Pain and Depression: A Fire in the Brain

You’re not imagining it. The majority of individuals who suffer from chronic pain also suffer from depression, and the majority of people who suffer from depression also suffer from chronic pain.

At first glance, these statements may seem like a double-dose of bad news for any patient suffering from fibromyalgia, painful autoimmune disorders, or any other serious, chronic pain condition.

But there is some good news to be found here. Recent medical studies of patients dually diagnosed with chronic pain and depression are revealing that these patients have a unique disease process. And this discovery is pointing toward some promising new diagnosis and treatment options.

The idea that patients with chronic pain in many cases also suffer from depression is hardly shocking, but you may be surprised by the numbers:

• Of the 47 million people who suffer from chronic pain each year, over half also meet the diagnosis criteria for a Major Depressive Disorder, and
• Fully two-thirds of the millions of individuals who are diagnosed with depression every year are also suffering from chronic pain.

A UNIQUE DISEASE PROCESS

Medical researchers are arriving at a new understanding of the physiological relationship between chronic pain and depression. A growing body of evidence is revealing that the disease processes occurring in a person who has been diagnosed with both chronic illness and depression are quite distinct from the processes occurring in someone who is suffering from only one of these conditions. I expect that this new understanding will lead not only to changes in treating individuals who are dually diagnosed but also to improved protocols for diagnosing and treating patients who currently are diagnosed with only chronic pain or depression.

CSS

The new term “Central Nervous System Sensitization Syndrome (CSS)” describes the unique process governing the interplay of chronic pain and depression within an individual. CSS is an inflammatory condition that damages the structure and undermines the functioning of the nervous system. It is both “neurodysregulatory” and “neurodegenerative.” Neurodysregulation refers to the extent to which CSS interferes with the healthy functioning of the body’s nervous system, undermining neural activity in the brain, spinal cord and other neural pathways throughout the body. Furthermore, when a person’s nervous system is operating sub-optimally, their hormonal and immune systems are likely to falter, which in turn, can lead to even more complicated health problems. Neurodegeneration refers to the actual injury and destruction of neural tissue in the brain and body. Both conditions (neurodysregulation and neurodegeneration) can cause or exacerbate physical pain, emotional suffering, and erode mental clarity. The mediating factor in this process is the production and release of inflammatory substances in the brain.

FACTORS THAT CONTRIBUTE TO CSS

CSS is a complex syndrome; many factors can contribute to its development, and it can manifest in a variety of ways. Underlying conditions that can increase an individual’s susceptibility for developing CSS include Lyme disease, hormonal dysfunction, periodontal disease, post-traumatic stress disorder (PTSD), mold-toxicity disorders, chronic viral infections, celiac disease, heavy metal burden and sleep disorders such as sleep apnea.

AN INFLAMMATORY CASCADE

To protect us, these underlying problems activate an inflammatory cascade within the body and brain. Here’s an example of how it works: A patient with celiac disease remains untreated for years. Consequently, inflammation develops, which disrupts the healthy functioning of her gastrointestinal system. This, in turn, compromises her ability to digest and absorb essential nutrients, eliminate waste and toxic substances, and keep out harmful substances. With her ability to absorb essential nutrients undermined, she develops nutritional deficiencies in magnesium, essential fatty acids, essential amino acids, and calcium. These deficiencies weaken her immune system and lead to more pain and depressive symptoms. In response to her gastrointestinal system’s inability to prevent the entry of harmful substances, the body responds with even more inflammation. It does this to create a hostile environment for the invading toxins, but the reaction also works to intensify the patient’s pain and depression.

CSS helps to explain why the symptoms of so many chronic conditions overlap and why obtaining an accurate diagnosis and effective treatment plan can be so challenging. In my practice, I often see patients who have been “correctly” diagnosed with one condition (accurately in the sense that the patient met the diagnostic criteria), but the patient’s health remained compromised because an underlying problem had not yet been identified or addressed. For instance, I have seen several patients who have been diagnosed and treated for fibromyalgia, but whose symptoms never improved until their underlying condition of mold toxicity was treated. Similarly, patients are sometimes accurately diagnosed and treated for thyroid disease, but the patients fail to regain their full health and vitality until their celiac disease is addressed.

In these examples, the point is to identify what was setting off the neuro-inflammatory syndrome known as CSS. In sum, conditions such as fibromyalgia, chronic fatigue syndrome, peripheral neuropathies, and PTSD and depression associated with pain, may be better understood not as diseases unto themselves, but as manifestations of Central Nervous System Sensitization Syndrome.

TREATING CHRONIC PAIN

Unfortunately, some of the most common ways of treating chronic pain can, in some cases, make a patient’s situation worse. For example, the long-term use of opioids such as morphine and oxycodone, and benzodiazepines, such as Valium, Klonopin, and Xanax, appear to exacerbate the inflammatory processes throughout the brain. Increased inflammation may promote or exacerbate pain and depression and can make both conditions even more difficult to resolve.

TREATING CSS

To combat the damaging effects of CSS, your treatment plan needs to include neuroregenerative therapies, such as sufficient sleep (7 to 9 hours per day), exercise (15-30 minutes aerobic activity per day), meditation (20 minutes per day), good nutrition (primarily low-carb diet with plenty of vegetables, fruit, low-fat protein, and supplements such as fish oil, Vitamin D and magnesium), and medication, as prescribed by your doctor. Second, all underlying medical problems need to be properly identified by completing a comprehensive medical history with your physician and undergoing laboratory testing as appropriate. Otherwise, the symptoms of CSS may persist even if other symptoms are being addressed. Finally, your treatment plan should include time with your physician to evaluate your progress and to discuss strategies that help you achieve your health goals. This may include treatments for sleep disorders, medication changes, physical therapy, acupuncture, psychotherapy or nutritional counseling.

The intersection of chronic pain and depression is complex, but medical research is beginning to show us a way forward. CSS is a new model of disease that I believe will help better equip us to identify the factors that are causing a patients’ pain and suffering. It also provides us with an incentive to adopt a more integrative treatment approach that will help more of our patients regain optimal health.

Have you or someone you know been battling with co-occurring chronic pain and depression? Has the possibility of CSS been discussed with the treating physician? If you have concerns you would like to discuss, call 703-532-4892 and schedule an appointment with one of our physicians.