Chronic pain is complex, and it may begin with an injury, condition, or physical source, the way it’s processed involves the brain, spinal cord, nervous system, emotions, and ultimately, our overall mental health.
For Mental Health Awareness month, we talked to William Hudson, MD, who treats patients at Commonwealth’s Paducah, KY location, about the connection between mental health and chronic pain.
Below, read what he says about pain, why it should never be dismissed as “all in your head,” and how a comprehensive approach to treatment can help patients stay motivated and find hope on even their toughest days.
Q: When we talk about the brain’s role in chronic pain, does that mean the pain is “all in your head”?
Dr. Hudson: No, and I think that is a really important distinction.
Our pain processing system requires the brain. When we experience a physical stimulation or an unpleasant sensation somewhere in the body, the brain is involved in interpreting that pain. But that does not mean the pain is imaginary or not real.
Some patients have been told, or have felt that they were being told, “We don’t see anything wrong with you, so this must be in your head.” That can be very frustrating and discouraging.
Now, there are chronic pain conditions, including complex regional pain syndrome and other pain syndromes, that may not show obvious findings on an MRI, X-ray, or nerve study. But that pain is still real to the patient. It is also being processed in the brain, often in some of the same areas involved when someone experiences severe trauma or significant physical pain.
So yes, the brain is involved. But that does not mean the pain should be dismissed. We have to be careful in how we explain this to patients because psychological support can be an important part of treatment, but patients should never hear that as, “Your pain is not real.”
Q: How do anxiety, depression, stress, or trauma affect chronic pain?
Dr. Hudson: We see this connection every day in chronic pain care. There is a mind-body connection.
Emotional stress, fear, trauma, anxiety, and depression can influence pain signals. Over time, they can amplify those signals. This can happen throughout the nervous system, from the area where the pain begins, to the spinal cord, and into the brain.
Depression and anxiety can also change a patient’s perception of pain. If someone already has chronic depression, even if it started separately from the pain, their experience of pain can be worse. Then the depression and pain can become tied together and create a snowball effect.
Part of the reason this happens is that mood and pain share some of the same pathways. Serotonin and norepinephrine, for example, are involved in mood, depression, cognition, and anxiety, but they are also involved in blocking and sensing pain signals.
That overlap is one reason it can be difficult to manage chronic pain without also addressing mental health.
Q: Can chronic pain actually change the brain over time?
Dr. Hudson: Yes. One of the fascinating things we see in chronic pain is a process called neuroplasticity, which is the brain’s ability to change over time.
Neuroplasticity can be positive or negative. In chronic pain patients, it can lead to physical and chemical changes in the brain. Certain areas, including the prefrontal cortex, may be affected. That area is involved in worry, anxiety, pessimism, decision-making, and other functions.
When chronic pain affects those areas, patients may experience brain fog, worsening depression, increased anxiety, and a stronger perception of pain.
This can become a difficult cycle. Once the nervous system and brain have adapted to chronic pain, it can be harder to get out of that pattern. That is why it is important to address each part of the problem. If we only treat one piece, such as pain with medication alone, we may miss other factors that are keeping the patient stuck.
But pain management has evolved. We now understand that a multimodal approach is often more effective. That may include medications, procedures or injections, physical therapy, mental health support, stress management, and other tools.
Q: What types of mental health support can help people with chronic pain?
Dr. Hudson: Cognitive behavioral therapy, or CBT, is one of the most studied approaches.
CBT can be done individually or in a small group setting with someone trained in that type of therapy. It focuses on some of the negative feedback loops that can develop around chronic pain. Patients may begin to feel hopeless, fearful, or pessimistic about their pain and their future. CBT can help patients recognize and change some of those patterns.
That does not mean we are telling patients the pain is not real. It means we are helping reduce the impact chronic pain has on their life.
Another approach is pain reprocessing therapy. It is similar in some ways to CBT and involves working with a counselor or therapist to change how pain signals affect the patient day to day.
Stress management is also very important. When we improve stress, mood, anxiety, and depression, we may also decrease the intensity of pain. It is very difficult to manage someone’s depression if they are in chronic pain, and it is very difficult to manage chronic pain if their depression and anxiety are not being addressed.
They overlap very closely.
Q: Why does chronic pain affect motivation and daily function?
Dr. Hudson: Chronic pain can have a major impact on motivation.
There was a study involving mice that looked at pain and motivation. Researchers found that after about a week of pain, the mice showed less motivation to do things they would normally want to do. What was especially interesting was that when they were given medication that relieved the pain, their motivation still did not immediately return.
That tells us pain is multifactorial. If we only address pain itself but do not address the effects it has on mood, motivation, anxiety, and overall well-being, we are not treating the whole patient.
We see this in people with chronic pain. A patient may want to get back to work, go out, exercise, or enjoy life, but the pain has affected their motivation and their confidence.
That is why small improvements matter. If a patient has had pain for years, it may take time to improve. But if we can make little gains month by month, that can help restore motivation, reduce pessimism, and improve function.
Q: Are medications for depression or anxiety ever used in chronic pain treatment?
Dr. Hudson: Yes. Some medications that are often associated with depression or anxiety can also be helpful in chronic pain.
Duloxetine, also known as Cymbalta, is one of the most commonly used examples. It has been approved for certain types of chronic pain, including neuropathic pain.
What is interesting is that patients may sometimes get improvement in pain at a lower dose than what might be required to treat clinical depression. These medications affect serotonin and norepinephrine, which are involved in mood but also help modulate pain.
Some patients will say, “My pain is a little better, but my overall outlook also seems better.” That tells us these medications can sometimes help in more than one way.
Other commonly used medications in pain management include certain seizure medications, which also affect the brain and nervous system pathways involved in pain processing.
Of course, medication decisions should be made carefully based on the patient’s individual symptoms, medical history, and treatment goals.
Q: What would you say to patients who feel discouraged or dismissed because of chronic pain?
Dr. Hudson: I would remind them that they are not alone.
Many chronic pain patients feel isolated, depressed, or at their wits’ end. They may have seen several doctors and still not found the relief they were hoping for. That can be extremely frustrating.
But their pain is not just “in their head.” It is related structurally, chemically, and physically to the brain, spinal cord, and the areas where pain signals are generated.
The encouraging thing is that some of the changes that happen in the brain and nervous system do not have to be permanent. If we can control the pain more effectively and also address depression, anxiety, stress, and motivation, patients can often improve.
Some people may always have some degree of chronic pain, but if the brain and nervous system become healthier, the overall effect of that pain can decrease. Patients may have less anxiety about waking up with pain, more motivation, and a better ability to function.
When we address both the physical pain and the mental health side, improvement in one area can help the other. That can create a snowball effect in the right direction.
About Dr. William Hudson
William Hudson, M.D. earned his Bachelor of Science in Biology from Murray State University and his Doctor of Medicine from the University of Louisville School of Medicine. Following his medical degree, Dr. Hudson embarked on an internship at West Virginia University's Department of Anesthesia.
Dr. Hudson furthered his expertise through an anesthesia residency at the University of Louisville and served as an Assistant Chief of Anesthesiology and President of Medical Staff before joining Commonwealth.
In addition to his clinical responsibilities, Dr. Hudson contributes frequently to research exploring the relationship between chronic pain and depression.
