Living with a sense of constant pain is a heavy burden for anyone. However, multiply it with depression – one of the most common diseases among people who suffer from chronic pain – and you get an almost unbearable condition.
Depression increases pain and makes the person helpless in the struggle against it. However, a good point in this case is that both of these conditions are inseparable. Therefore, if you relieve the symptoms of depression, you will find it easier to bear the pain.
According to statistics, 60% of cases of chronic pain in humans coexist with depression. These two phenomena are closely interrelated and can reinforce each other, creating a vicious circle.
Depression can actually be caused by pain, and may itself cause the development of chronic pain, and many have come to suffer severe chronic pain that has arisen as a result of various reasons.
The big controversy is caused not by the fact of the coexistence of chronic pain with depression but by the cause-and-effect relationship between pain and depression.
On the one hand, the existing long pain limits human capabilities on professional and personal level, makes people abandon habitual patterns of life, violates their life plans, reduces their general quality of life, etc.
All of this may give rise to secondary depression. On the other hand, depression may be the root cause of the pain or the main mechanism of “chronicness” of pain.
Thus, atypical depression may occur in different cases including a case of chronic pain, as indicated by the following expression: “Chronic somatic pain as a symptom of depression”, describing the existing depression and pain within depressive disorder “Somatization”.
Furthermore, Dysthymia a chronic condition that is characterized by a depressed mood most of the day for more than half of the days in the last two years can also cause major disruptions in human life.
Chronic pain and depression: a sweet couple
Chronic pain – it is such a pain that lasts much longer than a simple pain. If pain sensation becomes constant, the body can respond to it in different ways.
The phenomenon of chronic pain can be described as abnormal processes in the brain, low energy, mood swings, muscle pain and decreased brain capacity as well as that of the body.
Chronic pain condition deteriorates the body as neurochemical changes in the body increase the susceptibility to pain.
An overwhelming sense of pain causes irritability, depression, and can lead to suicide of those who no longer believe in the ability to get rid of the pain. Living with a sense of constant pain – it is a terrible burden. However, if a feeling of pain and depression have joined, this burden becomes even more terrible.
If you suffer from chronic pain and depression, you are not alone in this. It is a common condition and these two almost always occur together.
Depression is the most common ailment of people who suffer from chronic pain, which often enhances the feeling of pain and makes the treatment process more difficult. This is because patients suffering from chronic pain, very often do not notice the symptoms of depression.
It all just passes by without the required treatment. A physician usually takes complaints of pain. The patients do not usually complain of depression symptoms.
As a result, the patient develops depression, as it draws to a breach of sleep, loss of appetite, fatigue and decreased physical activity.
Ironically, all of this leads to even further increased pain. According to Stanford University professor Stephen Feinberg, if a person suffers from pain, then you should automatically assume that he also suffers from depression and begin treatment with this point of view.
Epidemiology and statistics
The relationship between depressive mood and symptoms of pain, especially chronic, has been proven in many clinical studies. According to the American Association of pain, about 250 million US citizens are turning to the doctor with a pain that does not last more than a year. Most of these people are also in the doldrums.
About 65% of patients diagnosed with depression also complain of persistent pain. People, whose pain affects their independence, are more prone to depression.
Here are the results of research, which compares people suffering from pain and depression to people who have just suffered from pain. In the first case, the patients stated that their pain intensified, they felt they have lost control over their lives and that they use unhealthy methods of dealing with the pain more often.
The very same patients often see signs of depression and pain symptoms. Epidemiological studies have found that the proportion of people, who complain of pain, is about 17.1% of the population. Of these, 16.5% of patients comply with the diagnostic criteria for depression and 27.6% comply with a chronic pain disorder.
In the general population, severe depression occurs in 4% of cases; 43.4% people with severe depression are consistent with the diagnostic criteria for chronic pain disorder. Only among the sample of individuals without depression, pain disorder patients are met four times less.
Describing the relationship between chronic pain disorder and the depressed confirms the previously made assumption expressed that if patients with chronic pain in primary health care were examined for the presence of comorbid depression, 60% of all depressive disorders in a population could be diagnosed by general practitioners.
In chronic pain and depression, there are many common links. Pre-emptive role in the pathogenesis of depression plays a deficiency of norepinephrine and serotonin according to the “classical” monoamine theory of depression a major role in the pathogenesis of depression is played by the reduction in the concentration of monoamines in the synaptic cleft – primarily serotonin and norepinephrine.
Most of noradrenergic neurons are localized in the brain stem – in the locus coeruleus. Most serotonergic neurons localize in brain stem nuclei seam.
It is known that the descending noradrenergic and serotonergic pathways are part of the anti-nociceptive system that are most commonly localized in the brain stem, and are actively involved in pain control.
Lack of descending analgesic systems is one of the mechanisms of chronic pain. Thus, it can be revealed to be a common pathogenetic mechanism of chronic pain and depression.
Discuss the pathogenesis of depression in recent years has been widely used as a concept of neuronal plasticity of brain structures.
Violations of neuronal plasticity in depression are associated mainly with stress-induced hyperactive responsiveness of the hypothalamic pituitary adrenal axis, and of the hypothalamic pituitary thyroid system.
Long term hyperactivity of the hypothalamic pituitary adrenal axis with a constant hyperactivity of corticotropin-releasing factor, adrenocorticotropic hormone and cortisol leads to decrease in synthesis levels of brain-derived neurotrophic factors, different phospholipid metabolism levels, change in the amount of substance P and other neurokinins.
In addition, it changes the sensitivity of glutamate NMDA and AMPA receptors with increased cytotoxic effect of glutamate on neurons. It is believed that depression through these mechanisms is responsible for the atrophic changes in the brain in a number of structures and most of all in the hippocampus.
Changes in the hippocampus and the amygdala play a crucial role in the persistence of symptoms of depression, anxiety and chronic pain.
Currently, the most attention is paid to the neurokinin theory of depression, according to which the main role in the pathogenesis of depression is played by a metabolic disorder of substance P receptors and increase in the activity of neurokinin-1 in the amygdala. Therefore, their role is the formation of chronic pain is pretty obvious.
The clinical picture
Symptoms of depression in chronic pain syndrome may be obvious, but often, chronic pain syndrome is just a “mask” of the depression. Depressive symptoms can actually act in an atypical form and hide behind the dominant symptoms in the clinical picture of pain.
A common feature of somatization depression is the presence of numerous painful physical symptoms along with mood disorders in their structure. Somatic symptoms come to the fore, covering affective depressive disorder including the depressive symptoms that are mild, erased or non-existent.
All of this is very difficult to diagnose as depression. The symptoms masking depression can come from almost every single system of the body, appearing as disorders of heart rhythm, dry mouth, shortness of breath, heartburn, nausea, constipation, excessive sweating, dizziness, semiconscious state, amenorrhea or other menstrual disorders, decreased libido , poor sleep mainly with early morning awakening, changes in appetite and weight loss, asthenia or pain of various parts of the body.
Furthermore, chronic pain as a mask of depression can occur in practically any part of the body: head, neck, the heart, back, joints, abdomen, even on the face.
Depending on the location and nature of the pain as well as the accompanying vegetative symptoms, the patient could find himself in the field of neurology, cardiology, gastroenterology, rheumatology, and so on.
Features of chronic pain in which the depression is major factor in gaining understanding of symptoms are the most important. Surprisingly, clinical phenomenology of chronic pain does not fit into any of the known physical and neurological diseases.
Numerous diagnostic tests are not capable to reveal the current organic disease, which could explain the pain. Burning, chills, feeling cold, crawling and wiggling under the skin, usually characterize the chronic pain, within the depression.
Chronic pain syndrome usually has more than one location such as in patients with chronic headaches, it can be identified in premenstrual and recurrent low back pain. Pain often changes its location and character migrating throughout the body.
Behavior of patients with psychogenic pain has its own specificity, which is defined, first of all, an internal picture of the disease and the patient’s belief in the presence of his physical or organic neurological disease.
It is important that patients with psychogenic pain reveal history of pain (pain episodes in different parts of the body in the past). Often, these patients would have had very close relatives suffering from long-term pain.
This suggests the genetic nature of the chronic pain as well as the depression even though various scientists have challenged this notion many times.
The most common variant of the course of depressive disorders in patients with chronic pain is nosogenic depression, which is formed under the influence of stress, as a reaction to physical illness.
In this case, a key role in its etiology is played by factors such as the sudden appearance of pain, progression of disease, bodily discomfort, external appearance of the defect associated with the main somatic-neurological disease, as well as limiting consumer and professional activity of the patient.
There are short-term and prolonged types of nosogenic depression. Short-term depression could even be formed under the influence of the stress of hospitalization. It usually does not exceed the duration of 1-2 months and gives only a relatively mild manifestation of pain.
At the same time, with the reduction of pain and rehabilitation, there is a reduction of affective disorders. Protracted nosogenic depression lasts longer than 6-12 months and is commonly evaluated within the framework of post-traumatic stress disorder.
Their clinical picture corresponds mostly with hypochondriacal depression with obsessive thoughts about the worst outcome of the disease at the same time involving anxious expectations of repeated attacks of pain.
Depression is always a difficult condition for these patients. It lowers the usual pain threshold and tolerance to pain and eventually prevents the successful relief of pain.
Sometimes patients feel depressive symptoms are a natural consequence of pain or even worse, they try to deliberately hide them. This is because from their point of view pain is a more socially acceptable condition than depression.
Treatment of chronic pain, even if there are no clear detected signs of a depressive state, must necessarily include antidepressants.
Particularly suitable for treatment of chronic pain has been found to be the antidepressants from the group of selective serotonin reuptake inhibitors (paroxetine, fluoxetine, and others) as well as III-generation antidepressants with dual action.
The serotonin reuptake inhibitors and noradrenalin such as venlafaxine, milnacipran and duloxetine can also be used for the purpose.
It should be noted that tricyclic antidepressants have a pronounced analgesic and antidepressant effects, but their use by neurologists and therapists, especially in ambulatory practice is limited due to the wide range of serious side effects and interactions with other drugs.
It is important to remember that Early recognition of depressive symptoms in patients suffering from chronic pain, prevents mutual induction of these states. This has to be the main task of provided skilled care.
As mentioned above, major depressive disorder and generalized anxiety disorder are often accompanied by chronic pain syndromes. Examples of such syndromes may be back pain, headache, pain in the gastrointestinal tract and joint pain.
In addition, the great difficulty of treatments are a number of pain syndromes that are not associated with depressive and anxiety disorders such as diabetic and post-herpetic neuralgia, cancer pain, fibromyalgia. Therefore, it can be quite hard to determine whether the patient is in need of anti-depressants at times.
Clinicians have been describing the relationship between major depressive disorder and generalized anxiety disorder with pain and painful physical symptoms for a long time.
In an international study, it has been shown that the initial evaluation of 69% of patients with major depressive disorders only had somatic complaints, and they did not have any psychiatric symptoms.
In another study, it was demonstrated that the increase in physical symptoms increases the likelihood of a patient’s depression or anxiety disorders.
In addition to major depression and generalized anxiety disorder, pain is one of the main complaints of fibromyalgia, irritable bowel syndrome, chronic pelvic pain, migraine, vulvodynia, interstitial cystitis, symptoms of temporomandibular joint.
Some researchers suggest that such violations of affective spectrum as major depressive disorder, generalized anxiety disorder, social phobias, fibromyalgia, irritable bowel syndrome and migraine may have a common genetic predisposition.
The exact causal relationship between chronic pain and depression is unknown, but the following hypotheses has been put forward. Depression precedes the development of chronic pain. Depression is the result of chronic pain.
Depressive episodes that occur before the onset of chronic pain predispose to depressive episodes after initiation of chronic pain.
Psychological factors, such as maladaptive coping strategies contribute to the formation of interaction between depression and chronic pain. Depression and pain have similar characteristics, but represent different disorders.
Numerous studies have shown that the dual-action antidepressants (selective serotonin reuptake inhibitors – SSRIs and noradrenaline) that are used for the treatment of depression, may also be effective in the treatment of chronic pain.
Double-acting drugs, such as tricyclic antidepressants (amitriptyline, clomipramine) and venlafaxine, or a combination of antidepressants with serotonergic and noradrenergic effect greater rigor demonstrated more treatment efficacy compared with antidepressants acting mainly on one neurotransmitter system.
Thus, fluoxetine (due to pre-emptive increase of serotonin) and desipramine (due to pre-emptive increase of norepinephrine) cause a faster and better therapeutic effect than monotherapy with desipramine.
In another study, it was shown that clomipramine (double-acting antidepressant) causes remission of depression in 57-60% of cases, compared with patients who received antidepressants citalopram or paroxetine with remission in depression rate of 22-28% among all patients.
A meta-analysis of 25 double-blind studies revealed a high efficiency dual action antidepressants compared to tricyclic antidepressants monoaminergic action and selective serotonin inhibitors.
Analysis of 8 clinical studies on the efficacy of venlafaxine in comparison with the selective inhibitors of serotonin, found that the incidence of remission after 8 weeks of supplementation were significantly higher in the group of patients treated with venlafaxine (45%) compared with those who received a selective serotonin reuptake inhibitor (35%) or placebo (25%).
Dual effects on serotonin and norepinephrine cause a more pronounced effect in the treatment of chronic pain.
Both serotonin and norepinephrine are involved in pain control through the descending path of pain sensitivity. This explains why most researchers discover antidepressants having an advantage of dual action for the treatment of chronic pain.
The exact mechanisms of action by which antidepressants cause analgesic effect remain unknown. Nevertheless, antidepressants with dual mechanism of action have a longer analgesic effect than antidepressants, which affect only one of the aminergic systems.
Treatment of depression and chronic pain: use of cognitive therapy in the treatment of chronic pain
The patients often wonder whether it would be possible for them to change their mind and use thoughts to cope with the pain. It may be hard to believe, but research suggests that using certain techniques to change the ways of thinking can be used to reduce chronic pain.
This can be done with the help of cognitive therapy. During therapy sessions, patients learn to recognize the automatic negative thoughts that accompany the feeling of pain.
These thoughts often twist reality. Cognitive therapy teaches you how to replace these negative thoughts so as to help ease the pain perception.
The essence of the therapy lies in the fact that our thoughts and emotions have a huge impact on the ability to cope with chronic pain. There is ample evidence that as a result of cognitive therapy, patients have become more tolerant to pain.
In one of his studies, Thorne noted that 95% of patients after 10 weeks of cognitive therapy have felt that their life improved, while 50% reported that pain became weaker. In addition, many patients felt that they were willing to reduce the dose of medication.
The best way to start the treatment is to see a doctor and plan the treatment with him. With the combination of chronic pain and depression, you need to work closely with your doctor for the treatment, even more than in other situations.
Here is what you should do at first. Make an appointment with your family doctor and tell him that you want to fully control your pain.
Once you have a plan, remember that the key to achieving the goal will be your versatility, since the action plan should touch every sphere of life, which came under the influence of pain.
If your family doctor does not have sufficient training in the fight against pain, ask him to recommend a good specialist.
If in your city, there are organizations that specialize in helping people with chronic pain, join them. This will provide you with support during treatment. Refer to a specialist in cognitive therapy, which specializes in controlling pain.
Chronic pain and depression: a vicious circle
This article does not attempt to differentiate the type of depression and all variants of chronic pain syndromes. Our goal is to focus attention on the doctor’s undoubted affinity of these two pathological syndromes and the part of their compatibility.
In order to emphasize the need to find depression in any chronic pain it needs to be learned to allocate clinical symptoms, indicating the presence of depressive symptoms.
All of the above is necessary to complete the care of the sick as well as depressed, regardless of its origin, primary or secondary to chronic pain syndrome, always degrades and modifies the clinical picture worsens the pain and suffering of the patient, reduces the quality of life of the patient.
The depression forms in the patient’s state of helplessness and total dependence on pain, creates a sense of the futility of treatment, leads to a kind of “disasterization” of his own state.
Figuratively speaking, between pain and depression is formed a kind of vicious circle, in which one condition aggravates the other.
Often in this vicious circle the pain or the depression are embedded as a local phenomenon or a more extensive muscle spasm. Thus, the proper treatment of the patient with chronic pain relief is impossible without coexisting depressive symptoms.
Affinity of pain and depression, due primarily to common pathogenesis and in chronic pain syndromes, depression determines the failure of the brain serotonergic systems.
Serotonergic theory of depression is currently the leading, also proved essential dysfunction of descending serotonergic analgesic brain systems in the formation of chronic pain.
In this context, it is important to determine what is considered acute pain and what exactly is chronic pain. Acute pain is always a symptom of an organic suffering.
In contrast, chronic pain, as a rule, is not a symptom, but actually a disease in which the crucial question is not the morphological tissue damage and defects of perception and dysfunction of other psychological processes.
Rather, chronic pain, according to the International Association for the Study of Pain, is considered to be the one that goes beyond the normal healing period, and lasts at least 3 months.
Currently, chronic pain is treated as an independent disease, based on the pathological process in the field of somatic and primary or secondary dysfunction of the peripheral and central nervous systems.
An integral feature of chronic pain is the formation of emotional and personality disorders, it can only be called in the dysfunction of mental health problems, i.e. the treatment idiopathic or psychogenic pain. Psychogenic chronic pain is the most common and most difficult to diagnose and treat.
The criteria for the concept of chronic pain used to refer to pain can be the one lasting more than 6 months according to some of the organizations.
Pain causes emotional outburst. Anxiety, irritability and anger – this is a normal reaction to pain. Nevertheless, with the departure of the pain these emotions also tend to subside. But, what happens if the pain does not subside?
Over time, this emotional reaction to the pain will cause more serious problems that lead to depression. In some cases, the relationship between depression and chronic pain may be explained by the biological factors.
This is because the pain and depression both depend on the same nerve endings. The information is being transmitted from a nerve to a nerve through these endings. They even share the same way of information is transmitted between nerves.
The impact that chronic pain has on human life, also gives a strong impetus to the development of depression. “This pain is caused by the loss,” says Feinberg. “The loss of employment, self-respect and respect for others, decreased sexual drive – all these issues provoke depression.”
Once a person becomes depressed, it increases the pain, which has already been present. Depression completely robs the patient the opportunity to deal with this pain.
It is important to remember that since chronic pain and depression are closely linked, both of these diseases can often be treated simultaneously. Treatment of chronic pain and depression could even become a lifelong process.
Chronic pain and depression fully affect the patient’s life. For this reason, the ideal treatment option is the one that addresses all of the spheres of life of the patient. Because of the close connection between these two diseases, it is natural that their treatments are also interrelated.
Since the same neurotransmitters are involved in depression and pain, it means that treating both of these conditions can use antidepressants.
“People do not want to hear that the disease is born in their heads, but that’s what happens with the pain,” says Feinberg. “And antidepressants, affecting the patient’s brain, change the patient’s perception of pain.” The most effective antidepressants are the so called tricyclic.
However, due to severe side effects, their use is limited. Many people with chronic pain and depression avoid exercise. This has mostly been attributed to the patients’ inability to distinguish the normal pain from “pleasant pain” that occurs after exercise.
However, the less you exercise, the more you lose form. This could lead to the fact that you are increasing the risk of injury or increasing the pain, which could further worsen the condition in terms of depression. That is why you need to break this vicious circle.
Doctors claim that regular and not too exhausting exercise is the key to victory over the pain. Everyone who experiences pain should perform physical exercises. Together with your doctor, you can make a list of exercises that are safe and effective for you.
In addition, it has been proven that the sport helps to relieve depression. Because exercise releases the same brain chemicals that antidepressant drugs, it can be claimed that they are natural antidepressants.
Chronic pain prevents you from living, working and performing your duties to the best of your abilities. This leads to the fact that you have changed the attitude toward yourself, and not for the better.
When the doctor first encounters with patients suffering from chronic pain, he often sees that the man has drowned in pain and turned into a victim. For this reason, the critical point in the treatment is to fight with the victim role.
The patients are often inactive, that leads to complete inactivity and to return the person to the desire for an active life, he needs to be feeling full control over his life.
If your doctor does not see you as a victim, then perhaps, you are not in need of treatment. The goal of the treatment should be the desire to turn the victim into a person who can control the pain and his entire life.
Diagnosis of the depression and chronic pain
Chronic pain can be observed in the clinical picture of any depression. Symptoms of depression in chronic pain syndrome may be apparent or erased.
Quite often, the pain is the mask for depression and depressive symptoms actually appear in the form of atypically and hidden behind the dominant pain in the clinical picture of pain.
Patients with typical symptoms of depression quickly find themselves in the field of mental health. In contrast, patients suffering with atypical proceeding and masked depression for a long time are commonly treated to no avail by general practitioners who are completely unable to recognize such a depression.
Chronic pain as a manifestation of the masked, somatisation of depression can be located virtually anywhere in the body.
In fact, it can even be a combination of several locations. Clinical symptoms can mimic different variants of somatic and neurologic pathology, therefore it is necessary to examine the patient in detail.
Typically, chronic pain is localized in the head, heart, stomach, and in the back. Examples of chronic pain can be chronic tension headaches, daily chronic headaches, and fibromyalgia.
Chronic pain is usually diffused, monotonous, constant, dull, aching, pulling, squeezing. Often, chronic pain aligns with other sensations. Usually, the patients poorly describe chronic pain and perhaps for this reason it is poorly localized.
Typically, the patient indicates too large of an area of pain, which may vary from inspection to inspection. Pain is almost never presented in isolation, but always combined with complaints of psychopathological and psycho-vegetative nature.
Statuses of distress, aggravation of psychological conflict, decompensation emotional and personality disorders always lead to intensification or generalization of pain.
Patients with chronic pain and depression have a long history of the disease. But to no avail, they persistently turn to doctors of different specialties. They then conduct numerous studies that do not support any physical or neurological organic disease.
These are patients who, despite months of inspection at various specialists, do not have a definite diagnosis. Often, they are treated symptomatically, trying to stop pain by various analgesics. Treatment is without result, and patients continue to see a doctor.
Diagnosing depression is difficult for non-psychiatrist doctor. For the diagnosis of depression, it is necessary to know its diagnostic criteria (ICD-10). Diagnostic signs of depression are:
– Low or sad mood,
– Loss of interest or feelings of pleasure,
– Decreased ability to concentrate,
– Low self-esteem and self-doubt,
– Ideas of guilt and self-abasement,
– Gloomy pessimistic vision of the future,
– Suicidal thoughts or actions,
– Sleep disturbances,
– Appetite disorders
The main three are the ones that manifest first clinically. Other symptoms are optional. For verification of major depressive episode in the clinical symptoms of the patient, the doctor should take check the role of first three major symptoms of depression, which are combined with at least four additional symptoms.
For the diagnosis of depressive episode, the doctor requires the presence of two basic and three additional symptoms. For easy enough depressive episode presence of two major and two additional symptoms are necessary.
In all three versions of the above episodes, main symptoms of depression should last at least 2 weeks.
The general practice in the main follow up of patients with mild to moderate depression is the following: if depressive episodes lasting at least 2 weeks are repeated at intervals of a few months at least twice, then recurrent depressive disorder are usually diagnosed. Recurrent depressive episodes may be triggered by a stressful situation.
Most often, the physician is faced with atypical depression occurring erased, and therefore it is necessary to focus on the atypical symptoms. It is necessary to emphasize the frequent occurrence of depression anxiety disorders, that often come to the fore, overshadowing the actual depressive symptoms.
The combination of depression and anxiety, according to research reaches 62%. Especially the combination of specific alarms combined with muscle tension and depression is chronic pain syndromes.
Special mention should be given to the patients with atypical depression, who can present complaints exclusively on certain persistent physical symptoms, the main ones being the constant feeling of fatigue and chronic pain.
The main complaint may easily be irritability. Atypical depression complaints of pain of a chronic nature are often associated with complaints of other unpleasant, poorly described and often poorly localized sensations throughout the body such as sleep disturbances, appetite, sex drive, fatigue, weakness, decreased performance, constipation and dyspepsia.
Women may have complaints of menstrual disorders without organic causes of premenstrual syndrome. When depressed, people may experience poor appetite and weight loss, and, on the contrary, increased appetite when the depression levels are too high, and consequently weight gain.
In these cases, eating is the only way to get positive emotions – all the other requirements are reduced drastically. For typical depression, it is more common to lose the appetite and body weight, atypical depression is frequently observed with the opposite pattern.
If the abundance of complaints, their unusual combination, does not fit the clinical picture of any medical condition, this is an especially good suggestion of masked depression. For specific depressions that all have unpleasant clinical symptoms, including pain, more represented in the morning and evening.
Sleep disturbances in depression may appear quite different: disturbances in falling asleep, frequent nocturnal awakenings, dissatisfaction with sleep, waking difficulties, the increase in the duration of nighttime sleep, daytime hypersomnia.
The most specific sign of depression is considered to be early morning awakening, in which the patient for no apparent reason constantly wakes up in the 4 – 5 hours in the morning and cannot sleep.
Dysthymia and body language
Quite often, the patients are faced not only with atypical depression, but also with the chronic version of its flow. In this regard, we consider it necessary to acquaint the physician with the diagnostic criteria of chronic depressive condition, which can coexist with chronic pain. The ICD-10 and DSM-IV are released under the name “dysthymia”.
Previously, this condition was classified as depressive neurosis and neurotic depression. It should be stressed that the dysthymia can include chronic depression, for which there are no suicidal thoughts and actions, although there might be severe social exclusion.
Patients with predominant complaints of general malaise, weakness, fatigue, sleep disturbance and appetite. These complaints, along with unexpressed typical depressive complaints result in the patient going not to a psychiatrist but to a general practitioner.
According to statistics the dysthymic disorder affects up to 5% of the adult population. This disorder is rarely recognized and therefore seldom adequately treated. There are several essential criteria for the diagnosis of dysthymia.
At least two of the following symptoms must accompany chronically depressed mood:
– Decreased or increased appetite,
– Sleep disorders, or hypersomnia,
– Low performance or fatigue,
– low self-esteem,
– Impaired concentration or indecisiveness,
– A sense of hopelessness.
These symptoms are often combined with long-term pain. Dysthymia can last indefinitely, begin at almost any age, dysthymia often precedes severe psychological trauma.
In a study of patients with chronic pain for the detection of depression, the attention was paid to the anamnesis.
Indications of depressive episodes in the past, mental illness in relatives, alcohol or drug abuse, expressed psychotraumatic situation or transferred emotional stress should alert the clinician to depression.
The doctors must try to identify the time when the relationship started and course of pain to the patient’s mental experiences. It is also very important to check childhood experiences.
Previous painful experience of the patient, chronic pain in close relatives, related to the pain in the family. Education features may also contribute to the formation of so-called “pain of the person.”
Every doctor knows how difficult it is to communicate with a patient with chronic pain. The patient is fixed at his pain, and often the doctor questions about his mood problems, lifestyle, childhood perceived negatively, causing irritation and aggression.
This may be due to the fact that pain, coexisting with depression serves as a protective mechanism, by distracting him intolerably, injuring his psyche, oppressive, painful experiences and memories. Knowing this, the doctor should be patient, sensitive and very careful in questioning the patient.
On examination, the patient is required to pay attention to the appearance of the patient, his posture, demeanor, speech patterns and behavior that can help in the diagnosis of the patient.
The patients with depression are characterized by carelessness, the preference of gray and dark tones, lack of hair, makeup and jewelry for women, lack of facial expressions and movements sometimes resembling stiffness, stooped posture, and inexpressive monotony of speech, monosyllabic answers, etc. In other words, the doctor makes a diagnosis analysis with body language, or non-verbal communication methods.
Thus, there are various combinations of chronic pain with various embodiments of depression. The physician should pay particular attention to the diagnosis of depression in chronic pain syndromes, as coexisting with pain, depression is much heavier and modifies the clinical picture of the disease.
Regardless of whether the depression is primary or secondary in relation to chronic pain, it is necessary to stop using psychotherapeutic and psychopharmacological effect methods.
When combined with a chronic pain syndrome in the primary depression, take antidepressant therapy, which does not only have the anti-depressant effect, but also analgesic one.
The efficacy of antidepressants in the treatment of chronic pain syndromes is as high as 75%. The higher the efficacy of antidepressants, the greater the role depression plays in chronic pain.
Analgesic mechanisms of action of antidepressants include:
– Analgesic effect due to the reduction of depression. This mechanism is especially significant if the pain was a mask of depression. This means that it was the depression, but both primary and secondary in relation to the reduction of pain depression always leads to a weakening of the pain syndrome.
– Analgesic effect due to the potentiating of actions as exogenous and endogenous analgesic substances, mainly opioid peptides
– Analgesic effect due to the stimulation of the descending antinociceptive mainly serotonergic systems in the brain.
Currently, the priorities in the treatment of chronic pain are antidepressants, which have serotonergic activity: tricyclic antidepressants – amitriptyline (triptizol), doxepin (sinekvan), clomipramine (Anafranil) are some of the best examples of this.
Overall, it is incredibly important that the chronic pain and the depression are strictly controlled by the doctors. The physicians need to be fully aware of all of the symptoms that are commonly caused by these diseases.
They must also be able to decide whether the patient has got feats of depression by just talking with them and noticing several symptom features. Since it is rather hard to determine the depression, the physicians of non-psychiatrist professions should directly address the psychiatrists for the advice.
Furthermore, it must be ensured that the patients get the correct therapies. There are plenty of modern types of therapies that could indeed help people with chronic pain and the depression.
The more such therapies are used to help the patients, the more benefit they will find eventually.
While, the two diseases may not be curable, it is certainly possible to more or less reduce the stress levels and improve the life quality of the patients and that is what every single doctor should be aiming to do.
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