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Anxiety, Depression

Pain, anxiety, and depression - Harvard Health

Pain, anxiety, and depression often coincide because the parts of the brain and nervous system that handle sensations and touch interact with those that regulate emotions and stress....

9/26/2021 10:00:00 PM

Pain, anxiety, and depression often coincide because the parts of the brain and nervous system that handle sensations and touch interact with parts of the brain that help regulate emotions and stress: HarvardHealth

Pain, anxiety, and depression often coincide because the parts of the brain and nervous system that handle sensations and touch interact with those that regulate emotions and stress....

, low back pain, headaches, and nerve pain. For example, about two-thirds of patients with irritable bowel syndrome who are referred for follow-up care have symptoms of psychological distress, most often anxiety. About 65% of patients seeking help for depression also report at least one type of pain symptom. Psychiatric disorders not only contribute to pain intensity but also to increased risk of disability.

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Researchers once thought the reciprocal relationship between pain, anxiety, and depression resulted mainly from psychological rather than biological factors. Chronic pain is depressing, and likewise major depression may feel physically painful. But as researchers have learned more about how the brain works, and how the nervous system interacts with other parts of the body, they have discovered that pain shares some biological mechanisms with anxiety and depression.

Shared anatomy contributes to some of this interplay. The somatosensory cortex (the part of the brain that interprets sensations such as touch) interacts with the amygdala, the hypothalamus, and the anterior cingulate gyrus (areas that regulate emotions and the stress response) to generate the mental and physical experience of pain. These same regions also contribute to anxiety and depression.

In addition, two neurotransmitters —serotoninand norepinephrine — contribute to pain signaling in the brain and nervous system. They also are implicated in both anxiety and depression.Treatment is challenging when pain overlaps with anxiety or depression. Focus on pain can mask both the clinician's and patient's awareness that a psychiatric disorder is also present. Even when both types of problems are correctly diagnosed, they can be difficult to treat. A review identified a number of treatment options available when pain occurs in conjunction with anxiety or depression.

Key pointsCognitive behavioral therapy (CBT) is not only an established treatment for anxiety and depression; it is also the best studied psychotherapy for treating pain.Relaxation training, hypnosis, and exercise may also help.Some antidepressants or anticonvulsants may alleviate pain while treating a psychiatric disorder but be aware of potential drug interactions.

Double-duty psychotherapyVarious psychotherapies can be used on their own to treat pain in patients with depression or anxiety, or as adjuncts to drug treatment.Cognitive behavioral therapy. Pain is demoralizing as well as hurtful. Cognitive behavioral therapy (CBT) is not only an established treatment for anxiety and depression, it is also the best studied psychotherapy for treating pain. CBT is based on the premise that thoughts, feelings, and sensations are all related. Therapists use CBT to help patients learn coping skills so that they can manage, rather than be victimized by their pain. For example, patients might attempt to participate in activities in order to improve function and distract themselves from focusing on the pain.

Relaxation training. Various techniques can help people to relax and reduce the stress response, which tends to exacerbate pain as well as symptoms of anxiety and depression. Techniques include progressive muscle relaxation, yoga, and mindfulness training.

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Exercise. There's an abundance of research that regular physical activity boosts mood and alleviates anxiety, but less evidence about its impact on pain.The Cochrane Collaboration reviewed 34 studies that compared exercise interventions with various control conditions in the treatment of fibromyalgia. The reviewers concluded that aerobic exercise, performed at the intensity recommended for maintaining heart and respiratory fitness, improved overall well-being and physical function in patients with fibromyalgia, and might alleviate pain. More limited evidence suggests that exercises designed to build muscle strength, such as lifting weights, might also improve pain, overall functioning, and mood.

Avoiding drug interactionsMany psychiatric drugs and pain medications have potential drug interactions. Here are a few common examples.Nonsteroidal anti-inflammatory drugs (NSAIDs) are helpful for both long-term and short-term pain, acting to alleviate pain and reduce inflammation. However, both

NSAIDsand SSRIs individually increase risk of gastrointestinal bleeding when used on an ongoing basis, so combining these drugs may raise the risk of bleeding even further. Prolonged use of NSAIDs can cause kidney failure in people who already have reduced renal function. Finally, use of NSAIDs and lithium together can lead to toxic levels of lithium in the bloodstream.

Acetaminophen reduces pain and does not increase risk of bleeding as much as NSAIDs. But acetaminophen is metabolized through the liver by the same enzymes that interact with manySSRIsand other psychiatric medications. Liver function should be monitored in any patient taking acetaminophen for prolonged periods while also taking a psychiatric drug. Patients with liver damage from hepatitis C or alcohol dependence should also use acetaminophen with caution or avoid it altogether.

Opioid analgesics are used to treat moderate to severe pain. In addition to being mindful of the usual cautions, such as risk of dependency, clinicians and patients should be aware of several potential interactions. For example, tramadol (Ultram), an

opioid, can interact with SSRIs to increase risk of seizure in patients who take both drugs at once. Opioids may also interact with benzodiazepines to cause respiratory difficulties. A patient who is taking a benzodiazepine should start an opioid at a low dose and titrate slowly up. Codeine and hydrocodone may be less effective when taken along with psychiatric medications that compete for the same liver enzyme (such as paroxetine [Paxil], bupropion [Wellbutrin], and duloxetine [Cymbalta]).

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Double-duty medicationsSome psychiatric medications also work as pain relievers, thereby alleviating two problems at once. So it is wise to check that evidence exists to support any"off label" (not FDA approved) uses for medications.Other patients may prefer to take one medication for the psychiatric disorder and another for pain. In this case, it's important to avoid drug interactions that can increase side effects or reduce medication efficacy (see sidebar).

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