Mental pain is less dramatic than physical pain, but it is more common and harder to bear. The frequent attempt to conceal mental pain increases the burden.
C. S. Lewis
A book on pain management would not be complete without a chapter on mood management. Most of my patients have told me that their pain has a negative impact on their mood. I think that anyone who has lived with pain can understand this.
You may not be depressed, and if your mood is generally good, I still think it is important to read this chapter. It contains information that you will find helpful in maintaining good mental health.
Depression is a condition that affects millions of people. It is one of the most common mental health problems worldwide, and the number of people experiencing depression is increasing. According to statistics released by the World Health Organisation in 2020, more than 264 million people of all ages suffer from depression.
Among people who live with persistent pain, depression is even more prevalent than it is among the general population. It is estimated that between 40% and 60% of people who live with persistent pain are depressed.[1]
As I said in a previous chapter, I think it helps to consider mental health as a continuum. It is like a sliding scale, with a notch that moves up or down, indicating how good or poor your mental health is at the time. At times in your life, your mental health will be better or worse; you will move up and down the sliding scale… the ‘continuum of mental health’. If you can develop a toolbox of resources that you can use to move towards better mental health, it will benefit you – whether you are depressed or not.
What is Depression?
Depression is a mood disorder characterised by persistent feelings of sadness, a lack of motivation, and a lack of interest in things. The symptoms of depression range from mild to severe. At its mildest, you may just feel persistently low in mood. At the extreme end of the spectrum, you may feel that you just cannot go on and that life is no longer worth living. When you are depressed, the symptoms can persist for weeks or months and can be so bad that they interfere with your work, family, and social life.
The symptoms of depression can be complex and vary a lot between people. I have listed the symptoms of depression below. Even if you are severely depressed, you may not experience all of them. However, the more symptoms that you have, the more likely it is that you are depressed. If you experience a number of these symptoms for most of the day, every day, for more than two weeks, it is worth seeing your GP or doctor about them if you have not already done so.
Emotions
- Feeling sad or low in mood.
- Feeling guilty.
- Feeling upset, numb, or despairing.
- Losing interest or enjoyment in things.
- Crying a lot or being unable to cry when a sad event occurs.
- Feeling alone even when in company.
- Feeling angry and irritable at the slightest thing.
- Feeling anxious or worried.
- Having low self-esteem.
Physical
- Tiredness.
- Lack of energy.
- Restlessness.
- Sleep problems – finding it difficult to get over to sleep and/or waking up very early in the morning.
- Feeling worse at a particular time of the day; for example, in the mornings.
- Changes in appetite leading to weight gain or loss.
- Poor memory or concentration.
- Aches and pains (even among people who don’t live with persistent pain).
- Constipation.
- Reduced interest in sex (low libido).
- Changes to your menstrual cycle.
Behaviour
- Having difficulty making decisions.
- Lacking the motivation to do things, including everyday tasks.
- Putting things off.
- Not doing things that you used to enjoy.
- Withdrawing or cutting yourself off from other people and taking part in fewer social activities.
- Poorer performance at work.
Thoughts
- Losing confidence in yourself.
- Expecting the worst to happen.
- Thinking that everything seems hopeless.
- Thinking that you are helpless.
- Thinking that you hate yourself.
- Thoughts of suicide.
Depression can often come on gradually, so it can be difficult to notice something is wrong. Many people try to cope with their symptoms without realising they are depressed. I have met many people who have been struggling with depression but who had not realised that they were depressed. Sometimes, it can take a friend, family member, or professional to suggest something is wrong.
Let’s look at the physical symptoms of depression that are listed above. You will see that many of them are also symptoms of persistent pain (like sleep difficulties) and that some of them are also side effects of pain medication (for example, constipation, tiredness, changes in appetite). As a result, it can be difficult for people living with persistent pain – and for the health care professionals working with them – to recognise that the person is suffering from depression.
Causes of Depression
There is no single cause for depression. It can occur for a large number of reasons, and it has many different triggers depending on a person’s circumstances. I will discuss some of the factors that can contribute to depression below.
Multiple Stressors
In a previous chapter, I talked about the impact of stressors on our mental health. I explained that if we encounter multiple stressors, we may go on to develop difficulties with anxiety and depression. Common stressful life events – like separation, divorce or bereavement – can contribute to the development of depression.
Living with persistent pain is undoubtedly a significant stressor and you can develop difficulties with depression and/or anxiety as a result. For example, let us consider the experience of a person we will call Max.
When Max developed persistent pain, he began to withdraw from friends, conserving all his energy for work. He was unable to engage in his hobby of playing indoor football two evenings a week, due to his pain, and he began to drink more in an attempt to manage his pain and improve his sleep, which had deteriorated since he developed his pain. This led to a ‘downward spiral’ of events that eventually led to Max becoming depressed.
Adverse Childhood Experiences
A lot of research has been carried out on the impact of adverse childhood events or ACEs on a person’s wellbeing in later life. ACEs are potentially traumatic events that occur in a child or adolescent’s life before they are aged 18. Physical, emotional, and sexual abuse are considered to be ACEs. Experiencing domestic abuse or living with an adult who was a problem drinking is also regarded as an ACE. Parental separation or divorce or feeling that no one in your family loved you or thought that you were important or special is an ACE.
The number of ACEs experienced by someone has a graded relationship to both the prevalence and the severity of depressive symptoms. However, it is important to note that not all children who experience early life stress go on to develop depression or other difficulties with their mental health. Having a significant adult (for example, a grandparent) who loves you, or having a teacher who understands and encourages you, or having a close friend who provides you with emotional support can help mitigate against the effects of these adverse experiences.
Personality
Some people have low self-esteem and tend to be highly critical of themselves. They may be this way because of their experiences when they were growing up. They may have experienced serious adverse events in childhood, like trauma and neglect.
Other people may not have experienced any serious events like this, but they may not have had the emotional support and positive reinforcement from their caregivers that they needed. Decades ago, when many of my patients grew up, parents and teachers were less aware of the importance of praising and encouraging children for achieving small things or for trying hard. Some people’s lack of confidence dates back to their childhood, when responsible adults simply didn’t do enough to encourage children and build up self-esteem.
When people develop persistent pain, their self-esteem can deteriorate further and they can become even more self-critical. Low self-esteem and a tendency towards self-criticism can be significant factors that contribute to the development of depression.
Family History
If a close family member has a history of depression, it is more likely that you will also develop difficulties with depression. However, it is important to remember that even if you have a family history of depression, it is by no means inevitable that you will develop difficulties with depression yourself.
Illness
People who have had a serious illness or a condition such as coronary heart disease or cancer have a higher risk of developing depression. Other conditions like an underactive thyroid (hypothyroidism) can place you at greater risk of developing depression.
Loneliness
In recent times there has been a lot of discussion in the media about loneliness. The headlines scream about a ‘loneliness epidemic’ and it appears that more and more of us feel lonely and disconnected from others, no matter how many friends we have on social media. The need for humans to connect with others is innate; we need human connection to maintain good mental and physical health.
We know that people can feel lonely even if they are around other people; for example, someone who is trapped in an unhappy marriage may feel the burden of loneliness. It is possible that someone who has family and friends who are great fun to have a gossip with, can still lack people to share worries or fears with. Loneliness can increase your risk of developing depression.
Alcohol/Drug Use
When life is hard, and when we feel down, we try to do what we can to cope with it. Many people ‘drown their sorrows’ with alcohol to numb their feelings and try to escape their low mood. Some people use illicit or prescription drugs to try and cope. Unfortunately, this only provides a short-term fix and we know that drugs and alcohol often make depression worse.
Depression and Persistent Pain
As I mentioned earlier on in this chapter, while depression is common in the general population, it is even more common among people who live with persistent pain. We know that some people become depressed after they develop their pain, while others may have been depressed before they developed their pain.
When I consider the high prevalence of depressive episodes among people living with pain, one of the biggest factors that contribute to the development of depression is the multiple losses that people living with persistent pain have to endure. When people first develop their pain, they are often hopeful that their pain will follow the pattern of acute pain; that is, they hope that their pain will improve over weeks or months and that it will eventually resolve. However, as their pain persists, they can begin to experience a large number of losses: loss of self-confidence, loss of social life, loss of hobbies and interests, loss of employment, and financial loss. Their self-concept can change; they no longer feel like the person they were before they developed their pain.
In my experience, people who live with persistent pain can struggle with the changes to their identity. For example, many patients tell me they have struggled with the impact that their pain has had on their working lives, their ability to provide financially for their family, their identity as ‘a breadwinner’. Others have told me that they have struggled with the fact that they now need emotional and practical help and support, themselves. This is particularly true for people who, before they developed their pain, regarded themselves as a person that others could turn to for help.
Grieving for the loss of something or someone that is valued is a normal human response. Loss and grief can be a fundamental part of living with persistent pain. The picture is complicated by the fact that pain can be a hidden condition. If you endure a ‘public’ loss – like the death of a partner – that loss and your grieving will be acknowledged by friends, family, and colleagues. When you live with persistent pain, your losses and associated grieving may not even be noticed or fully appreciated by others. This lack of acknowledgement can be particularly difficult to cope with, and can make it even harder to grieve.
People can change how they think about themselves when they live with pain and depression. Thoughts like, “I am useless,” “I am a burden,” “I am not a good partner,” “I am a failure,” “I am a disappointment” are common. We know that when we are depressed, we can get very caught up and ‘fused’ with the stories that our minds generate about how useless or powerless we are. We can fuse with stories about how hopeless our future is, and feel disempowered and helpless. Everything can become a struggle; even getting up, getting showered and dressed can feel like it requires superhuman effort.
Thoughts and Depression
Let’s look a little closer at the role that thoughts play in depression and low mood. We know that everyone has negative thoughts. However, we also know that people who are depressed are more troubled by negative thoughts. Often, they pay more attention to their negative thoughts and get caught up in them. People sometimes think that a person who is depressed could, and should, just learn to stop these thoughts in their tracks, to stop them from forming in the first place. Unfortunately, it is not as easy as that.
Psychologists describe such negative thoughts as ‘automatic’, because they just pop into our minds instinctively. When people are depressed, they can develop unhelpful thinking styles. Earlier in this book, I mentioned an unhelpful thinking style, one that I notice a lot among people who live with pain; that is the tendency to ‘mind-read’ – to assume that they know what others are thinking about them. I will talk a little more about this, below. There are also a lot of other unhelpful thinking styles that people have.
Comparing Yourself Negatively to Others
It is human nature to compare ourselves to others. We all do it; we are hard-wired to do so. There are some positives associated with comparing ourselves to others. However, when we compare ourselves to others, we often perceive ourselves to be lacking in some way.
Comparison is the thief of joy.
Theodore Roosevelt
You have probably come across this quotation before, but I think it is worth considering. Many times, I hear people comparing themselves to others and concluding that they – or their lives – are lacking in important ways. This can be particularly true for people who are living with depression.
Emma was 18 when she injured her shoulder in a horse riding accident. She had lived with persistent pain in her shoulder since the fall two years ago. Emma had become increasingly aware of the comparisons she made when she used social media. When she went online and checked her social media accounts, everyone seemed to be living ‘their best life’. Everyone appeared happy and seemed to be living fulfilled lives. Her life was difficult and stressful in comparison. She noticed that when she compared her life to that of her friends, as portrayed on social media, her mood was lower.
I know that Emma is not alone in noticing this lowering of mood when she uses social media. I think that many people forget that people always show their ‘best face’ in public and that nobody, no matter how healthy or wealthy they are, lives a charmed life.
Everyone has stressors to cope with in life. That picture of the perfect family holiday doesn’t show the reality of a grumpy teenager, a tired toddler, or a hot and hassled mother. It is just a snapshot that is not reflective of reality. This was brought home to me a couple of years ago when I was on holiday. I overheard a conversation between a young woman and someone who I assumed was her partner. She was asking him to take photographs of her so that she could post one on her Instagram account. Eventually, after about fifteen minutes, much posing, a few irritable exchanges – and what appeared to be hundreds of photographs – she seemed satisfied with one photograph. The people viewing that photograph only saw the finished product and not the ‘real life’ that went on behind it. They only saw a heavily edited view of that one day on holiday.
If you notice that your mood is lower after using social media, consider taking a break from it or not following those people who make you feel less than adequate. Some people have stopped using social media completely, and they report that their mood is better as a result. Consider whether this might be an option for you.
Even if you don’t use social media, I am quite sure that you frequently compare yourself to other people. Many patients have spoken to me about the stories that this comparison generates in their minds. “Joanne brought her daughters for a full day shopping. You are an awful mother; all you can manage is a couple of hours in the shops” or “the Jones are going to Florida for a big family holiday. My children are never going to get to do that because I am only able to work part-time because of my pain” or “Rebecca is twenty years older than me, and she is so much fitter,” and so on and so on.
By tuning into your mental chatter, you can begin to notice these comparison stories. By becoming more aware of your comparison stories, you can stop yourself from getting hooked on them, and this can help stop you from spiralling into negativity.
Mind Reading
As I stated before, we often engage in mind reading – we assume that we know what other people are thinking. Often, this mind reading is focused on what others are thinking about us, and we typically assume that their thoughts about us are negative or critical in some way.
For example, you may notice somebody watching you walk slowly and believe, “They think that I am putting this on, that I am only looking for attention” or “He thinks there is nothing wrong with me, that I am just being lazy.”
Psychologists know that people are very poor mind readers, that non-verbal communication is hard to interpret, and that we often make mistakes when we try to work out what other people are thinking. My experience is that mind reading can be problematic for people who live with pain; they can start avoiding social contact as they believe that other people are judging them or thinking negatively about them. This avoidance of social contact can have a very significant negative impact on psychological wellbeing and quality of life. As I said earlier in this chapter, social contact and staying in touch with family and friends are very important for a person’s wellbeing.
You can work with your tendency to mind read by becoming aware of your thoughts. If you notice that you have started to ‘mind read’, you can take a break from it by bringing your awareness back to your breath or your body. By becoming aware of your breath – even for the duration of just three breaths – you can break that cycle of negative thinking. By bringing your awareness back to your body, by noticing how your feet feel on the ground, or the contact that your body is making with the chair, you can prevent the escalation of suffering by stopping your thoughts and stories taking over.
Mental Filter
You have probably heard the old saying about seeing the world through ‘rose-tinted glasses’. We all wear glasses or use a lens when we think about ourselves, the world, and our future. Our beliefs colour the way that we see the world. When someone’s mood is low, they are drawn towards noticing the negative aspects of life.
When you are living with pain every day, it is very easy to get drawn into only noticing how difficult life is, and failing to see the more positive aspects of your life.
It can feel as though a negative filter has permanently slid across your mind’s eye. When you have your negative mental filter in place, your mind can generate all sorts of stories to explain why positive events don’t count; for example, “My friend really didn’t enjoy my company tonight, she was just being nice when she said that she had a good time.”
It can be helpful to become aware of your thoughts and notice when you are using a negative mental filter to look at the world.
Critical Self
As I have said before, most of us have an internal critic – that voice that likes to put us down and criticise. When you become more aware of your thoughts, you develop the capacity to notice self-critical stories. You may notice that you apply labels to yourself, for example, labelling yourself by saying things such as, “I am a total idiot,” “I am a waste of space,” “I am pathetic.”
You may have noticed that since you developed persistent pain, your internal critic has become very vocal; frequently commenting on what you can no longer do and what you should be doing. Often this critic will refer back to your life before pain and compare what you are doing now with your previous life. The internal critic does not carry out this comparison in a compassionate and supportive way; it does so in a harsh, judgemental way.
By becoming aware of your thoughts, you will be able to recognise when this internal critic is to the fore. If you develop the capacity to observe the critic, you are less likely to get drawn into the stories he/she tells you, and you will be better able to see the criticism for what it is; stories and projections in your mind.
Catastrophising
If your mood is low, or if you are depressed, you are likely to catastrophise about your situation. We all catastrophise at times, and when we catastrophise, we make things out to be much worse than they really are. For example, you might make a mistake at work and get caught up in stories of how you are going to lose your job as a result. If you are experiencing a flare-up of your pain, you might get caught up in thoughts like, “This is awful, I can’t stick another minute of this” and “I can’t go on like this” or “What if this never ends, what if the pain doesn’t ease?”
Again, developing the capacity to become aware of your thoughts and making the decision to bring your awareness back to your body or your breath, even for a few moments, can prevent you from getting caught up in those stories in your mind. You can learn to become an observer of your mind and, in doing so, begin to recognise that this is the ‘catastrophising’ passenger in your mind speaking. You can remember that you, like all people, are wired to overestimate threat and that you can choose not to take on board your mind’s dire predictions.
All or Nothing Thinking
We know that thinking in an ‘all or nothing’ way can have a negative impact on our mood. We can use Jane’s experience as an example of this.
Jane was very close to her cousin. Her cousin’s hen party involved an outdoor activity centre for the day, followed by dinner and drinks in the evening with an overnight stay. Jane was very dismayed when she heard about the activities planned for the hen party and decided to cancel, due to her inability to participate in the daytime activity because of the pain she suffered. She immediately discounted the fact that she could fully take part in the rest of the hen party but – in her mind – if she couldn’t take part in all of the hen party, she wasn’t taking part in any of it.
When Jane reflected on this, she realised that she was missing out on an important event in her life and that she could choose to listen to her inner voice saying, “There is no point in going unless you can take part in it all” or she could choose to move towards her values and attend the hen night. In the end, she attended the hen night and was glad to enjoy this special event with her cousin.
In this chapter, we have looked at the symptoms of depression and some of the causes of depression. We have also explored how thoughts influence mood.
In the next chapter, I will explore strategies that have been shown to help manage difficulties with low mood and depression and improve mental health.
Things to Remember
- Depression is one of the most common worldwide mental health problems.
- It is estimated that between 40 and 60% of people who live with persistent pain are depressed.
- Multiple factors lead someone to develop difficulties with depression.
- Everyone experiences negative thoughts. People who are depressed are more troubled by them, and they engage in unhelpful thinking styles more frequently than others who are not depressed.
- If you believe that you are depressed, or experiencing low mood, turn to the next chapter to discover some strategies that have consistently been shown to help manage these difficulties.
[1] Bair, M. J., Robinson, R. L., Katon, W & Kroenke, K (2003) Depression and comorbidity: A literature review. Archives of Internal Medicine, 163, 2433-45.