Wednesday, August 10, 2011

Chronic Pain & Rumination

I was planning to write separate posts on chronic pain and on rumination; but I have found that these subjects are related to each other, so I thought I would combine them.

In this article, I am defining "rumination" as frequent, repetitive thoughts about symptoms or problems.  Such recurrent thinking can consume so much time and energy, that little is left in the mind to permit quality of life.  And the ruminations, while understandable in the context of troubling symptoms or problems, do not help to resolve the problems at all.  Rumination can also refer to a gastrointestinal problem, which I am not discussing here.  

Chronic physical pain obviously has a huge negative impact on quality of life.  The presence of physical pain symptoms is a strong risk factor for suicide. (references: ; )

If physical pain and depression are combined, the severity of both problems is substantially elevated.

Treatment of chronic pain requires good comprehensive medical care.  Investigation and treatment of underlying medical causes is obviously important.  Coordinated involvement of a mutlidisciplinary team is ideal, though often lacking in many people's experience. 

In the psychiatric realm, a variety of therapies can help:

1) mindfulness meditation.  Jon Kabat-Zinn developed much of his work on mindfulness meditation with patients suffering from physical pain.  In my opinion, meditation is extremely important, since it carries no risk, has a variety of possible and probable benefits, and is likely to help with both emotional and physical symptoms.

This study shows similar reductions in pain from a mindfulness program vs. a multidisciplinary pain program without a meditation focus: 

This study shows improvements in various types of chronic pain conditions, with greater improvements in symptoms when subjects practiced more at home:

This study showed that mindfulness strategies probably work best for those who already have higher levels of mindfulness to begin with, as a type of character trait: 

This study shows a slight advantage for a mindfulness meditation program to treat back pain:

An interesting study showing improvement in distressing intrusive thoughts and images following a meditation program.  This shows that mindfulness exercises can substantially improve symptoms of rumination and even psychosis.  In chronic pain, ruminations and intrusive thoughts about the pain itself are a very common feature, and an element of the vicious cycle of pain perpetuation and reduced quality of life.  The study was of good quality, and the effect was quite substantial and robust:

Similarly, a study showing the mindfulness training specifically increases ability to "let go" (in this case, of OCD thoughts).  "Letting go" of ruminations about pain is very helpful in managing chronic pain conditions: 

Here's another study once again showing that mindfulness is specifically helpful to reduce rumination:

2) Cognitive-behavioural therapy
There is a significant research literature showing the effectiveness of CBT for managing pain conditions.  Here are some research examples:
non-cardiac chest pain:
chronic TMJ (jaw) pain:
severe back pain:
back pain (here, active behavioural/physical therapy was necessary for optimal improvement in performance, as expected):
chronic headaches:

3) Medications
 a) antidepressants:

Several antidepressant types could help with chronic pain:  tricyclics such as amitriptyline have been used in this way for decades, with reasonable evidence-based support.  Cymbalta (duloxetine) has been marketed for this, and is reasonable to try.  However, venlafaxine (Effexor) is probably just as effective for pain symptoms.
There have been no studies comparing venlafaxine with duloxetine in pain patients; I suspect that there would be little difference.  Currently, duloxetine is more expensive, so I do not believe it should be a first-line agent.  SSRI antidepressants or bupropion appear not to be consistently helpful for treating physical pain.

Here`s an animal study showing a difference favoring a tricyclic over an SSRI or bupropion for pain management:   

Here`s a negative study on moclobemide for physical pain:

This study shows equivalent benefits from amitriptyline and duloxetine, with over 50% of patients having good pain relief in diabetic neuropathy:

This study shows benefits from duloxetine in fibromyalgia; again with over 50% of patients feeling much better, compared to about 30% with placebo:

This study shows significant benefit in treating osteoarthritis pain with duloxetine; the pain relief was not related to any change in depression scores (which, in this population, were quite low and did not change very much with either duloxetine or placebo).  I find this study quite significant, in that it is looking at a different variety of pain than most of the other research:

This study shows relief attributable to duloxetine in depressed patients with idiopathic pain symptoms:

Here, venlafaxine is shown to be an effective agent to prevent migraine headaches:

Venlafaxine shown to be effective in treating functional chest pain: 

A 2007 Cochrane review concluding that venlafaxine and tricyclics are effective for chronic pain: 

b) anticonvulsants, e.g. gabapentin, pregabalin, carbamazapine, topiramate

A comparison of gabapentin, pregabalin, and amitriptyline in treating neuropathic cancer pain.  All of these drugs clearly helped, with pregabalin probably the best. Aside from direct relief, these drugs resulted in lower doses of opiates being needed:

A review of gabapentin treatment for neuropathic pain, affirming its usefulness, particularly at higher doses of 1800-3600 mg per day: 

This is a negative review article, showing that lamotrigine is unfortunately not likely to be useful in treating chronic pain:

An interesting study showing that pregabalin can reduce postoperative morphine requirement acutely:

This is an example, and a review article, part of the large literature showing that topiramate is an agent of choice to prevent or treat recurrent or chronic migraine.  There is preliminary evidence at a case-report level that topiramate could help with other types of pain:

c) opiates, such as codeine or morphine -- outside of the scope of this posting.  These  may have a role in managing non-malignant chronic pain, but supervision is needed from someone with experience prescribing opiates, a pain clinic, etc. Long-acting opiates such as methadone are being used more often in acute or chronic non-malignant pain conditions.  Of course, there is a balance here between pain relief and addictive risk.

Here is a recent review, which basically affirms that the use of opiates for chronic non-cancer pain is an "iffy" practice, yet I do affirm that in some cases it may be necessary.  In any case I think that experienced and specialized prescribers, such as those at a pain clinic, would be highly preferred:

d) Atypical opiate:  tramadol.  This is an interesting drug, for various reasons, including that it has antidepressant activity as well as being a physical analgesic.  It is an opiate, but a significant portion of its analgesic properties come from non-opioid mechanisms, such as neurotransmitter reuptake inhibition.  It does a potential for addictive problems, but the risk is clearly less than other opiates.  For this reason, I think it is reasonable to think of using tramadol before using other opiates (such as codeine or morphine) in treating pain syndromes.   

Chronic CNS effects of tramadol differ from those of morphine, supporting the evidence that tramadol has a smaller risk of inducing opiate dependence/addiction:

Tramadol can be identified subjectively as having opiate-like effects, but mainly at higher doses:

Here are animal studies using a mouse model of depression, suggesting effectiveness of tramadol..  However, I would want to see longer-term studies of this sort, as the acute beneficial action of any therapy does not necessarily prove that the benefits will last, in fact many acutely beneficial things can become harmful if used long-term (e.g. benzodiazepines):

An animal study suggesting that tramadol and anticonvulsants (in this case, specifically topiramate) can work synergestically (cooperatively) in relieving neuropathic pain:

Treatment of refractory major depression with tramadol monotherapy:

Rapid remission of ocd with tramadol:

Restless legs treatment with tramadol:

Treating catalepsy with tramadol:

Tramadol dependence :  in general these articles show that tramadol dependence occurs, but is significantly less likely than with stronger opiates:

There is a risk of serotonin syndrome with tramadol, particularly if combined with other serotonergic drugs, such as SSRI antidepressants:

Other direct approaches to treat rumination:

Here is a study showing effectiveness using a modified form of cognitive therapy called  competitive memory training.  It basically involves teaching techniques to either accept, or become indifferent to, the themes of the rumination:

Here`s a similar recent study showing improved relief in chronic depression with a CBT style modified to target rumination: 

An interesting study from the psychology literature which shows that rumination is associated with a type of cognitive deficit involving reduced ability to manage negative material in working memory.  This suggests to me that cognitive exercises, ones which train working memory, could have a role in treating depression and rumination.  Conversely, it suggests to me that practicing ways of "letting go" such as via CBT or meditation, could improve working memory (by freeing working memory space of irrelevant, ruminative, or intrusive negative material), and therefore improve intellectual functioning, academic performance, etc.

Here's one of many articles discussing rumination as a risk factor for depressive relapse or chronicity.  Clearly, tactics to help manage or prevent rumination are very important in both acute treatment and in prevention:

Another article discussing the role of rumination as a sort of emotional amplifier, which causes "impaired down-regulation of negative feelings" -- thus preventing the maintenance of positivity or relationship health after a stressor.  Such a dynamic would be a recipe for life disappointments to consistently derail one's emotional life.  Once again, practicing ways to manage rumination directly could therefore help with emotional resilience, and prevent a recurrent depressive cycle:

In summary, there are a variety of ways to treat or manage chronic pain and rumination.  Rumination itself may be an important perpetuating factor in pain syndromes.  Due to the presence of many symptoms in such syndromes, affecting both physical and emotional domains, it is important to have a cohesive, integrated treatment plan.   There is a risk of having multiple sources of therapy, each of which targeting only part of the symptom complex, which potentially could complicate or confound efficient treatment efforts.  In physical pain, emotional pain, or rumination, it can be extremely valuable to practice ways of "letting go." 


Anonymous said...

thanks for this entry.

Two questions, do the same things apply to acute pain? Like say you have a kidney stone and you need to just do something so you not bothered by pain too much while you you wait for ambulance?

Also, isn't rumination just related to pain? I mean if you sitting in the office and you back spasms or hurts or whatever, the pain keeps reminding you to pay attention to it, no? Ignoring it would be like trying to ignore the elephant in the room. You could mindfully try to do your taxes but unlike an actual elephant in the room, the pain bothers you even if you look away. I know some sports players play through the pain, broken bones or something but for the average person, very hard to ignore or not ruminate on pain.

GK said...

I do think similar ideas could apply to acute pain. Hypnosis, for example, is probably more effective for acute than for chronic pain.

Yet, of course, one must be careful to attend appropriately to pain stimuli. People often make the fatal mistake of ignoring early cardiac pain, instead of rushing appropriately to the hospital.

Rumination is an understandable and arguably normal response to pain. Yet, as with many human phenomena, sometimes the rumination itself can work itself into a heightened state, without any change in the physical pathology. The rumination becomes a separate, out of control problem, in addition to the physical pain, and these two problems then magnify each other in a feedback cycle. I think it is valuable to be aware of this risk, and to consider working on rumination as an important element of managing pain syndromes.

Anonymous said...

hi thanks for the answer.

while we here, can I ask another?

Does preparation make pain less or more? And practice? And is that like when you start running a bit for a big marathon? I mean I once tried to take up jogging again and went speed walking a couple days in a row, and then when one day I went jogging my body was so sore, I was to point of tears and had almost no energy and too much pain. I had to stop. I think I sensitized my body to pain. But isn't that how studying works, like you pratice and your mind gets smarter and more ready for the exam, like a muscle that you been working out and it gets stronger? But with pain, I don't understand. I mean professional athletes, I don't know if they can tolerate more pain because of all the exercise or if they're just like that genetically but there is got to be a way to increase pain tolerance over time. All I know is that what I was doing did the opposite.

Sorry for the rambling.

Anonymous said...

Do you think that certain therapeutic styles (or perhaps therapeutic intervention in general) can exacerbate rumination? (Actually, I think that you might have already addressed this a bit in an earlier post, ie possible negative effects of therapy/ treatment).

I notice that for me exposure to a certain type of therapeutic discourse-- or even sometimes any writings on psychiatry. therapy, etc-- can really drive this kind of rumination. I notice sometimes that I feel worse when I am engaged in treatment/ therapy, for the simple reason that this type of rumination increases. (even with objectively good therapy, or an objectively good therapist, etc).

I find that for me the main problem is that I often find it very difficult to articulate what i think or believe (or it seems this way to me-- I can't seem to say what I want to, I feel frustrated with my inability to express myself). Though it probably seems ridiculous for therapy to seem hostile or antagonistic, at times I do feel that I am being called on to defend my beliefs-- or to justify my behaviour-- and I feel frustrated because I don't feel able to do this. I think that this is probably especially true for cognitive therapy, though I think that for me it applies to other types of therapy as well.

I find that in these instances I spend a lot of time thinking about the problem in an attempt to basically better shore up my defense!-- or in any case, to better understand why I believe what I do, and why I disagree so strongly with some therapeutic ideas. At times it feels like therapy (or therapeutic discussions anyway) presupposes a kind of verbal fluency or clear-headedness that I don't think everyone possesses. I suspect that perhaps this kind of rumination is an attempt to clear through "foggy-headedness", but in any case it still results in rumination (about problems, symptoms, etc etc etc). Also, it contributes to a feeling of hostility/ anger that I don't find helpful.

Now, I think that you'd agree that this kind of rumination is unhealthy, and perhaps only entrenches various unhealthy (and maybe unrealistic) beliefs. However, I do wonder if this is a common problem.

GK said...

Yes, I think therapy itself can exacerbate rumination. It's hard to figure out what to do with a problem like this, other than of course to try some other therapy style.

I've seen analogous problems in other areas, such as addiction treatment: some people who attend AA, for example, are so put off with philosophical and practical objections with the meetings, that they just get more and more agitated and annoyed when they go. My advice about this type of situation is to consider trying a different style. Or to attempt to stay with the group, but to selectively make use of the positives of the group (e.g. the community support, etc.) while actively setting aside the objections (e.g. in AA I think it would be unhelpful to engage in a philosophical debate about the "Big Book", etc.)

In any case, I've come to realize that attempting to help with rumination itself can be a valuable therapeutic focus, one which ironically may require LESS discussion or intellectual analysis. Here, I think most therapists have something to learn from meditation teachers, etc. and I generally welcome the infusion of meditation-related ideas into more mainstream psychotherapy.

GK said...

With respect to the question about preparation or sensitization, I'd have to look into that in the pain literature.

In the psychology or physiology of things generally, I see that symptoms could be either sensitized or desensitized with practice. With exposure therapy for anxiety, for example, an exposure trial could be traumatizing. I think such risks can be minimized with the following rules for preparation or practice:

1) take it very slowly and gently (often times we are tempted to speed up the process)
2) gentle trials repeated hundreds of times, with gradual increases in time or difficulty, are much more effective than harsh trials repeated a small number of times with sudden increases in difficulty
3) with each trial of practice or preparation, it is important to maintain a continuous sense of freedom or control of the activity, so that you never feel that you are involuntarily trapped in the activity. That way, your will is always the "boss", on a moment-to-moment level, which leads to a sense of mastery over the fear or symptom.
4) education about what to expect with the work is important: it is necessary to know that you may have a type of soreness or discomfort normally expected, rather than be surprised when it happens and be tempted to worry about it.