Depression afflicts 50 percent of chronic pain patients*, and some have estimated the figure to be much higher**. Most experts agree that symptoms of depression occur following the onset of pain and are more likely to be present in people who are psychologically susceptible (Sullivan et al. 2001).

In addition, people with chronic pain seem to experience more problems with anxiety than the general population (Craig 1994). Fears of reinjury and pain, worries about future losses (especially of functional abilities and finances), and a sense of threat of psychological harm from the stress and strain of chronic pain are common (Rosensteil and Keefe 1983). Anxiety, when present, contributes to higher levels of distress and disability associated with chronic pain (Waddell et al. 1993).

Anger is also a frequent problem for many people with chronic pain (Fernandez and Turk 1995). Patients in our clinic often report feeling more irritable and angry after the onset of their pain. Anger, in turn, interferes with activities and increases pain intensity and symptoms of depression (Tearnan and Lewandowski 1992; Kerns, Rosenberg, and Jacob 1994), fueling a vicious cycle. Anger may also significantly interfere with motivation and acceptance of treatment goals in people with chronic pain (Gatchel 2005).

Depression, anxiety, and anger have another debilitating effect: They often make people believe they’ve changed into someone they don’t like—a person who is always angry and discontented, someone indecisive and lacking confidence, a shell of their former self. And in fact, it is difficult to feel or think like your former self when you’re depressed, anxious, or angry. However, you haven’t lost the things you cherish about yourself— your values and core beliefs. They still reside within you.

Before working on specific techniques to improve your mood, you need to understand the nature of depression, anxiety, and anger. This will help you recognize when you’re having problems. Also, bear in mind that negative emotions rarely exist in isolation. When people are angry, they’re often depressed and anxious. The suggestions and interventions in this chapter are effective in modifying all three negative emotions.

Tools for Enhancing Emotional Well-Being

It’s misleading and harmful to assume that negative mood is the inevitable consequence of chronic pain and therefore normal. This belief implies that eliminating your pain is the only way you can restore your emotional well-being and reduce your suffering. But in fact, there are many techniques you can use to enhance your emotional well-being in spite of your pain. This will be extremely helpful, as negative unrealistic beliefs can trigger a negative mood. Also consider referring to The Feeling Good Handbook by David Burns (1999), an excellent source for understanding and implementing strategies to change nonproductive belief patterns associated with negative mood.

Take Time to Relax

Negative mood and physiological arousal go hand in hand, especially when you’re feeling anxious and angry. Tense muscles, a churning stomach, racing thoughts, and worry are common symptoms reported by people in pain. Learning to relax is a useful skill and one that has been shown to have significant health benefits, including lowering blood pressure and improving sleep.

You may have found that the hardest thing about relaxing is giving yourself permission to sit down quietly and take a few minutes to unwind. You may say to yourself that you’re too busy, and you may view relaxation as akin to laziness. Or you might think, “I’m already doing hardly anything as it is. Why would I want to be less active?” Relaxation is not laziness, nor is it doing nothing. It involves active concentration on thoughts, feelings, and bodily sensations and is worthwhile because it promotes a general sense of well-being. It doesn’t take a lot of time, and it won’t seduce you into wanting to do less and less, as some people fear.

Relaxation will also help you gain more of a sense of personal control, though the reason may sound paradoxical. To relax, you need to learn to feel more comfortable letting go of control. But by letting go of control, you actually put yourself in more control; in a sense you’re telling your emotional brain that everything is fine and you aren’t in any danger. Otherwise, you wouldn’t be letting go! Letting go also is a way of moving toward, not away from, your pain, and this can help counter nonproductive beliefs about negative outcomes. When you truly give up control, you allow yourself to feel whatever comes to you, including your pain. You are in a sense making a very strong statement that the “pain won’t hurt me, won’t destroy me.” The more you learn to relax and feel whatever comes to you, the more you’ll be able to tolerate painful sensations instead of believing you have to block them constantly from your awareness.

There are many ways to relax. You’re probably already taking time out to passively relax by doing things like listening to music, resting, and taking short walks. However, active relaxation techniques will produce more benefits, including deeper feelings of relaxation and lower levels of muscle tension. Learn a relaxation technique that includes controlled breathing, letting go of muscle tension, and focused concentration. Guided relaxation, slow breathing, and biofeedback, discussed below, are all recommended. But do stay away from progressive muscle relaxation. Although it incorporates all of these aspects and is useful for many people, it requires tensing and releasing various muscle groups, which can trigger more gain in people with chronic pain problems.

Relaxation therapy is best if practiced daily. During your relaxation practice, turn off your phone and ask others not to disturb you. Set aside the countless things that must be done and give yourself permission to enjoy the benefits of letting go and relaxing.

Exercise: Choosing Mastery Experiences

Use the list of mastery experiences below as a starting point for generating a list more pertinent to you. Pick those activities you think will help counter your beliefs of helplessness and add anything else that suggests itself to you.

• Meeting your daily pacing goals
• Having a lively or open and frank talk with family or friends
• Playing chess, checkers, or other games
• Writing a letter to an old friend
• Helping someone or volunteering in your community
• Building something
• Making a special meal
• Painting a picture, doing crafts, playing music, and other creative endeavors
• Driving skillfully
• Suggesting to your doctor or physical therapist something you might try, such as a new exercise
• Cleaning or redecorating a room
• Paying bills
• Working in your garden

*Fishbain et al. 986

**Romano and Turner 1985

excerpt from 10 Simple Solutions to Chronic Pain: How to Stop Pain from Controlling Your Life by Blake H Tearnan Ph.D.