as a result of
depression, may cause chronic pain.
