‘We receive almost no training in pain’: Breaking the cycle of chronic pain, depression

SCOTTSDALE, Ariz. — Understanding the relationship between mental and physical distress is essential to breaking the cycle of chronic pain, according to a presenter at the Basic and Clinical Immunology for the Busy Clinician symposium.

According to Pavan Tankha, DO, of the center for spine health at the Cleveland Clinic, there is a critical disconnect regarding pain management that can be found across health care specialties. In a straw poll of attendees, he determined that almost no one present had received comprehensive instruction on pain in medical training.

“We receive almost no training in pain,” he said. “However, chronic pain is the primary reason patients present to their providers, so we are essentially winging it for the No. 1 reason patients show up to our offices.”

Most rheumatologists follow a common playbook for minimizing pain in their patients — recommending more exercise, better sleep, smoking cessation and reducing stress — according to Tankha . However, he argued that the more important and difficult task is to focus on suffering.

He described a cycle of maladaptive thoughts and behaviors, as well as psychological distress, which he referred to as a “suffering pie.”

“It is a cycle of suffering,” he said. “A suffering pie. If we can knock out one leg we can break the cycle.”

Regarding maladaptive thoughts, Tankha noted that “pain catastrophizing” is common.

“Patients magnify their pain,” he said. “They have thoughts and expectations about their pain that lead to ongoing suffering. Catastrophizing itself is associated with worse pain severity, interference, depression and more frequent visits to health care professionals.”

Rheumatologists are encouraged to view this part of the pie as no different from anxiety or depression, Tankha said. Meaning, it is a psychological condition that needs to be treated with some combination of therapy and medication.

Meanwhile, psychological distress refers to the interconnection between pain and emotion. Tankha suggested that as many as half of patients with chronic pain disorders demonstrate PTSD or some type of past or childhood trauma that contributes to their condition.

“We need to treat these first before we treat the pain,” he said. “This is where we as clinicians come into play, in helping explain to patients the complexity between pain and emotion.”

All of this psychological distress frequently leads to maladaptive behaviors, according to Tankha.

“These are behaviors that patients learn over time that can make their pain symptoms worse,” he said.

An example is the association between depression and a lack of motivation to get out of bed or off the couch, Tankha said.

“Depression can lead to immobility, which can lead to muscle weakness, which can lead to physical pain,” he added.

The most effective way to break the cycle is cognitive behavioral therapy (CBT), according to Tankha.

“CBT addresses the relationship between maladaptive thoughts, distress and behaviors,” he said.

A pain psychologist may be necessary to help patients understand these relationships and stop catastrophizing their condition.

Social treatment can also be effective, Tankha added.

“Family members play a significant role in initiation and maintenance of chronic pain treatment,” he said. “We can do all the work we want in the clinic or treatment programs, but if they go back to a hostile environment, we will not be getting the end result we are looking for.”

Ultimately, the most important component is buy-in from the patient themself.

“Empowering the patient is a key component to get the outcome you want,” Tankha said.