My Treatment: Pelvic Pain - Treatment Options: Psychology of Pain

Pelvic Pain Psychology of Pain

Psychological factors may increase the likelihood that pain will become chronic; however, chronic pelvic pain and vulvar pain rarely result from a psychological disorder. Most women with pain will have a significant degree of anxiety, depression, sexual dysfunction and social withdrawal. There also is higher prevalence of major depression, affective disorder, panic disorder, somatization disorder (the brain assigns pain to a specific area that appears normal), and sexual abuse as well as physical abuse in women with chronic pelvic pain. Therefore, the majority of patients with chronic pelvic pain have abnormal psychological profiles; however, the patients without obvious causes for their pain do not appear to be psychologically different from those who have diagnosed disease. Trigger points, nerve entrapments, pelvic congestion syndrome, interstitial cystitis, irritable bowel syndrome, excessive pain with endometriosis and adhesions are all common sources of pelvic pain which can create changes in the central processing of signals entering the spinal cord and brain from the more distant structures. The psychological state can certainly play a role in sensitizing "the nervous system" — either by increasing transmission of ascending impulses or decreasing signals — and inhibit normal pain processes that can contribute to long-term pain.

Clinical Depression: What Pain Patients Need to Know
You hope to find a physician who respects and believes in you and the pain and suffering that you have experienced so far. But this validation of you and your experience can only go so far in helping you.

What you need more is a logical, systematic, coordinated, and comprehensive strategic plan to help you get better. This plan includes the involvement of several other approaches, disciplines and colleagues including the following:

a medication regimen to help allay the pain experience

local anesthetic nerve blocks to decrease the pain signal where it originates

physical therapy to give relaxation and strength of adjoining muscles, ligaments and tendons

psychology to assist with the mental anguish that accompanies pain, and

personal empowerment or development of inner strength.

What about depression then? What is the cause? Who is at risk? How can it be identified? Can it be treated? Patients with pain have enough problems to attend to without the added burden of depression. This brief descriptive about depression is to acquaint you with some of the signposts so you can identify it yourself and report it early on before it takes a heavy toll in regard to happiness and eventual recovery.

There is no single cause of depression. It can occur anytime and can last a variable time period. Sometimes a combination of biological, psychological, and environmental factors may generate a risk for depression when before there was none. These factors include hormonal fluctuations, sleep deprivation, mood swings, and feelings of loss, shame, or even guilt.

For some, there may be uncontrollable crying, sadness, even loss of self-assurance. In others, there may be mood swings. Some may develop feelings of hopelessness and despair. Many women who suffer from clinical depression have feelings of confusion, irritability, anxiety and psychosis. Symptoms of clinical psychosis include feelings of inadequacy, mood swings, hallucinations or delusions. It should be noted that some women get better on their own, but many others do not. These women can end up much worse over time and sometimes their recovery can be delayed substantially. The pathway to successful recovery is based upon detection and immediate treatment, not delay and isolation.

Where can you go for help? Can clinical depression be prevented? What are logical first steps in recognizing you may have clinical depression? One of the first steps should be a medical evaluation that includes a comprehensive thyroid screening. It is interesting that about 10% of women who develop depression have a history of thyroid illness. Often, women who suffer clinical depression in silence know something is wrong, but due to feelings of guilt or shame, will not ask for help. Try to talk about feelings. Don't hide them from those who can help you. The sooner you get help, the better off you'll be.

You may be surprised or hurt when the doctor you trust refers you for a psychological evaluation, especially if your doctor says he or she believes you and that your pain is not in your head. If this is the case, why then is a referral to a psychologist necessary?

Your current pain and physical distress are considered real and valid. Unfortunately, the misunderstandings about where the pain is coming from are confusing and often the reason your pain may not be identified for some time. Actually, a psychological evaluation during a pain work-up is becoming more and more common. In time, it may even become a routine procedure, used to help your doctor in developing the best plan possible for you. We know that pain and suffering create emotional and social stresses that eventually affect the way you respond to all sorts of stimuli, including medical therapy. This can significantly affect your recovery even if your doctor has the correct diagnosis and has initiated the correct therapy.

Findings from this psychological evaluation can help your doctor to help you with development of a better plan for getting you well again. Completion of this type of evaluation can also help to identify and uncover some concerns that were not even considered. This type of complete understanding of your psychological status can help you personally to become stronger and give you an opportunity to resolve many "unrecognized problems" and thus enhance your ability to heal and become strong again.

You should meet with a qualified, experienced psychologist. Typically such meetings consist of an interview and then testing as decided for your particular case. Psychologists play an important role in helping doctors to help you for the following reasons noted below:

People with illness or injury undergo great turmoil and stressful times that they often do not even realize. When pain or stress build up, other problems can arise. This can cause certain personality changes that may include family discord and disharmony and also problems in the workplace. Some patients also have difficulty sleeping.
The above may trigger other alterations regarding work that include the stress of losing one's job or getting less pay for a period of time.
Conflicts in the workplace also may cause more stress and affect our feelings of self-worth. Happiness may disappear and be replaced with loneliness, despair and depression.
Certain medications may be necessary to help you on the road to recovery and may in fact, speed up your return to good health.
Some of the alternative treatment methods may be indicated and may be recommended by the psychologist. Also some of the pain conditions have been found to be responsive to treatments that are administered by psychologists themselves, including biofeedback and psychotherapy sessions.

Cognitive behavioral therapy
Cognitive behavioral therapy is a treatment modality useful in teaching and promoting coping skills, allowing the patient the ability to deal with contributing stresses and reverse the adverse outcomes of chronic pain. The treatment includes phases of education, skills acquisition, behavioral modification, and maintenance.¹ Examples of such treatment include muscle relaxation, deep breathing, distraction techniques and imagery, which decrease generalized muscle spasm and arousal.² An important goal of this type of therapy is to succeed in overcoming the fears of daily life activities, including returning to work.

Progressive activity programs are useful in increasing physical activity and decreasing disability behaviors, thus helping to decrease the effects of chronic pelvic pain.³ Stress management is essential to any effective cognitive behavioral therapy. This can be attained by learning to identify and attempt to alter these stresses in conjunction with providing support in avoiding stresses. These goals are coordinated with education and understanding of the importance of nutrition, exercise, sleep, relaxation and avoidance of substance abuse and are attainable in most cases.⁴ As is seen with both interstitial cystitis and irritable bowel syndrome, dietary modifications, such as a decrease in acidity, and avoidance of stimulants, such as alcohol and caffeine, will help control symptoms and allow patients a better quality of life.

References:

Milburn A, Reiter RC, Rhomberg A. Multidisciplinary approach to chronic pelvic pain. Obstet Gynecol Clin N Am 1993;20:643-661.
Holzman AD, Turk DC, Kerns RD. The cognitive-behavioral approach to the management of chronic pain. In:Holzman Ad, et al. Pain management: A handbook of psychological treatment approaches. New York: Pergamon, 1986.
Hanson RW, Gerber KE. Coping with chronic pain: a guide to patient self-management. New York: Guilford, 1990.
Milburn A, Reiter RC, Rhomberg A. Multidisciplinary approach to chronic pelvic pain. Obstet Gynecol Clin N Am 1993;20:643-661; Hanson RW, Gerber KE. Coping with chronic pain: a guide to patient self-management. New York: Guilford, 1990.