I invite you to try a new practice each week. To enjoy life more, you can decrease the negative or increase the positive. Unfortunately, for those of us with chronic pain, we sometimes can’t lower that negative experience. So these practices will be designed to increase the positive!

Smile! It’s such a simple thing to do, but it can have profound effects. Your mood can improve, your stress hormones can go down, your outlook can be happier, and you can spread these positive effects to those near you.

Your Invitation: Smile as often as you can, as often as you remember. It can be a little inner smile or a great big grin. You don’t have to feel cheery inside to do this.

This article is in our series Why You Should See a Pain Management Psychiatrist.

What are the newer treatments such as mirror therapy and graded motor imagery for pain. In chronic pain, your brain is changed so that signals stuck in pain-mode. Chronic pain creates actual changes in your brain. As well, when you’re in pain, you often use your body part less, so there are less signals of normal movement registering in your brain. This can create a downward cycle:

Pain,
less use of your body,
fewer normal movement signals competing with pain signals,
more pain,
less use of your body, etc.

How can you break this cycle?

There are newer treatments based on the concept that re-training your brain can decrease pain. These treatments are exciting, and some patients using them have had good success decreasing their pain.

Mirror therapy uses your visual system to “see” normal movement and reassure your brain that it no longer needs to produce pain signals. Graded motor imagery is a step-wise program aimed at breaking up movement into components, allowing your brain to slowly resume normal movement without producing pain.

Mirror therapy has been shown to be helpful in:

• early CRPS
• phantom pain
• stroke
• low back pain

Graded motor imagery has been shown to be helpful in:

• chronic CRPS
• phantom limb pain

Ongoing research is helping us learn more about these exciting treatments and fine-tune our use of them.

This article is in our series Why You Should See a Pain Management Psychiatrist.

For many years, I’ve offered Coping with Pain support groups. These sessions have both skill-building (learning exercises such as relaxation and visualization) and discussions on living with chronic pain (issues such as family issues, staying positive, working towards acceptance). Some patients find them so helpful, they attend more than 1 series.

What are the benefits of these types of groups?

1. Decrease isolation
Many people with pain lose work friends, and can’t do as much with friends and family. Pain can be very isolating. Groups can increase your socialization. Groups can help people realize they aren’t the only ones with significant pain – others in the group really understand your pain. You feel less isolated.

2. Problem-solve with others
Each person in a group knows ways to cope with pain. Sharing these can help others, and group members benefit from things others have learned. There’s less re-inventing the wheel to figure out how to cope with pain.

3. Help others
Patients with pain often do less – at work, at home, hobbies, etc. They become the help-ee rather than the help-er, mostly receiving assistance. Helping others in support groups lets patients have more balance between helping and being helped. Helping others often increases self-esteem.

4. Expand support networks
As we said above, pain can be isolating. Adding new people to your support network can be good for you, to have other people to rely on. As well, this can lessen the load of those already in your support network, who may sometimes feel overburdened from the impact of your chronic illness.

5. Share resources
Living with chronic pain often means living with limitations and challenges – living a new type of life. Sharing resources, information, and tricks and tips is an advantage of a group.

One important challenge of a group is to keep it focused on coping with pain. Groups should not settle into complaining, focusing on pain, or focusing on whose pain is worse.

Welcome to the series Why You Should See a Pain Management Psychiatrist.

Can supportive therapy be helpful to you?  It helps people cope with a difficult situation through listening and support, problem-solving, and instilling hope. How does it help?

1. Telling your story

Chronic pain is often a life-changing situation. Research by Viederman and others has shown that telling your story to someone who listens, cares and responds is important. Exploring how this life-changing situation fits in with your life story is also beneficial. Life Narrative work has been done with patients with cancer and is very positive. Sometimes an outlet in addition to your family and friends is needed, so having a place to talk about and make sense of your experiences is necessary.

2. Ongoing adjustment

Adjusting to chronic pain is not a one-and-done task. It usually requires on-going adjustment, as your condition changes. As well, other things in your life change, and your pain will impact your life differently at different points. For example, when you have little kids, not being able to do some activities with them can be discouraging, and can require creativity to work around. In contrast, when your kids are older, they may require less physical interaction. But then, perhaps, the financial stress of not working may affect your family more. Having a place to work through these issues as they come up is important.

3. Family support

As you know, your pain affects not just you, but your family and friends too. Having your family get support during difficult times is useful, too. In my practice, I often see not just the person with pain, but a spouse or family, too. A good resource for families is: Surviving a Loved One’s Chronic Pain.

Welcome to the series Why You Should See a Pain Management Psychiatrist.

Let’s look at making changes in how you see your pain condition and the disability it causes. Both pain itself and the negative changes it causes in your life are CHALLENGING to cope with. People experience a lot of loss – loss of:

• good health
• being pain-free
• doing enjoyable activities with family and friends
• going to work
• hope or spirituality

Many go through the Stages of Grief, which are:

• Denial – you can’t believe this is happening to you
• Anger – that so many negative changes are occuring
• Bargaining  – you’d do anything to get back your previous life
• Depression – difficulty coping, and mourning the loss of your pain-free life
• Acceptance – coming to terms with pain and the changes it brings

These stages are a process, a working through, and for many, are slow. I believe that to move forward, you often must first recognize and mourn for what you’ve lost.

Let’s look more at acceptance, acceptance of both pain and the changes in your life.

Acceptance is:
1. No longer struggling with pain.
You might say, I don’t like this, but I accept that this is the situation I’m in.

2. A realistic approach to pain.
You might say, I’ll put realistic energy towards getting better, but not put my life on hold waiting for my pain to go to zero.

3. An engagement in positive everyday activities.
You might say, I’ll put my energy towards my life.

Is this worthwhile to work towards? Yes! A pain researcher, McCracken, has shown that- no matter what level of pain intensity – greater acceptance of pain all by itself predicts:

• lower reports of pain
• less pain-related anxiety and avoidance
• less depression and disability
• better work status

How can you move towards acceptance? Again, the process is often slow. What I’ve found to be helpful is:

• Grieve for what you’ve lost
• Mindfulness training = acceptance of what is
• Have a goal of living a full life despite pain

Welcome to the series Why You Should See a Pain Management Psychiatrist.

Let’s look at behavior changes that can help you live better and get better.

Do positive activities

It’s important that you keep up activities when you have chronic pain. A pain management psychiatrist will help you with pacing, which is not doing too much nor too little. A clever idea is using the concept of $1 to help you pace yourself. You’ll also learn how to motivate yourself to regularly do your assigned physical therapy exercises.

Alter old activities or choose new ones

A pain management psychiatrist will work with you to figure out what activities you can do, what you should avoid, and, if you need to, how to replace or alter favorite activities so you can still do them. Let’s say you love gardening, but you can’t do as much as you once did. It’s important not to drop something you really enjoy. So figure out what aspect of gardening you love. If it’s seeing green by your front door, try container gardening instead of doing the whole frontyard. If it’s being outside, garden for 15 minutes instead of 5 hours, then sit in or walk through a garden to enjoy the outdoors. You get the idea – alter what you need to, so you can continue to enjoy your favorites.

These changes in behavior help in several ways:

• you focus on what you can do
• you avoid having pain determine what your life is like
• you focus on living, rather than pain
• your nervous system benefits, too, by having signals from normal activity nudge pain signals over

Welcome to the series Why You Should See a Pain Management Psychiatrist.

What psychological skills you can learn to decrease and cope with pain? There are many types of relaxation exercises you can learn. Breathing, basic relaxation and visualization all help in several ways. They:

• help you relax and decrease anxiety
• decrease the stress response associated with pain
• help you get better sleep
• may indirectly help decrease pain

Here are several from the How to Cope with Pain website:

• breathing exercises
• relaxation exercises

Guided imagery and hypnosis, which use suggestions of decreasing pain paired with imagery, help in the same ways that relaxation exercises do. In addition, these exercises can directly decrease pain through these suggestions.

Here are 2 examples of guided imagery exercises:

• guided imagery exercises

You can learn all of these skills and then practice them regularly on your own. That regular practice is key!

Welcome to the series Why You Should See a Pain Management Psychiatrist.

Let’s look at using psychiatric medication for pain.

Antidepressants are, obviously, best know for treating depression. But there’s more! Antidepressants can be used for chronic pain itself, separately from treating depression. This means they are sometimes prescribed even if someone has no depression – just to treat pain itself. Let’s look at 3 different categories of antidepressants used to treat pain.

1. SNRI (Serotonin-norepinephrine reuptake inhibitors) Dual-action antidepressants, those that work on both the serotonin and norepinephrine systems, help with pain. An example is Cymbalta, which is helpful in both diabetic peripheral neuropathy and fibromyalgia, and Savella, which is approved for fibromyalgia.

2. Tricyclics (TCAs) These are older antidepressants which help in many different pain disorders. In fact, they are the most-studied antidepressants for pain. However, even though they work, they are not FDA-approved to treat pain. Examples include Amitriptyline (Elavil) and Nortriptyline (Pamelor).

3. SSRIs (Selective serotonin reuptake inhibitors) There is some evidence, thought research has been mixed, that SSRIs help with headaches, both migraines and chronic daily headache.

Overall, antidepressants are sometimes helpful in treating pain itself. As we know, pain often exists along with depression and anxiety, so these medications can be a good choice when psychiatric symptoms are present along with pain. Using 1 medication for multiple symptoms is a good idea. An important point to remember is that if your doctor recommends an antidepressant, it doesn’t mean that your pain is “”in your head” or that you’re simply imagining your pain.

Welcome to the series Why You Should See a Pain Management Psychiatrist.

People with pain also develop psychiatric disorders. For example, depression (8-50% of patients with pain), anxiety (19-50%), PTSD (10%), sleep disturbance (50% or more), and drug and alcohol problems (3-19%) are common in patients with pain. Let’s look at some important issues related to treating these problems.

1. Identifying symptoms

To be able to treat psychiatric symptoms, they first have to be identified. Your medical doctor should be asking about these common symptoms and referring you for treatment if appropriate. You should also report if you’re having such symptoms. Don’t be embarrassed or feel like you’re complaining. Getting help is important!

2. Taking symptoms seriously

If you’re having significant depression, anxiety or other symptoms, it’s important to report these to start to get treatment for them. These symptoms should not be dismissed as, Of course you have depression, it’s because of your pain. Chronic pain does not automatically  mean depression, anxiety and disturbed sleep. There’s treatment for these symptoms! And they should be treated!

3. Treat all the disorders that are present

We know that if a psychiatric problem is present along with pain, it’s crucial to treat both. Treating just 1 doesn’t make the other go away. For example, if someone has depression and pain, treating just pain doesn’t necessarily mean the depression will go away. And sometimes neither gets better unless you treat both.

4. Treatment

There are both therapies and medications to treat nearly all psychiatric diseases. Medication should be used only along with therapy. Unless symptoms are severe, I strongly recommend trying therapy first, before medication, to see if just therapy alone can work. There are times, when psychiatric symptoms are severe, that both will be started together, but that’s less common. Most people with pain disorders are already on several medications and have side effects, so trying non-medication treatment first makes sense.

Welcome to the series Why You Should See a Pain Management Psychiatrist.

When I see someone for psychiatric pain management, I initially do a psychiatric evaluation which includes these areas:

1. Prior psychiatric functioning and psychiatric diagnoses

This lets me understand if someone has had difficulty with anxiety, depression, sleep, etc, even before confronting a pain disorder. If so, there’s a higher risk for these symptoms to recur.

2. Current psychiatric symptoms

Unfortunately, psychiatric disorders often accompany pain. Let’s look at some of the data:

• Depression – 8-50% of patients with pain
• Anxiety – 19-50%
• PTSD – 10%
• Sleep disturbance – 50% or more
• Drug and alcohol problems – 3-19%

We know that if multiple disorders are present, it’s crucial to treat them all. For example, if someone has depression and pain, treating just 1 doesn’t necessarily mean the other will go away. And sometimes neither gets better unless you treat both.

3. Psychiatric interactions with medications

Many drugs used for pain cause psychiatric symptoms, including sedation or depression. It’s important for someone on your treatment team to figure out what’s causing what and make recommendations to minimize side effects. Some pain medications cause unusual or serious side effects. For example, medications which are NMDA receptor antagonists such as Dextromethorophan or Ketamine can cause anxiety, hallucinations, or cognitive problems. Most doctors prescribing these require a prior psychiatric evaluation to be sure there aren’t underlying psychiatric disorders which might be worsened by these medications.

4. Treatment of psychiatric disorders

If psychiatric symptoms or disorders are found, treatment is crucial. Having an expert in this area is important. Treatment might include therapy, medication or both. It’s also helpful to know that a good pain management psychiatrist will know how to treat issues related to pain. Your treatment shouldn’t be just talking about how bad things are. It also shouldn’t be treating a medical pain disorder as if it’s psychiatric.