Living a Healthy Life with Chronic Pain (10 page)

Sleep apnea can be a serious or even life-threatening medical problem. It has been linked to heart disease and stroke. Sleep experts suggest that people should be evaluated for sleep apnea or other disorders if they are tired all the time in spite of a full night’s sleep or need more sleep now than when they were younger. It is especially urgent that you are checked if you (or your spouse) report snoring.

You can self-manage many sleep problems with the techniques we have discussed, but there are times when you need professional assistance. When should you get help?

• If your pain causes sleep problems two to three times a night and you are unable to fall asleep in a timely manner once you awaken
  

• If poor-quality sleep continues to seriously affect your daytime functioning (your job or your social relationships), after you have faithfully followed the self-help program described in this chapter
  

• If you have great difficulty staying awake during the day and your daytime sleepiness causes or comes close to causing an accident
  

• If your sleep is disturbed by breathing difficulties, including loud snoring with long pauses, chest pain, heartburn, leg twitching, or other related physical conditions
  

• If your sleep problems are accompanied by depression or problems with alcohol, sleeping medications, or addictive drugs
  

Don’t put off asking for help. Most sleep problems can be addressed. Once sleep is improved, many people find that there is an improvement in their chronic pain and their mood.

Most people with chronic pain feel depressed sometimes. Scientists think that an imbalance of certain chemicals in your brain (such as the neurotransmitters serotonin and norepinephrine) is involved in chronic pain, depression, and sleep disorders. Just as there are different degrees of pain, there are different degrees of depression. These range from feeling occasionally sad or blue to serious clinical depression. Clinical depression, which is also referred to as major depression, is characterized by a constant feeling of hopelessness and despair. About 27 percent of people with chronic pain who seek the care of a family doctor experience clinical depression. The rate of clinical depression is even higher for those who attend a pain clinic.

Sometimes a person may not realize he or she is depressed. And often people do not want to admit to being depressed. How you handle depression makes the difference.

Feeling sad sometimes is natural. “Normal” sadness is a temporary feeling, often linked to a specific event or loss. We sometimes mistakenly use the word
depressed
to describe feeling sad or disappointed: “I’m really depressed about missing out on visiting with my friends.” In these circumstances we feel sad, but we can still relate to others and find joy in other areas of our lives.

Sometimes sadness affects you more deeply or lasts longer, as when you lose a loved one or are diagnosed with a serious illness. If, however, those sad feelings are especially severe, long-lasting, and recurrent, you may be experiencing clinical depression. Clinical depression drains the pleasure out of life, leaving you feeling hopeless, helpless, and worthless. With clinical depression, you may become numb, and even crying brings no relief.

Depression affects everything: the way you think, the way you behave, the way you interact with others, and even the way your body functions.

Depression is not caused by personal weakness, laziness, or lack of willpower. Heredity, chronic pain conditions, medications, even the weather may all play a role in depression. The way you think, especially negative thoughts, can also produce and sustain a depressed mood. Negative thoughts associated with depression can be automatic, recur endlessly, and often are not linked to any event or triggering cause.

Certain feelings and emotions also contribute to depression. They include:

• Fear, anxiety, or uncertainty about the future.
  Worries about finances, your family, or your pain condition or treatment can lead to depression. If you face these issues as soon as possible, both you and your family will spend less time worrying and have more time to enjoy life. This can have a healing effect. We talk more about these issues and how to deal with them in
  Chapter 20
  .
  

• Frustration.
  Frustration can have many causes. You may find yourself thinking, “I just can’t do what I want,” “I feel so helpless,” “I used to be able to do this myself,” or “Why doesn’t anyone understand me?” The longer you accept these feelings, the more alone and isolated you are likely to feel.
  

• Loss of control over your life.
  When you are living with chronic pain, many things can make you feel like you are losing control. These include having to rely on medications, having to see a doctor on a regular basis, or having to count on others to help you do things you used to do yourself. Feeling like you have lost control can make you lose faith in yourself and your abilities. Even though you may not be able to do everything yourself, you can still be in charge. Remember: as a self-manager, you are the coach for your team.
  

A person may not even realize they have depression, or they may feel it but attempt to hide it. Sometimes unrealistic cheeriness masks what a person is really feeling, and only the wise and sensitive observer recognizes the brittleness or phoniness of the mood. Refusal to accept offers of help, even in the face of obvious need for it, is a frequent symptom of unrecognized depression.

Depression can lead to withdrawal, isolation, behavior is that the more you engage in isolaand cessation of physical activity. These behav-tionist behavior, the more you drive away the iors can cycle back to create more depressed people who can support and comfort you. Most feelings. The paradox of depression-related of our friends and family want to help us feel
better, but often they don’t really know what to do. As their efforts to comfort and reassure us are frustrated, they may eventually throw up their hands and quit trying. Then the depressed person winds up saying, “See, nobody cares.” This again reinforces the feelings of loss and loneliness.

All these factors, along with chronic pain itself, can contribute to an imbalance in the chemicals in your brain called neurotransmitters. This imbalance can result in changes in the way you think, feel, and act. Thinking and behaving in a more positive, proactive manner can be a powerful and effective way to change your brain chemistry, lighten depression, and even simply improve ordinary bad moods.

The most effective treatments for depression are antidepressant medications, counseling, and self-help. We discuss each of these in the material that follows.

Antidepressant medications that help balance brain chemistry are highly effective. They can also help relieve pain directly, lessen anxiety, and improve sleep (see
Chapter 16
). It can take several days to several weeks for most antidepressant medications to begin to work. Then they usually bring significant relief. Don’t be discouraged if you don’t feel better immediately. Stick with it. To get the maximum benefit you may need to take some medications for six months or more.

Side effects of antidepressant medication are usually most noticeable in the first few weeks and then lessen or go away. If the side effects are not especially severe, continue to take your medication. As your body gets used to the medication, you will begin to feel better. It is important to remember to take your medication every day. If you stop because you’re feeling better (or worse), you may relapse. Antidepressant medications are not addictive. If you have significant side effects or if the medications are not helping, talk with your doctor before stopping or changing the dose.

Several types of psychotherapy, particularly cognitive-behavior therapy, can be highly effective in relieving symptoms of depression. As with medications, counseling rarely has an immediate effect. It may be weeks (or longer) before you see improvement. Therapy time can be brief, usually involving one to two sessions a week for several months. By teaching you new skills and ways to think and relate, psychotherapy may also help reduce the risk of recurrent depression.

Self-help for depression can be surprisingly effective. You can learn many psychotherapy techniques on your own. For mild to moderate depression or just to lift your mood, the self-management strategies discussed here can be very productive. One study showed that reading and practicing self-help advice improved depression in nearly 70 percent of patients.

These skills and strategies can be used alone or to supplement medications and counseling.

• Eliminate the negative.
  Being alone and isolating yourself, crying a lot, getting angry and yelling, blaming your failure
  or bad mood on others, or using alcohol or other drugs usually leaves you feeling worse. Tranquilizers or narcotic painkillers such as Valium
  ^®
  Librium
  ^®
  , Restoril
  ^®
  , Vicodin
  ^®
  , codeine, sleeping medications, or other “downers” intensify depression or may cause depression as a side effect. However, if you have been prescribed one of these medicines, do not stop taking it before first talking with your doctor. There may be important reasons for continuing its use, or you may experience withdrawal reactions.
      Alcohol is also a downer. For most peo ple, one or two drinks in the early evening is not a problem, but if your mind is not free of alcohol during most of the day, you are having trouble with this drug. Talk this over with your health care provider or seek help from Alcoholics Anonymous.
  

• Plan for pleasure.
  When you are feeling blue or depressed, the tendency is to withdraw, isolate yourself, and restrict activities. That is, in fact, the wrong thing to do. Maintaining or increasing activities is one of the best antidotes for depression. Go for a walk, look at a sunset, watch a funny movie, get a massage, learn another language, take a cooking class, or join a social club. Activities like these can help keep your spirits up and prevent you from falling into a depression.
      But sometimes having fun isn’t such an easy prescription. You may have to make a deliberate effort to plan pleasurable activities. Don’t leave good things to chance. Consider making a schedule of what you’d like to do with your free time during the week. Even if you don’t feel like doing it, try to stick to your activity schedule. That nature walk, cup of tea, or half hour of listening to music may well improve your mood despite your initial misgivings.
      If you are feeling hardly any emotion and the world seems devoid of color, make an effort to put some sensation back into your life. Go to a bookstore and look through your favorite section. Listen or dance to some upbeat music. Exercise or schedule a massage so you can reconnect with your body. Eat some spicy food. Treat yourself to a fragrant herbal bath, or try a cold shower. Go to a garden center and smell all the flowers.
      Make plans and carry them out. Look to the future. Plant some young trees. Look forward to your grandchildren’s graduation from college even if your own kids are in high school. If you know that one time of the year is especially difficult, such as Christmas or a birthday, make specific plans to be active during that period. Don’t wait to see what happens. Be prepared.
  

• Take action.
  Continue your daily activities. Get dressed every day and take pride in your appearance. Make your bed, get out of the house, go shopping, walk your dog. Plan and cook meals. Force yourself to do these things even if you don’t feel like it.
      Taking action to solve your most immediate problems provides the surest relief from negative feelings. More important than what you change or how much you change are the confidence-building feelings that come from successfully changing something—anything! Taking action is the important thing. You might decide to clean or
  reorganize a room, for instance, or a closet or even a desk drawer. Even a single simple action can boost your mood. Get a new magazine subscription, or call an old friend.
      When you are feeling emotionally vulnerable, do not set difficult goals for yourself or take on a lot of responsibility. Break large tasks into small ones, set some priorities, and do what you can as best you can. Learn some of the proven steps for taking successful action (see
  Chapter 2
  ). It may be wise not to make big life decisions when you are feeling depressed. For example, don’t move without first visiting the new setting for a few weeks and learning about the resources available to you in this new community. Moving can be a sign of withdrawal, and depression often intensifies when you are in a location away from friends and acquaintances. Besides, many troubles may move with you. At the same time, the support you may need to deal with your troubles may have been left behind.
  

• Socialize.
  Don’t isolate yourself. Try to seek out positive, optimistic people who can lighten your heavy feelings. Make an effort to see family and friends you enjoy. Get involved in a church group, a book club, a community college class, a self-help class, or a nutrition program. If you can’t get out, consider joining a group on the Internet. If you join an online group, be sure it is moderated—that is, that someone is in charge to enforce the rules of the group.
  

• Move your mood.
  Physical activity lifts depression and negative moods. Depressed people often complain that they feel too tired to exercise. But the feelings of fatigue associated with depression are not due to physical exhaustion. Try to get at least 20 to 30 minutes of some type of exercise every day. It can be walking, yard work, chair dancing—anything. If you can get yourself moving, you may find that you have more energy (see
  Chapters 7
  to
  9
  ).
  

• Think positive.
  Many people tend to be excessively critical of themselves, especially when they’re depressed. You may find yourself thinking groundless, untrue things about yourself.
      Challenge your automatic negative thoughts by rescripting the negative stories you tell yourself (see
  Chapter 5
  ). For example, one of your underlying beliefs may be, “Unless I do everything perfectly, I’m a failure.” Perhaps this belief could be revised to, “Success is doing the best that I can in any situation.” Also, when you are depressed, it’s easy to forget that anything nice has happened at all. Make a list of some of the good or positive events in your life.
  

• Do something for someone else.
  Lending a helping hand is one of the most effective ways to change a bad mood, but it is one of the least commonly used. Arrange to babysit for a friend, read a story to someone who is ill, or volunteer at a soup kitchen. When you’re depressed, you may greet this advice with thoughts like, “I’ve got enough troubles of my own. I don’t need anyone else’s.” But if you can bring yourself to help someone else, even in a small way, you’ll feel
  better about yourself. Feeling useful is good for self-esteem, and you will be temporarily distracted from your own problems. Helping others who are needier than yourself can help you appreciate your own assets and capabilities. Your problems and difficulties may not appear as overwhelming. Sometimes helping others is the surest way to help yourself.
      Don’t be discouraged if it takes some time to feel better. If, however, these self-help strategies alone are not sufficient, seek help from your physician or a mental health professional. Often some “talk therapy” or the use of antidepressant medications (or both) can go a long way toward relieving depression. Seeking professional help and taking medications are not signs of weakness. They are signs of strength.