The Role of Anxiety in Chronic Pain Management

Posted on Thursday, March the 5th at 12:17pm

By: Dr. Stephen F. Grinstead, LMFT, ACRPS, CAADC-II

It is not uncommon for a person experiencing a pain condition to begin to wonder if the pain will ever go away, or if they’ll ever get better. These types of thoughts lead to anxiety. Although most people believe that their anxiety will subside when the pain goes away, the anxiety frequently leads to a significant increase in pain perception. This results in a vicious cycle of pain, anxiety, more pain, and more anxiety.

In most cases, anxiety about pain is more likely to occur in the acute pain stage while depression prevails in the chronic pain stage. A sub-acute stage occurs after the acute stage but before the chronic stage at about the three- to six-month range. At the acute stage the person in pain generally feels a reasonable sense of hope that the pain will resolve within the near future. In the sub-acute stage and at the beginning of the chronic stage, people’s thoughts and emotions about the pain begin to change.

Anxiety can occur at different intensities, all the way from mild nervousness to full blown panic attacks. Anxiety can be characterized by the following:

• Muscle tension, including shakiness, jitteriness, trembling, muscle aches, fatigue, restlessness, and inability to relax.
• Nervous system hyperactivity, including sweaty palms, heart racing, dry mouth, upset stomach, diarrhea, lump in throat, shortness of breath, etc.
• Apprehensive expectations, including anxiety, worry, fear, anticipation of misfortune.
• Trouble concentrating, including distractibility, insomnia, feelings of edginess or irritability, and impatience.

Excess anxiety and tension can cause someone to experience heightened emotional upset (anxiety, depression, anger, etc.), increased pain, slower healing times, and increased side-effects to medications, among other things. An ongoing stress response causes numerous negative problems such as increasing muscle tension and pain while also decreasing the activity of the immune system and blood flow to the body extremities.

Common chronic pain conditions and diseases that occur with anxiety disorders

According to the Anxiety Disorder Association of America (ADAA), chronic pain disorders are highly prevalent in people with anxiety disorders. The following are among the most common the ADAA reports are listed and briefly described below:

Arthritis — Arthritis is a wide-ranging term that describes a group of more than 100 medical conditions that affect the musculoskeletal system and specifically the joints, which is where two or more bones meet. Arthritis-related joint problems include pain, stiffness, inflammation, and damage to joint cartilage and surrounding structures. Damage can lead to joint weakness, instability, and deformities that may interfere with even the most basic daily tasks. Some forms of arthritis are systemic, meaning they can affect the whole body and can cause damage to virtually any bodily organ or system.

The prevalence of anxiety and mood disorders (such as depression) is higher in individuals with arthritis than in the general population. Some studies have found anxiety disorders are even more strongly associated with arthritis than is depression. A co-occurring anxiety disorder or mood disorder is more often found in arthritis sufferers in younger age groups.

Fibromyalgia — Fibromyalgia is characterized by widespread musculoskeletal aches, pain, and stiffness, soft-tissue tenderness, general fatigue, and sleep problems. The most common areas of pain include the neck, back, shoulders, pelvic girdle, and hands, but any part of the body can be affected. People with fibromyalgia experience a range of symptoms that can vary in intensity. Symptoms may also include irritable bowel, headaches and migraines, dry eyes and mouth, rashes and other skin problems, vision problems, and poor coordination. The causes of fibromyalgia are unknown, and there is currently no lab test that can diagnose the condition.

In a recent study of 336 adults, published in the Journal of Clinical Psychiatry, those with fibromyalgia were almost seven times more likely to have suffered from an anxiety disorder than those without the disorder. They were also about three times more likely to have suffered major depression than those who had not experienced fibromyalgia. The study found the onset of an anxiety disorder or other mental illness in people with fibromyalgia preceded the onset of the fibromyalgia, suggesting that anxiety or depression may be more than just a reaction to the chronic pain. The researchers noted there may be a “shared vulnerability” between the psychiatric disorders and fibromyalgia, possibly genes or environmental factors such as chronic stress. However, the connection remains unknown and requires further study.

Migraine — A migraine is severe pain felt on one or both sides of the head. The pain normally occurs around the temples or behind one eye or ear. A migraine may also cause nausea and vomiting and sensitivity to light and sound. The pain can last a few hours or up to two days. In a classic migraine a person experiences an aura, or visual symptoms such as losing vision or seeing flashing lights 10 to 30 minutes before an attack. During a common migraine a person may have nausea, vomiting, or other symptoms, but does not experience an aura.

Migraines (and chronic daily headaches) are highly prevalent in people with anxiety disorders, as well as those with mood- and substance-abuse disorders. Many studies have found that generalized anxiety disorder and panic disorder are particularly associated with migraines or other types of headaches. Moreover, in people with a co-occurring anxiety disorder and migraines, the likelihood of major depression increases. As with fibromyalgia, researchers have suggested that there may be a common predisposition to anxiety disorders, depression, and migraines.

Back Pain — Anxiety disorders and back pain often co-occur; back pain is more common in people with anxiety and mood disorders than those without them. Illness, accidents, and infections are among the causes of back pain. According to WebMD, no matter the cause, back pain symptoms are the same, and they include persistent aches or stiffness anywhere along the spine; sharp, localized pain in the neck, upper back, or lower back, especially after lifting heavy objects or engaging in strenuous activity; and chronic ache in the middle or lower back, especially after sitting or standing for extended periods.

An anxiety disorder and a co-occurring chronic pain condition can make a person’s health more difficult to treat. But a variety of treatments and lifestyle changes can offer relief. Possible health complications are noted below:

• Increased disability or reduced functioning
• Lower quality of life
• Poorer response to treatment
• Inconsistent treatment adherence including medication management
• Increased perception of disease severity

People living with chronic pain who also have an anxiety disorder often experience lower pain tolerance or a lower pain threshold. People with an anxiety disorder may be more sensitive to medication side effects or more fearful of harmful side effects of medication than people who aren’t anxious, and they may also be more fearful of pain than someone who experiences pain without anxiety.

Recommended treatment interventions for people with an anxiety disorder and chronic pain

According to the Anxiety Disorder Association of America (ADAA), a comprehensive plan with a number of treatment components is necessary. A doctor will work with a patient to develop a treatment approach tailored to specific conditions and symptoms. Below is more information about some treatment options recommended by the ADAA for people experiencing anxiety disorders and chronic pain.

Cognitive-Behavior Therapy (CBT) — CBT helps patients identify, challenge, and change unwanted and unproductive thoughts and feelings, as well as modify and gain control over unwanted behavior. The patient learns recovery skills that are useful for a lifetime. CBT is used to treat anxiety disorders as well as chronic pain conditions.

Medication —Very useful in the treatment of anxiety disorders and chronic pain, medication is often used in conjunction with therapy and other treatment techniques. Depending on the individual, medication may be either a short-term or long-term treatment option. The choice of medication should be discussed thoroughly between doctor and patient, and it will always depend on individual circumstances. Some people with an anxiety disorder and chronic pain may be able to find one medication that helps alleviate the symptoms of both conditions. Others may take one medication for anxiety and another for pain management.

Relaxation Techniques — Relaxation techniques may help individuals develop the ability to cope more effectively with the stresses that contribute to anxiety and pain. Common techniques include breathing retraining, progressive muscle relaxation, and exercise.

Complementary and Alternative Methods — Yoga, acupuncture, therapeutic massage, and biofeedback (controlling how the body reacts to stress to reduce its effects) are among the complementary and alternative techniques that relieve the symptoms of both anxiety disorders and chronic pain.

Basic lifestyle changes recommended for people living with an anxiety disorder and chronic pain
Many lifestyle changes that improve the symptoms of an anxiety disorder also help the symptoms of chronic pain. Below is more information about some areas of change recommended by the ADAA for people experiencing anxiety disorders and chronic pain.

Good Nutrition — Nutrition and diet can influence both anxiety and chronic pain symptoms. People with anxiety should limit or avoid caffeine and alcohol, which can trigger panic attacks and worsen anxiety symptoms. According to the National Fibromyalgia Association, certain foods aggravate some musculoskeletal conditions; they include dairy products, gluten (found in wheat, oats, barley, and rye), corn, sugar, and members of the nightshade family (potatoes, tomatoes, eggplant, peppers, and tobacco). The association recommends that individuals who experience pain reduce their intake of tea, coffee, alcohol, red meat and other acid-forming foods. A doctor can provide patients with more guidance on foods to eat regularly and those to avoid.

Exercise — Regular exercise produces many positive effects for people with anxiety disorders and chronic pain. It strengthens muscles, reduces stiffness, improves flexibility, and boosts mood and self-esteem. Some people with chronic pain find exercising difficult to do, but because it often helps reduce overall pain, its benefits may be worth any temporary discomfort. All individuals, particularly those with chronic pain, should check with their doctors before beginning an exercise regimen.

Sleep Management — Getting a good night’s sleep is key for anxiety disorders and chronic pain conditions. Symptoms of both types of conditions often become worse without proper or enough sleep. Consistent sleep and wake times, a good sleep environment (comfortable room temperature, no TV or other distractions), and avoiding caffeine late in the day and at night can help promote restful sleep.