MARCH 2022 - 1
M A R C H 2 0 2 2
Feature Intro: Chronic Pain & Mental Health: How our Physical Pain Affects our Mental Wellbeing When I’m not writing for ONC, I work as a counseling intern for an agency providing outpatient mental health services. I work with clients from all backgrounds, of all ages and all levels of education, income and wellbeing. Some of my clients seek help with communication in their marriages. Some clients wish to better control anger or want to explore traumatic events from the past. But for many of my clients, their mental health is affected by their physical health, and chronic pain is a present, daily struggle. Helping to identify and understand the connection between chronic pain and mental health is the first step in making things better. When we know the battle we’re facing (and fighting), we can create a plan to lessen the pain we feel all around. Just like physical pain might need multiple solutions (medication, physical therapy, surgery), mental pain is the same. We can address it from multiple perspective, but first we have to understand it. In this article we’ll explore how we define pain, how chronic pain and mental health are related and what we can do to interrupt the pain cycle and feel better.
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CONTENTS ASK THE EXPERT: TUNING IN FEATURE: CHRONIC PAIN & MENTAL HEALTH: HOW OUR PHYSICAL PAIN AFFECTS OUR MENTAL WELLBEING RECIPE: PEANUT BUTTER BREAD
LETTER FROM THE EDITOR
Amy Phariss, Editor-in-Chief, OutreachNC | editor@outreachnc.com
MARCH 2022 - 2 The sky is sunny as I write, a welcome relief after days of rain. I remind myself that after the rain, the world blooms. Tiny flowers are beginning to show in my yard, and I thought I saw a slight sheen of pollen on the windowsill just yesterday. The Sandhills are about to bloom. In no time, our mailboxes will be entangled in wisteria and sales of Claritin will surge. In this month’s feature, we explore the link between chronic pain and mental health. For many who live with chronic physical pain, there is also a mental toll. In what feels like a never-ending cycle, physical pain causes mental anguish, and emotional pain causes more physical pain. We get stuck in this loop, which can be overwhelming and frustrating. In this month’s feature we define pain, learn how pain affects mental wellbeing and offer suggestions for addressing the mental health toll of chronic pain. In Ask the Expert, Amy Natt answers a reader’s question regarding his mother and the frustrations he feels with some of her daily behaviors. Natt helps us understand why our aging parents might, for example, play games or watch the same television shows. She also addresses what caregivers can do to deal with this frustration and help both themselves and their loved one.
can’t control, as well. We must sometimes accept pain, adjust to a new normal or identify what we can’t control so we can focus on what is within our control. None of this is an easy road, yet many of us are walking down it. Michael J. Fox, who lives with Parkinson’s disease, says:
“Acceptance doesn’t mean
resignation; it means understanding that something is what it is and that there’s got to be a way through it.”
Just like the rain, which sometimes feels dreary and never-ending, there is always a way through. We find support, seek out solutions and sometimes, we sit back and wait for the clouds to clear. In solidarity,
Much of this ONC issue is about acceptance. People behave in ways we can’t control, which requires acceptance from us. Our bodies behave in ways we facebook.com/agingoutreach/
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ASK THE EXPERT: TUNING IN
MARCH 2022 - 4 Q: My mom sits all day and watches TV. She watches old shows, and she watches the same ones over and over. It’s the same stuff all day. She won’t watch anything new. She does that or sits on her phone and plays games. I can’t get her to go out or do anything else. And it’s driving me nuts. It makes me irritable. I don’t like listening to those shows all day long. What can I do to help her and me? A: There are a few thoughts that came to mind when I received your question. First, good for you for asking the question. Many adult children and caregivers experience high levels of frustration and irritability at times. It is important to talk about them and try to find solutions. As you pointed out, it impacts both of you, so it is important to address.
While I do not know the specifics of your mom’s current medical or cognitive status, I can say that repetition and routine often bring comfort as a person is aging. There are several reasons for this.
1. Many things in life, beyond our control, change as a part of the aging process. When we feel a lack of control in certain areas of life (illness, friends moving, changes in mobility) we tend to overcontrol those that we can. This can be the simple things, like meals, when to bathe, what to watch on television, etc. These can help restore a sense of normalcy. 2. Some older adults experience cognitive changes. Short term memory loss can lead to repetition. It might be repeating certain phrases or thoughts. It might also be reading or watching the same thing over and over. It is likely she can relate to what she is watching and that brings about comfort. 3. The games bring a sense of success, something your mom feels she can accomplish, enjoy, and participate in. There may be other things in her life that seem out grasp or cause frustration. The games are something she knows she can navigate and have become a part of her routine. 4. How is your mom’s mood? Have you noticed any changes in eating, sleeping or general affect? Have there been changes in her social network and the things she has always enjoyed? These could all be indicators of a larger mental health issue that should be discussed with her physician.
MARCH 2022 - 5 There is a phenomenon I have witnessed many times over my 25 years of working with older adults. I call it battening down the hatches. People tend to shrink their life to feel manageable. Over time, this can become smaller and smaller. It is something to be aware of, but what to do about it can be more challenging.
There are also private duty caregivers who can come in and be a “friend” for few hours. This can become part of the daily routine and broaden her activities from television and games on her phone. It might take a few tries to get her to participate, but it does eventually work into a routine. This gives you and mom a break.
Sometimes it is appropriate. People adapt and make changes based on ability. However, it can also be very isolating and lead to depression, reduced mobility and declining cognitive abilities. You want a person to be appropriately engaged and stimulated without causing increased stress for them.
Now to the practical. Would your mom wear over the ear headphones? Or could you put on some noise canceling headphones? Is there a place in the house (like a den, sunroom, or small living area) she can go, but with doors that can help block noise? I had one family put in glass doors to their sunroom to create a space for dad to watch TV at a higher volume; maybe something like that could work in your situation?
In your situation, I would try adding something to the routine.
Exercise is really important to maintain mobility and tends to boost mood. Incorporating a daily walk or even something stationary, like a pedal exerciser can be beneficial. Cognitive stimulation is also important. She enjoys the games on her phone, perhaps she could do a puzzle or play cards? There are some simple board/card games you could try playing with her. Would she do a craft? Fold Laundry? Set the table? Water window plants? Some type of routine task you could ask her to help with. Here is something else to consider. Maybe you need a break from mom? Is there a friend or relative that could come a couple times a week and engage her in some of the above ideas?
My last suggestion is to look for a local support group for family caregivers. This can be formal or informal but would give you a routine sounding board and source for ideas. Many adult children face similar challenges, and it is helpful to see that you are not alone and that your feelings are perfectly normal. If you are caring for mom on an ongoing basis, build your support network now; you will need them to take breaks.
Caregiver stress is real. The television may just be the thing to help you realize that its time to bring some other resources into to mix.
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MARCH 2022 - 6
CHRONIC PAIN AND
Mental Health
How our Physical Pain Affects our Mental Wellbeing by Amy Phariss
MARCH 2022 - 7
continued from page 1 How do we define pain? Pain is defined by Merriam-Webster as, “a localized or generalized unpleasant bodily sensation or complex of sensations that causes mild to severe physical discomfort and emotional distress and typically results from bodily disorder (such as injury or disease).” In 2020, the International Association for the Study of Pain (IASP) revised its definition of pain for the first time since 1979. This new definition was presented in the hopes of helping doctors and patients better understand the nuances and complexity of pain. This, the IASP hopes, will lead to better treatment and management of pain.
Chronic pain lingers. Chronic pain is defined as pain that lasts longer than six months; it can continue even after the illness or injury that caused it has healed. According to Cleveland Clinic, “Some people suffer chronic pain even when there is no past injury or apparent body damage.”
The IASP’s new, updated definition of pain is “An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.” Also, six notes are included with this definition to better help us understand the complexity of pain including:
High-impact chronic pain is another important definition in the pain picture. High-impact chronic pain is pain that impacts multiple areas of a person’s life and/or work activities. Having high-impact chronic pain means we’re not going to work or we’re having to change jobs. It means we’re not playing with the grandkids or able to sit in the car long enough to go out with the family for a day trip. The CDC (2020) writes, “Chronic pain and chronic pain that frequently limits life or work activities, referred to in this report as high-impact chronic pain, are among the most common reasons adults seek medical care and are associated with decreased quality of life, opioid dependence, and poor mental health.”
1. Pain is a personal experience and influenced by factors other than physical sensation, such as our environments, our relationships and more (biopsychosocial).
Understanding that chronic pain affects more than just our physical comfort is key in identifying the other areas of life impacted by this pain. Our social lives are affected. Our relationships are impacted.
2. Pain and nociception are different from each other. Nociception is the sensory nervous system’s process of encoding or identifying noxious stimuli. 3. Pain is learned by the individual throughout our life experiences. 4. A person’s report of pain should be respected. 5. Pain plays an adaptive role and can affect a person’s social and psychological well-being. 6. Verbal description of pain is only one way to indicate pain. A person’s inability to verbalize pain does not mean it’s not there. These notes help us see how complex pain can be and how individual the experience of pain is. Pain is not a one-size-fits-all experience. Acute pain is defined as pain that lasts less than six months and comes on suddenly, typically a result of something specific. Surgery, a broken bone, a burn or cut, dental work or labor/childbirth are examples of specific experiences that may cause acute pain. Acute pain goes away.
M E N TA L
HEALTH
M E N TA L
HEALTH
M E N TA L
HEALTH
MENTAL
HEALTH
The ways we engage with our loved ones, with our environment and with ourselves are all influenced by the pain we feel. M E N TA L
HEALTH
M E N TA L
HEALTH
For those of us who live with chronic pain, the cycle of pain is both physical and emotional. The physical pain leads to emotional pain, and the emotional pain in turn leads to more physical pain. The cycle is repeated and in constant motion. Physical Pain
Greater Emotional Pain
Emotional Pain More Physical Pain
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THE PICTURE OF CHRONIC PAIN IN AMERICA The Centers for Disease Control and Prevention (CDC) collects data regarding chronic pain and, as of 2020, reports the following numbers: •
In 2019, 20.4% of adults had chronic pain and 7.4% of adults had chronic pain that frequently limited life or work activities (referred to as high impact chronic pain) in the past 3 months.
•
Chronic pain and high-impact chronic pain both increased with age and were highest among adults aged 65 and over.
•
Non-Hispanic white adults (23.6%) were more likely to have chronic pain compared with nonHispanic black (19.3%), Hispanic (13.0%), and non-Hispanic Asian (6.8%) adults.
•
The percentage of adults with chronic pain and high-impact chronic pain increased as place of residence became more rural.
The National Pain Advocacy Center reports: •
Chronic pain affects more Americans than any other disease (including cancer, heart disease and diabetes)
•
1 out of every 6 Americans experiences daily pain
•
40 million Americans live with severe pain
•
20 million Americans live with pain that restricts their work and life activity
•
Chronic pain is the #1 cause of disability
•
People living with chronic pain are also four times more likely to suffer from depression or anxiety and have higher rates of suicide.
•
The cost to society, which ranges from direct costs to lost work, reaches upward of $638 billion a year.
Sources: https://www.jpain.org/article/S15265900(12)00117-4/fulltext#relatedArticles https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC486942/ https://www.aafp.org/news/health-of-thepublic/20180521acupuncture.html
How does chronic pain affect mental health? Chronic pain affects mental health in several ways. Many of my clients feel highly irritable due to chronic pain. A grandchild may come in with a question or simply want to show a grandparent what she found outside, but the grandparent with chronic pain becomes irritated. Irritation turns to frustration or impatience with this child, and suddenly, everyone feels bad. The child’s shoulders slump and she turns away. The grandparent feels guilty and ashamed of becoming so easily frustrated. This guilt begins to fester, and for many of my clients, the day becomes either a focus on feelings of failure or an attempt to stop thinking of how bad they feel. They might take a nap, go into their room to be alone or have a beer to relax. This loop of physical and emotional pain continues. By the time dinner rolls around, many of my clients refuse to eat with the family because they feel so badly for behavior earlier in the day or because they don’t have the energy to sit through the meal. All of the energy spent living in chronic pain and enduring the mental toll of that pain has exhausted them. They remain in the bedroom or the den or the back porch, and they sit alone. Emotional pain is an isolating experience for everyone. Irritability and frustration are not only experienced by the person and their family. Research published in The Journal of Pain (2012) reports, “Elevated levels of irritability are often reported among those suffering from chronic pain. Irritability and frustration may be directed towards the pain condition, health care providers, employers, and even towards the patient themselves, for not being able to accomplish “normal” activities of daily living” (Holtzman et al). Pain affects the relationships we have at home and beyond as well as the relationship we have with ourselves. Another emotional symptom of pain my clients report is guilt for feeling like a burden. I have many clients who say to me, “I feel like I’m holding my family back. They want to go out and do stuff, but I can’t. I’m in too much pain. So they either go without me or stay home.” The guilt and shame associated with not being able to “keep up” with loved ones is very real for many people living
MARCH 2022 - 9 with chronic pain. They might push themselves to attend events and “pay” for it the next day or later that night. If someone with chronic back pain, for example, plays with the grandkids all day, he might be in bed the next two days with higher levels of pain. This is a frustrating and ultimately depressing cycle for so many of my clients. There is guilt at not being able to keep up, shame for being a burden to others and depression from the mental exhaustion of feeling so bad for so much of the time. Ultimately, many of my clients begin isolating themselves. They figure they’d rather stay home than hold up anyone else’s good time. If they can’t keep up at the zoo, they might as well stay home rather than making the grandkids slow down. So, they decline the invitation for a day trip to Asheboro, which feels sad and disappointing. The sadness is a lingering companion to the day and becomes all too familiar with each invitation declined. The guilt of missing out on time with family festers. Shame begins to set in as clients think, “I’m weak and unreliable.” This cycle of guilt, shame and isolation is a key ingredient in the development of depression.
M E N TA L
According to Mental Health America, “Research shows that those with chronic pain are four times more likely to have depression or anxiety than those who are pain-free.” MENTAL
HEALTH Pain can cause depression, and depression can HEALTH
cause pain. For many depression sufferers, there is physical pain associated with their symptoms such as unexplained back pain and headaches. While most of us think of depression as a mental health issue, it is directly linked to physical pain. In fact, aches and pains are often the first symptoms of depression leading people into the doctor’s office. They present with vague aches, and it turns out to M E N TA L M E N TA L be depression. In the cycleHEALTH of pain and depression, HEALTH existing pain can cause depression, too. Chronic pain can lead to depression (guilt, shame, isolation, etc.), and depression can also lead to chronic pain (headaches, insomnia, joint pain, GI issues). In a 2004 article in the Primary
Care Companion Journal of Clinical Psychiatry, researchers write, “Physical symptoms are common in major depression and may lead to chronic pain and complicate treatment. Symptoms associated with depression include joint pain, limb pain, back pain, gastrointestinal problems, fatigue, psychomotor activity changes, and appetite changes. In the primary care setting, a high percentage of patients with depression present exclusively with physical symptom” (Trivedi). This is a loop many people live with: chronic pain causes depression, and depression causes chronic pain. It can feel like a chicken-and-egg question for many people living with both physical and emotional pain. Anxiety is another mental health issues closely associated with chronic pain. According to the Anxiety & Depression Association of American, chronic pain and anxiety disorders are commonly linked. Chronic pain and anxiety show up in several physical disorders including fibromyalgia, migraine, back pain, and arthritis. Dealing with chronic pain and an anxiety disorder (such as Generalized Anxiety Disorder (GAD)) can be especially challenging. Those who suffer from an anxiety disorder and chronic pain may have lower pain tolerance, may be more sensitive to the side effects of pain medication and might also be more fearful of pain and medication. This fear can cause even more anxiety, and once again, a loop is created. Chronic pain leads to fear about the pain. Will I reinjure myself? Will I be able to sleep? Will the pain get worse? Will the pain ever end? M E N TA L
M E N TA L
This fear leads to tension, which leads to more pain. HEALT HEALTH Or the fear leads to avoidance of activity, which can also lead to more pain down the road. A client, for example, might fall and break a hip. Then, the client becomes fearful of steps, for example. He worries he will fall again. So, he doesn’t go out the front door to take the trash to the curb. He worries. The trash doesn’t get picked up that week, and there is anxiety M E N TA L M E N TA L about that. The cycle continues. HEALTH HEALT For many, depression and anxiety can co-exist with chronic pain. This can make pain even worse,
MARCH 2022 - 10
& commitment therapy (ACT), dialectical behavior therapy (DBT), interpersonal therapy (IT) and eye movement desensitization reprocessing (EMDR). Each of these therapies has plenty of empirical evidence to support its efficacy, which means a lot of studies have been done to make sure they’re effective. A counselor or psychologist can help explain the differences and determine which form of therapy might be most helpful for your situation.
which makes the depression and anxiety worse. Interrupting this loop can be a great relief for many who suffer from what feels like endless pain, both physical and mental. How do we interrupt the pain cycle? Several therapies are helpful for addressing the mental health issues related to chronic pain. •
•
Medication can be helpful for many mental health issues including depression and anxiety. You can talk to your primary care doctor about medication, and you can also see a psychiatrist for medication management. For many people with chronic pain, medication management is part of the overall therapeutic intervention. Having a psychiatrist or psychiatric NP on board can be helpful in finding a medication that works well with other medications. Cognitive behavioral therapy (CBT) is an evidence-based therapy for the treatment of depression and anxiety, and many counselors and therapists are trained in this treatment. Other effective therapies include acceptance
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•
Complementary treatments can also be helpful. Massage therapy is far more than scented oils and Swedish massage. Clinical massage therapists can be integral in addressing physical and emotional pain. Acupuncture can also be effective. According to the American Academy of Family Physicians (2018), “acupuncture is effective for the treatment of chronic pain, that the effects of acupuncture persist over time, and that the benefits of acupuncture cannot be explained away solely by the placebo effect.”
Often, a combination of tools yields the best results. A client may begin taking medication for depression, which gives her the energy and motivation to begin counseling to address negative thought patterns and process feelings of guilt. Massage therapy can be an additional support for both the mental and physical pain. Together, over time and with consistency, pain can be better managed, and quality of life improves. For so many of us who live with chronic pain (I have migraines and IBS myself), the fear of pain, the guilt of our perceived limitations and the isolation we experience can feel overwhelming. We become angry. We feel misunderstood and even neglected by doctors and the medical field in general. We feel frustrated, alone and hopeless. We retreat, and the cycle continues. There is hope, however, for feeling better. There aren’t any light switches. It takes time to discover and unearth some of our negative self-talk. We have to think about how we’ve coped with our pain. Are those coping skills useful? We have to take ownership of what we can control and let go of what we can’t. But with support, we can accept our pain, ourselves and our circumstances and begin to make them better, one step at a time.
MARCH 2022 - 11 We started the month out with the best kind of celebration. March 1, 2022 is officially National Peanut Butter Lover’s Day. We know. We’re excited and pausing to consider all the nutty options.
Directions
To celebrate, we’ve chosen a Depression-era favorite: Peanut Butter Bread. You might remember it from your grandmother’s kitchen or want to try something new. Either way, fire up the oven and start spooning out the gooey thickness we (well most of us) love, with or without jelly.
2. Combine dry ingredients (flour, sugar, baking powder and salt) into a bowl. Whisk ingredients to combine.
Peanut Butter Bread One Loaf (9x5 inch loaf pan) Ingredients •
2 cups all-purpose flour
•
¼ cup to 1/3 cup granulated sugar (depending on your preference for sweetness)
•
4 teaspoons baking powder
•
½ teaspoon salt
•
1 ½ cups creamy peanut butter (we used Jiff, which is more stable than natural options)
•
¼ cup honey
•
1 1/3 cups milk (we used 2% but have also used whole milk with good results)
1. Preheat your oven to 325 degrees and grease a 9x5 inch loaf pan.
3. Mix together peanut butter and honey. With an electric mixer or standing mixer, combine the dry ingredients and the peanut butter/honey mixture. Add the milk, with the mixer on low. Scrape down the sides of the bowl and fold the batter together to ensure there are no flour streaks. 4. Bake at 325 degrees for approximately one hour or until a toothpick inserted into the middle comes out clean. 5. If your bread needs more than an hour to bake, you might tent foil over the top to avoid too much browning. 6. Let bread cool for 5-10 minutes, then turn out onto a wire rack to cool completely. We let it sit for at least 30 minutes if not an hour. It’s a challenge in self-control, which seems fitting for a Depression-era recipe. 7. Prepare yourself for not only the wonderful aroma of this bread but the delicious combination of bread, peanut butter and, if you choose, a slather of jelly. This is Americana at its best.
MARCH 2022 - 12
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