Goldstein describes mindfulness as “paying attention to something on purpose and with fresh eyes.” This is why mindfulness is so helpful. Instead of focusing on how badly we want the pain to stop, we pay attention to our pain with curiosity and without judgment.

This approach is very different from what our brains naturally do when we experience the physiological sensation of pain. Our minds typically launch into a litany of judgments and negative thoughts. According to Goldstein, we start ruminating about how much we hate the pain and want to wish it away. “We judge the pain, and that only makes it worse.” In fact, our negative thoughts and judgments not only exacerbate the pain, they also fuel anxiety and depression, he said.

What also makes matters worse is that our minds start brainstorming ways to soothe the pain. Goldstein likens this to the Roomba, a robot vacuum. If you trap the Roomba, it just keeps bouncing off the edges. Our brains do the same with scouring for solutions. This “creates a lot of frustration, stress and feeling trapped.”

Mindfulness teaches people with chronic pain to be curious about the intensity of their pain, instead of letting their minds jump into thoughts like “This is awful,” said Goldstein, also author of The Now Effect: How This Moment Can Change The Rest of Your Life and co-author of A Mindfulness-Based Stress Reduction Workbook.

It also teaches individuals to let go of goals and expectations. When you expect something will ease your pain, and it doesn’t or not as much as you’d like, your mind goes into alarm- or solution-mode, he said. You start thinking thoughts like “nothing ever works.”

“What we want to do as best as we can is to engage with the pain just as it is.” It’s not about achieving a certain goal – like minimizing pain – but learning to relate to your pain differently, he said.

Goldstein called it a learning mindset, as opposed to an achievement-oriented mindset. In other words, as you’re applying mindfulness to your pain, you might consider your experience, and ask yourself: “What can I learn about this pain? What do I notice?”

As Jon Kabat-Zinn, Ph.D, writes in the introduction of The Mindfulness Solution to Pain, “From the perspective of mindfulness, nothing needs fixing. Nothing needs to be forced to stop, or change, or go away.”

Kabat-Zinn actually founded an effective program called mindfulness-based stress reduction (MBSR) in 1979. While today it helps individuals with all sorts of concerns, such as stress, sleep problems, anxiety and high blood pressure, it was originally created to help chronic pain patients.

“In MBSR, we emphasize that awareness and thinking are very different capacities. Both, of course, are extremely potent and valuable, but from the perspective of mindfulness, it is awareness that is healing, rather than mere thinking…Also, it is only awareness itself that can balance out all of our various inflammations of thought and the emotional agitations and distortions that accompany the frequent storms that blow through the mind, especially in the face of a chronic pain condition,” Kabat-Zinn writes in the book.

Mindfulness provides a more accurate perception of pain, according to Goldstein. For instance, you might think that you’re in pain all day. But bringing awareness to your pain might reveal that it actually peaks, valleys and completely subsides. One of Goldstein’s clients believed that his pain was constant throughout the day. But when he examined his pain, he realized it hits him about six times a day. This helped to lift his frustration and anxiety.

If you’re struggling with chronic pain, Goldstein suggested these mindfulness-based strategies. He also stressed the importance of paying attention to what works for you and what doesn’t.

Body Scan

A body scan, which also is included in MBSR, involves bringing awareness to each body part. “You’re bringing attention to what the brain wants to move away from,” Goldstein said. However, instead of immediately reacting to your pain, the body scan teaches “your brain the experience that it can actually be with what’s there.”

You’ll find helpful videos with a three-, five- and 10-minute body scan on Goldstein’s website.

Breathing

When “pain arises, the brain reacts automatically,” with thoughts, such as “I hate this, what am I going to do?” Goldstein said. Though you can’t stop these first few negative thoughts, you can calm your mind and “ground your breath.”

Goldstein suggested simply breathing in slowly and saying to yourself “In,” and breathing out slowly and saying “Out.” Then you also might ask yourself, “What’s most important for me to pay attention to now?”

Distractions

A distraction can be a helpful tool when your pain is high (such as anything above an 8 on a 10-point scale), Goldstein said. The key is to pick a healthy distraction. For instance, it could be anything from playing a game on your iPad to focusing on a conversation with a friend to getting lost in a book, he said.

Mindfulness is an effective practice for approaching chronic pain. It teaches individuals to observe their pain, and be curious about it. And, while counterintuitive, it’s this very act of paying attention that can help your pain.

Some individuals experience a decline in mood with a sense of loss, he said. Others experience a loss of interest or pleasure in activities they previously enjoyed. Still others experience “an increased irritability, impatience or lower tolerance for the normal stresses of daily life.”

Chronic pain also creates many stressors, which can lead to depression, said Beverly Thorn, Ph.D, Clinical Health Psychology Professor and Chair at The University of Alabama whose research focuses on painful conditions. Chronic pain interferes with a person’s daily functioning. It lasts at least three months, more days than not, she said.

“People might be unable to work or work the way they used to.” Consequently, they might have financial problems, and a new role in their family. Patients have told Thorn that not being the main provider has made them feel worthless or like they’re not contributing to their family unit.

Treating Both Conditions

It’s important to treat both chronic pain and depression, Kerns said. “Many people with pain and depression say things like ‘If you had my pain you’d be depressed, too,’ or ‘If you would treat my pain, I wouldn’t be depressed.’ However, reducing pain doesn’t necessarily reduce symptoms of depression, he said.

That’s why Kerns suggested people work with providers who treat each condition (instead of an either-or approach). Some studies suggest that a collaborative and integrative approach is best. This study published in the Journal of the American Medical Association found that a course of antidepressants followed by a pain self-management program improved both depression and pain.

If you haven’t yet, consult a pain specialist for a treatment plan, along with a mental health specialist for a proper evaluation and treatment for depression, Kerns said. It’s also important to communicate regularly with your providers and pay attention to changes, Thorn added.

When to Proceed with Caution

One of the biggest challenges of treating both pain and depression is that feelings of helplessness and hopelessness lead people to try cures that are ineffective and even damaging, according to Kerns. “Continued doctor-shopping is problematic.”

Also problematic is pursuing more and more aggressive pain interventions, which he said only reinforce the “sense of helplessness and hopelessness and demoralization.”

Opioid medication is another concern. According to Kerns, there’s very little evidence that opioids are helpful for chronic pain. Instead, there’s “abundant evidence of the potential harm of long-term opioid therapy.”

For people with pain and depression, “who may be vulnerable to pursue these kinds of interventions,” it’s best to be cautious. Most experts “argue for very limited use of pharmacological agents and support education, encouragement and judicious use of non-opioid, over-the-counter [medication],” along with a healthy lifestyle and self-management techniques, he said.

How Psychotherapy Helps

Experts used to think that the amount of pain a person felt was equal to the amount of damage in their body, Thorn said. Today, however, we know that our thoughts and emotions can influence the perception of pain, making it much worse or less intense, she said. Psychotherapies, such as cognitive-behavioral therapy (CBT), harness this concept “by re-teaching your brain.”

Research has found that CBT is highly effective for managing both pain and depression. (“Some of the strongest evidence supports CBT,” Kerns said. But he also noted that other therapies such as behavioral activation and Acceptance and Commitment Therapy show promise.)

For instance, CBT teaches individuals to pay attention to their thought processes, which can maximize or minimize pain. Thoughts like “This pain has ruined my life, and there’s nothing left to be done,” negatively affect your emotions and behaviors, said Thorn, author of Cognitive Therapy for Chronic Pain: A Step-by-Step Guide. They also make you more likely to get depressed and withdraw. Plus, “If you feel like there’s nothing you can do, you won’t do anything,” which is “really dangerous for someone with chronic pain.”

For instance, one of Thorn’s clients, who has lower back pain, kept saying that his spine was disintegrating because his MRI showed some damage. Thorn asked him how this thought was affecting his emotions and behavior. “It makes me panic, and I’m afraid to do anything.” This thought also spiked his blood pressure, breathing and heart rate. Thorn suggested he find another perspective that’s more realistic and less of an emotional noose. He came up with the following thought: “There’s still some damage to my spine, but no amount of surgeries will help that damage. [However] it is the kind of damage that would be helped with muscle strengthening.”

Today, Thorn’s client plans to work with a physical therapist to strengthen his muscles. “As soon as someone has an empowering thought, they start to feel like they have a little bit more control over their life,” Thorn said. “His spine is damaged. He’s had three surgeries. But does he have control? Yes, he does.”

Paying attention to your thoughts is especially helpful when your pain level rises. For instance, Thorn suggested asking yourself, “What just went through my mind? What am I saying to myself?” If you become aware of a negative thought that’s emotionally laden for you, “stop, breathe and then consider your options.” This helps to interrupt your reflexive reactions, such as lashing out at yourself or your loved ones. It helps you choose a different path, and reminds you that you have more control than you think you do, she said.

In CBT, along with other therapies like behavioral activation, clinicians also help patients discover the kinds of physical activities they can engage in without exacerbating their pain, Thorn said. They also help them make realistic goals and manage defeatist thinking.

For instance, a person who used to run 10 miles might be able to walk for a few minutes today. They might easily think that such a minor activity isn’t even worth it. However, as Thorn said, walking for 5 minutes several days a week adds up. Soon you might be able to walk for five days, and so on. “That kind of gradual increase will build on itself.” Plus, regular physical activity helps to improve mood and energy levels.

Living with chronic pain can be especially debilitating. It can lead to or exacerbate clinical depression. Fortunately, these conditions are highly treatable. The key is to seek treatment for both, and to remember that a fulfilling life is absolutely possible.

Further Reading

Thorn and Kerns both recommended the book Managing Pain Before It Manages You by Dr. Margaret A. Caudill. Kerns suggested John Otis’s Managing Chronic Pain: A Cognitive-Behavioral Therapy Approach Workbook.

Also, these are excellent organizations: the American Chronic Pain Association, led by people with chronic pain, and the American Pain Society, Kerns said.

According to the International Association of Reiki Professionals (IARP), “Reiki is [a] subtle and effective form of energy healing using spiritually guided life force energy… [p]racticed in every country of the world.” While often considered to be spiritual in nature, Reiki is not “[a]ffiliated with any particular religion or religious practice.”

Reiki is increasingly offered in hospital, hospice, and private practice settings, applied to a variety of illnesses and conditions. Those who receive such treatments report relief of symptoms from numerous health challenges, including mental health issues. Research shows that reiki primarily helps in the reduction of stress, anxiety and depression, as well as relief of chronic pain — the last of which can bring on anxiety and depression, or make episodes worse.

Many Studies, Varying Quality

There are now sufficient peer-reviewed, published research results available to begin to sort out Reiki’s effectiveness in various areas. The Center for Reiki Research has intensively examined a group of them through their “Touchstone Process,” “…a uniquely rigorous peer review method for analyzing a group of scientific studies” [using Reiki]. Its end product is a set of critical summaries derived from an impartial and consistent process…. [T]he process incorporates existing best practices for scientific review…” (CRR)

This process looks at all aspects of the study design and how each investigation was actually carried out. Results are analyzed, and study strengths and weaknesses are determined. The Touchstone Process has produced a group of nearly three dozen carefully analyzed studies. The CRR draws some conclusions about Reiki’s effectiveness from only the studies they have examined that they judge to be of at least satisfactory or better quality. (CRR)

In addition to the CRR/Touchstone studies, a varied body of research on Reiki demonstrates its effect on mental health. For example, Joe Potter, a Reiki Master in the United Kingdom, has been conducting an ongoing investigation into Reiki’s effectiveness. An online search in PubMed lists dozens of studies involving Reiki or other healing touch methods, investigating a broad range of conditions in many different populations.

Some investigations were conducted on animals, which helps eliminate some questions of bias and design control among Reiki recipients. Some studies used “sham” Reiki as a form of control (nonpractitioners administered a “Reiki-like” treatment), and others involved distance Reiki (Reiki delivered from too far away to permit touch). Each of these variables lends something importing to understanding the efficacy of the treatment itself.

Demonstrated Effects on Stress, Depression, Anxiety and Pain

Potter reports that “[s]tress was the most common word written by clients as a description or part description of their condition during their first session. Here 20.27% of the total client group treated used this word on their initial visit for Reiki treatment….” In animal studies, Reiki treatment produced clear signs of reduced stress as indicated by changes in autonomic, biological measurements such as heart rate (Baldwin, Wagers and Schwartz, 2008) and certain cellular signs of stress-related damage (Baldwin and Schwartz, 2006). In a study of nurses with “burn out syndrome,” biological indicators of a significant relaxation response were found as a result of Reiki treatment (Diaz-Rodriguez et al., 2011). When nurses administered Reiki to a group of patients with acute coronary syndrome, physiologic indicators of a significant relaxation effect were recorded. (Friedman et al., 2011)

Shore (2004) followed patients being treated for mild depression and stress. After six weeks of treatment and for up to a year afterward, those who had received Reiki showed both immediate and long-term improvements in depression, stress and hopelessness. In a small study, complete elimination of typical postoperative depression was seen in heart surgery patients given Reiki during surgery (Motz, 1998).

Pain often causes depression and anxiety. Reducing difficult-to-treat chronic pain can have a substantial effect on psychological well-being. Some studies have found Reiki to be effective for pain, anxiety and depression relief. However, their design or conclusions are unclear as to whether Reiki’s emotional benefits were a result of pain reduction or a separate phenomenon. Nonetheless, research demonstrated Reiki’s positive results for both pain and anxiety or depression.

Dressing and Sing (1998) found that among cancer patients, Reiki brought about significant levels of pain relief, anxiety and depression reduction, improvements in sleep quality, relaxation and general well-being. This effect was stronger in men than women. These benefits remained when checked after three months. Among abdominal hysterectomy patients, Reiki helped reduce pain and anxiety, particularly in a preoperative setting (Vitale and O’Conner, 1998).

Investigating Effects of Gentle Touch, Distance

Research shows that gentle touch in a safe environment aids stress reduction and pain relief (for example, Weze et al., 2005). Since Reiki generally involves a similar type of touch, the results of Reiki studies often can be confounded by the known impact of gentle touch vs. the effects of Reiki itself. Studies that include sham Reiki treatment groups, as well as those that involve a distance Reiki group, have been important to help sort out the relative effects of Reiki versus gentle touch – or even the effects of the presence of a “therapist,” real or sham.

Reiki is becoming an increasingly accepted presence in hospitals and clinics. (The Center for Reiki Research website lists 70 institutions at the time of this article that include Reiki in their offerings.) It is seen as an effective and cost-reducing method to improve health outcomes and quality of care. Hospital staff, such as physicians and nurses, are adding Reiki treatments to their work. Scientific validation of Reiki’s effectiveness have helped bring this method to the mainstream, where it is able to aid patients in all realms, including those with mental health challenges.

References

Baldwin, A. L.. Reiki, the Scientific Evidence. (Fall, 2011). pp. 29-31.

Baldwin, A.L., Schwartz, G.E. (2006). Personal Interaction with a Reiki Practitioner Decreases Noise-Induced Microvascular Damage in an Animal Model. Journal of Alternative and Complementary Medicine, 12(1):15–22, 2006. In Center for Reiki Research, Retrieved June 23, 2012, from http://www.centerforreikiresearch.org/

Baldwin, A.L., Wagers, C. and Schwartz, G.E. (2008). Reiki improves heart rate homeostasis in laboratory rats. Journal of Alternative and Complementary Medicine, 14 (4): 417-422. Retrieved June 23, 2012, from http://www.centerforreikiresearch.org/

Center for Reiki Research (CRR). Retrieved June 23, 2012, from http://www.centerforreikiresearch.org/

Diaz-Rodriguez, L., Arroyo-Morales, M, Fernández-de-las-Peñas, C., García-Lafuente, F., García-Royo, C. and Tomás-Rojas, I. (2011). Immediate effects of Reiki on heart rate variability, cortisol levels, and body temperature in health care professionals with burnout. Biol Res Nurs, 13: 376 originally published online 5 August 2011. In Center for Reiki Research, Retrieved June 23, 2012, from http://www.centerforreikiresearch.org/

Dressin, L.J., Singg, S. (1998). Effects of Reiki on pain and selected affective and personality variables of chronically ill patients. Subtle Energies and Energy Medicine, 9(1):53-82.

Friedman, R.S.C., Burg, M.M., Miles, P., Lee, F. and Lampert, R. (2010). Effects of Reiki on Autonomic Activity Early After Acute Coronary Syndrome. Journal of the American College of Cardiology. 56: 995-996. In Baldwin, Fall, 2011.

International Association of Reiki Professionals (IARP). Definition of Reiki. Retrieved June 22, 2012, from http://www.iarpreiki.org/

Motz, J. (1998). Hands of Life. New York: Bantam Books.

Potter, Joe, Research Report, Introduction and General Findings. Retrieved July 21, 2012 from http://www.reiki-research.co.uk/

PubMed. Retrieved July 24, 2012 from http://www.ncbi.nlm.nih.gov/pubmed

Shore, A.G. (2004). Long term effects of energetic healing on symptoms of psychological depression and self-perceived stress. Alternative Therapies in Health and Medicine, 10(3):42-48.

Vitale, A.T., O’Conner, P.C. (1998). The effect of Reiki on pain and anxiety in women with abdominal hysterectomies. Holistic Nursing Practice, 20(6): 263-272, 2006. In Center for Reiki Research, Retrieved June 23, 2012, from http://www.centerforreikiresearch.org/

Weze C, Leathard H.L., Grange J, Tiplady P, Stevens G. (January, 2005). Evaluation of healing by gentle touch. Public Health. 119(1):3-10.

Patients have “substantial physical, school, social and emotional impairments,” says Dr. Susmita Kashikar-Zuck of Cincinnati Children’s Hospital Medical Center in Ohio. As there is no solid evidence for the effectiveness of current treatments, Dr Kashikar-Zuck and her colleagues carried out a randomized trial of cognitive behavioral therapy (CBT).

They recruited 114 adolescents between the ages of 11 and 18 years who suffered from juvenile fibromyalgia. Usual medical care was given for eight weeks. While some patients then saw a psychologist for eight weekly CBT sessions plus two booster sessions over six months, others simply received education on disease management.

CBT was found to be “significantly superior” to disease education at reducing functional disability, showing a 37 percent improvement vs. 12 percent.

Depression scores dropped in both groups, with the average score for both groups falling into the range of normal/healthy. The researchers say, “This implies that attention and support from health care providers via intensive weekly individual sessions can in and of themselves reduce emotional distress.”

They add, “These nonspecific positive effects were also observed in both groups on more global measures of patient-reported health-related quality of life. However, CBT clearly had the additional benefit of significantly improving daily functioning over and above the positive effects on overall well-being.”

Nevertheless, pain was not reduced significantly (i.e. by 30 percent or more) in either group. The effects on sleep quality also were very small, and the sensitivity of so-called “tender points” was mostly unchanged. But the authors say it is encouraging that a marked improvement in the patients’ ability to carry out previously avoided activities such as going to school, doing chores, going out with friends, and the like was achieved without increasing pain or interfering with sleep.

Almost 90 percent of the participants completed the treatment plans and followups. Much of the high retention could probably be attributed to the strong relationship that participants and parents developed with the therapists, say the researchers, because anecdotal reports were positive and treatment credibility ratings at the end of the study were high.

Details were published in the journal Arthritis & Rheumatism. The authors conclude, “In this controlled trial, cognitive behavioral therapy was found to be a safe and effective treatment for reducing functional disability and depressive symptoms in adolescents with juvenile fibromyalgia.” They add that, when added to usual medical care, CBT was “clearly the superior choice for the treatment of juvenile fibromyalgia.”

Dr. Kashikar-Zuck said, “When added to standard medical care, cognitive behavioral therapy helps to improve daily functioning and overall well-being for adolescents with fibromyalgia. All the research we’re doing shows this is something that can and should be managed early, and when left untreated can essentially lead to long-term problems.”

Interestingly, the relatively strong improvements found in this study contrast with quite small improvements in studies of adult fibromyalgia. One reason for this, the experts suggest, might be that adults with fibromyalgia have likely had the symptoms and their related dysfunctions for many more years.

Furthermore, involving the patients’ parents may have “increased support in the family environment to enhance or maintain treatment effects,” the experts write. They suggest that early identification and effective treatment of symptoms that are first noticed in adolescence “might mitigate long-term problems with disability.”

They call for further followup studies to examine longer-term effects of CBT. They also propose that future research tests whether CBT can be used to increase the patient’s ability to exercise more vigorously, and whether this combination of CBT plus exercise leads to improved functioning or reduced pain. The addition of specifically-targeted sleep training within CBT might be useful, they add.

Internet-based CBT may be another possibility for the treatment of pain in children. It has been shown to be safe, and to impart self-management skills which are sustained for at least six months after the end of treatment. This approach could be modified for use in young fibromyalgia patients, say the experts.

Reference

Kashikar-Zuck, S. et al. A Randomized Clinical Trial of Cognitive Behavioral Therapy for the Treatment of Juvenile Fibromyalgia. Arthritis & Rheumatism. Published online November 22, 2011
http://doi.wiley.com/10.1002/art.30644

Rosenthal shares her battle with Stevens-Johnson Syndrome (SJS), leading us from her diagnosis at age 13 through 24 subsequent years of psychological repercussions. Rosenthal recounts the story of how she fought for years to overcome her PTSD, and managed to slowly climb her way out of a serious case of depression and anxiety, experiencing a rebirth along the way. Ultimately this results in a remarkable tale of personal strength and post-traumatic growth.

The book is divided into four sections: ‘Shock;’ ‘Confusion;’ ‘Clarity;’ and ‘Healing,’ with each of these representing a different stage in Rosenthal’s journey. The first, ‘Shock,’ describes Rosenthal’s life ‘before the world intruded’ – the innocent childhood cut short by the onset of her terrible illness. ‘Confusion’ and ‘Clarity’ cover her emotional journey in coming to terms with this trauma, and ‘Healing’ describes her eventual recovery and return to happiness.

Not only is Johnson one of the 0.5 people per million to suffer from SJS, but in her case it also develops into its most extreme, life-threatening form, Toxic Epidermal Necrolysis Syndrome (TENS).The symptoms of this are a form of blistering so serious that Rosenthal has to be treated in a hospital burn unit. She recounts the condition’s sudden onset with such excruciating accuracy and vivid attention to detail that you may find yourself wincing as you read about the unbelievable pain she had to endure. Rosenthal recalls meeting the hospital psychiatrist, and being unable to put her experience into words at the time:

I did not tell her how drastically I felt changed. I did not say out loud that I was trying to suppress the memory of a pain so intense it defied words. I could not explain that I was struggling not to be overwhelmed by a staggering number of new fears and feelings, nor even the latest fear: that I had survived the physical onslaught only to be outdone by the emotions in its wake.

Indeed, it is these subsequent emotions which later cause Rosenthal to become disconnected from the rest of the world. She survives a near-death experience, and then sinks into a state of deep depression, anxiety, insomnia, and eating disorders.

Rosenthal shares the following quote from Dr. David Biro’s memoir One Hundred Days: My Unexpected Journey from Doctor to Patient:

Doctors love a good zebra. Patients with rare, exotic diseases. We crowd around to see them, touch them, photograph them. We put them on display at conferences. We write their stories in journals. We do all this, I suspect, because they reawaken the spirit that first pushed us into medicine: a fascination with the human body, its incredible achievements and its terrifying failings.

It is this idea of an “exciting zebra” for the medical community that Rosenthal most strongly identifies with throughout her struggle. She reluctantly adopts this as her identity, labeling herself as a “medical anomaly, alone, a freak.”

Eventually, 16 years after her initial diagnosis, and following countless fruitless attempts at a cure by her doctors, Rosenthal decides to seek a different kind of help. She arranges to see a psychotherapist, named Greg. It is this work with Greg, and an introduction to transcendental meditation, that signals a change for Rosenthal: She talks about her experiences for the first time and begins to discover her true voice, escaping the fearful clutches of her Ego voice. Remembering her college days, Rosenthal writes that “[W]riting was good for me. It gave me a focus outside my physical discomfort and limitation. It gave me something in which to bury the emotional angst I carried and also a place to explore how and when and why to find language and choose words.”

As her sessions with Greg evolve, Rosenthal recalls that:

I became more of a full self: I defined boundaries, learned how to communicate, and started more consciously mulling the question, ‘What do I want?’… I made a list of twenty-two things I was afraid of. At the top of the list: ‘I am afraid of myself.’ And yet, I wanted more and more to become myself. Writing seemed to be the path to that connection.

She begins to make significant progress, and to feel in control of her life, so Rosenthal terminates the sessions with Greg. But another onset of the illness sparks a relapse into her depressed state, as she is once again forced to resign herself to the role of patient, or ‘zebra.’ It is this relapse which finally triggers the turning point for Rosenthal, as she fully acknowledges the fear she has lived with – and denied – for so long. She decides once and for all to “reclaim myself,” with Greg’s help:

We break through the fear to a point where I begin to imagine for myself a different life than the invalid one I am used to. This happens oh, so slowly, but I hear the machinery grinding in my head. I fantasize I could be her, the girl of such vast energy I glimpsed for just a moment in the hospital. I imagine myself strong and free and vibrant and healthy and able to succeed without enduring the pitfalls of illness. One day, walking along the beach I feel myself as I would like to be: happy, unafraid, able to live without looking back, a strong source of joyful vitality.

Crucially, through her ongoing therapy sessions, and by reading two life-changing books – Joan Didion’s ‘The Year of Magical Thinking’ (a parent’s perspective of a child’s grave illness) and Elizabeth Wurtzel’s ‘More, Now, Again: A Memoir Of Addiction’ – Rosenthal realizes just how important her writing is to her, and how it can offer her a solution to her problems:

Socrates wrote that language is ‘an activity that moves the soul towards definition.’ Words can deliver us from our solitude, or deepen it. They are our most specific form of translating what exists in a heart through the landscape of a mind. I have always used language as a fence, as a guardrail against truth, definition, and exposure. So often my words have cloaked my self in disguises designed to ensure anonymity. Or, the lack of words has kept me separate from even myself. Recently, however, I sense the ability to use language in another way. I begin writing poetry again, starker poems and more to the point, writing more directly than ever about the aftereffects of illness and its consequence on identity… I begin to feel safe… I understand the problem has been that I never acknowledged my past and then came back to the present. Instead, I have lived in the trauma and run away from myself in every moment. It is time to sit still.

This will certainly sound familiar to anyone who has ever studied the concepts of Narrative Therapy, and it is ultimately — through her writing, a discovered love of music and dance, and a new identity – that Rosenthal finally overcomes the trauma of her illness and truly achieves happiness. At the end of the book she states that:

I can describe myself as if TENS never happened: I am a dancer, I am a writer, a creator, a lover, a partner, a daughter, a sister, a friend. I am a dog owner, a Floridian, a beachwalker, a homeowner. I am a joy seeker. I am a believer in my self. I have conquered the past. Now, I am creating my future as a woman who is connected, strong, and free.

Notably, Rosenthal is many things, but she is no longer a ‘zebra’.

Today Rosenthal works as a post-trauma coach, using the wisdom gained from her own experiences to help others, and employing the philosophy that “we can’t always find meaning in our trauma, but we can learn to make meaning come out of it.”

This is an honest, triumphant story of personal courage in the face of adversity, and will undoubtedly help anyone who has ever dealt with the effects of trauma or illness. At one point in the book, Rosenthal states that “Writing seems like the only thing that can save me,” and I am grateful that it has. Rosenthal is a survivor, and hopefully her story will help many other victims of PTSD work toward their own recovery and post-traumatic growth, finding happiness and a new sense of identity along the way.

Before the World Intruded: Conquering the Past and Creating the Future, A Memoir
By Michele Rosenthal
Your Life After Trauma, LLC: April 9, 2012
Paperback, 230 pages
$14.95

Through its holistic, compassionate approach, this valuable guide empowers with knowledge, instills with confidence and gives women a direction for finding doctors who are truly knowledgeable about their disorders and able to treat their pain.  As is read in its introduction, “This book is the product of our passionate belief that all women with sexual pain need both physical and emotional support.” 

Deborah Coady and Nancy Fish provide a detailed, empathic guide that that offers a wealth of physical and emotional suppport. I highly recommend Healing Painful Sex: A Woman’s Guide to Confronting, Diagnosing, and Treating Sexual Pain.

Millions of women suffer from sexual and pelvic pain in America today, yet it is frequently misdiagnosed or not diagnosed at all.  Because of the multidisciplinary nature of sexual pain, which falls between the disciplines of experts, women have often been told that pain is “all in your head”  or that nothing can be done to help them.  As Coady and Fish point out, “We’re here to tell you that none of that is true.  Sexual pain is almost always caused by an identifiable, verifiable medical condition; it can be treated and is not in your head.” 

Nancy Fish had suffered from severe pelvic pain and had seen seven specialists before visiting Deborah Coady.  Coady, while having years of experience with women suffering from sexual pain, nonetheless took some time to uncover all of Fish’s difficulties.  Fish, like most women suffering from sexual pain, through inadequate treatment had several conditions that had compounded and spread.  A licensed certified social worker specializing in chronic illness, Fish found great hope in Coady’s insistence that she never give up on herself. She was inspired to form a partnership with Coady to help those with the chronic illness of sexual pain. 

Deborah Coady, through her personally developed teams of colleagues in neurology, dermatology, orthopedics, pain management, gastroenterology, urology, peripheral nerve surgery, physical therapy and psychotherapists, demonstrates in Healing Painful Sex how fruitful their holistic approach can be. As they write, “Even in your most difficult situations, you can experience a significant reduction in your pain and can find help for reintroducing sex as a joyous and nourishing part of your life.  We promise:  Things can get better.”

The book is organized into three parts. Part 1: Naming the Problem begins with the difficult situation of talking about sexual pain.  It helps the reader learn how to share her situation with one or two other people who can then help make medical decisions.  The book then discusses the often arrogant, uninformed or downright abusive physicians who exist.  As stated in the book, “The degree of incompetence, insensitivity, and indifference among gynecologists, other specialists, and general practitioners is hard to overstate.”  Hoping to aid their emotional healing along the way to ending their sexual pain, Coady and Fish outline the ways in which the reader can understand what to do when the doctors get it wrong. 

The first section of the book ends with a chapter dedicated to finding a doctor who will offer effective treatment and provides a detailed holistic guide on beginning one’s healing by following guidelines on pain, sleep hygiene, diet and supplements, exercise and relaxation techniques and learning of how to be gentle with oneself.

Part 2: Understanding the Problem, provides the reader nine chapters of detailed information covering the symptoms and conditions of pelvic floor dysfunction, vulvodynia, pudendal nerve pain, clitorodynia, pelvic organ problems, endometriosis, painful bladder, and irritable bowel syndrome, skin disorders, such as lichen sclerosis, and hormonal, surgical, and post-cancer causes of pain.  Interwoven with detailed explanations of the causes of sexual pain, the book contains full-page anatomical illustrations, checklists for particular disorders, and details on the types of tests needed as well as lists of the common misdiagnoses given for a disorder and ways to rule it out.  It contains details on how the various conditions can co-occur and affect one another.  It tells the potential patient of what to expect during an examination and offers guidance based on the doctor’s performance and recommendations.

Part 3: Overcoming the Problem presents valuable information and guidance devoted to fulfilling one’s life with the joys often taken away in sexual pain.  Coady and Fish hope to return libido, desire, partner intimacy, healthy relationships with friends and families to women undergoing sexual pain.  Their many personal case studies validate and underscore the valuable guidance they provide.  The book closes with excellent resources, including recommended books, helpful websites, psychotherapists, as well as relevant organizations and associations.

Healing Painful Sex: A Woman’s Guide to Confronting, Diagnosing, and Treating Sexual Pain
By Deborah Coady, MD & Nancy Fish, MSW, MPH
Seal Press: November 1, 2011
Paperback, 400 pages
$18

The team used a group of 19,478 participants who were born in a single week in 1958, and followed them through childhood and adulthood. Childhood behavior was recorded by parents and teachers at ages 7, 11, and 16, based on aspects such as restlessness, worrying, solitariness, ability to make friends, obedience, stealing, sucking thumbs and biting nails, lying, bullying, or displaying truant behavior. Pain in adulthood was measured at 45 years.

Children whose teachers reported “severe persistent behavior problems” at all ages had more than double the risk of chronic widespread pain by the age of 45 compared with children without behavior problems at all ages. A weaker link also existed for parent-reported behavior, possibly because teachers are more experienced and can be more objective, the researchers speculate.

In the journal Rheumatology, the authors conclude, “Maladjusted (social) behavior is associated with increased long-term chronic widespread pain beyond childhood and adolescence.”

Dr. Pang said, “Aspects of childhood behavior are strongly related to children reporting chronic widespread pain. However, until now, it was unknown whether maladjusted behavior in children was a long-term marker for chronic widespread pain in adulthood. Our study shows that it is.”

The association could not be explained by social class, says Dr. Pang, and was not thought to be due to the known link between psychological distress in adults and chronic widespread pain. He says that the underlying biological mechanism is not known, but suggested it may be “a long-term neuroendocrine dysfunction beginning in early life,” involving the hypothalamic-pituitary-adrenal axis which controls reactions to stress.

This dysfunction, possibly triggered by early trauma, could underlie both the childhood behavior and the adult chronic widespread pain, he believes. “Further research at molecular and genetic levels is needed to clarify this theory,” he states.

Psychological distress was measured at the age of 42, and this also showed a link with childhood behavioral problems. Long-term depression and anxiety, suicidal behavior, substance abuse and treatment for psychiatric illness were more common among those deemed to have early behavior problems.

Co-researcher Professor Gary Macfarlane added, “This study helps us to understand the factors in childhood that can lead someone to get on a trajectory of ill health, including chronic pain. The disruption to the hypothalamic-pituitary-adrenal (stress-response) axis is one biological marker of the effect of such experiences and this could help to identify persons at higher risk of chronic pain. Interventions would be lifestyle-focused and would include identification and treatment of behavioral and emotional factors, but would also address lifestyle factors such as increased physical activity.

“We plan to undertake some studies in children to understand what range of factors cause a disturbance to the stress-response axis; such work can then inform what intervention studies may be appropriate.”

The study of lifetime influences on chronic pain is still in its infancy, the team concludes. Future studies are required to confirm potential links between early life events and pain across the life course.

Other recent studies confirm that the hypothalamic-pituitary-adrenal axis is associated with at least some aspects of childhood behavior. Tests on a group of 1,768 10- to 12-yea-olds showed that girls with “externalizing” behavior problems (such as aggression, delinquency, and hyperactivity) had significantly higher cortisol levels, representing greater activity in the hypothalamic-pituitary-adrenal axis. But this link was not seen in boys, or for “internalizing” behavior problems (such as anxiety and depression).

A further study suggests that abnormalities in the hypothalamic-pituitary-adrenal axis may indicate a vulnerability to chronic pain. Current pain and psychosocial profiles were measured in a large group of adults. Of these, 267 were deemed to be at future risk of pain based on their psychosocial profile, and their hypothalamic-pituitary-adrenal axis function was tested.

Fifteen months later, 12 percent of the entire group had developed chronic widespread pain. They were significantly more likely to have dysfunction of the hypothalamic-pituitary-adrenal axis, represented by morning and evening cortisol levels. “Dysfunction of the hypothalamic-pituitary-adrenal axis helps to distinguish those who will and will not develop new-onset chronic widespread pain,” say the researchers.

References

Pang, D. et al. Influence of childhood behaviour on the reporting of chronic widespread pain in adulthood: results from the 1958 British Birth Cohort Study. Rheumatology, published online March 10, 2010.

Marsman, R. et al. HPA-axis activity and externalizing behavior problems in early adolescents from the general population: the role of comorbidity and gender The TRAILS study. Psychoneuroendocrinology, Vol. 33, July 2008, pp. 789-98.

McBeth, J. et al. Moderation of psychosocial risk factors through dysfunction of the hypothalamic-pituitary-adrenal stress axis in the onset of chronic widespread musculoskeletal pain: findings of a population-based prospective cohort study. Arthritis and Rheumatism, Vol. 56, January 2007, pp. 360-71.

Hahnemann suggested two key principles. First, he asserted that “like cures like.” In other words, a substance that produces certain symptoms in a healthy person can be used to cure similar symptoms in a sick person. Second, he claimed that very small doses of a remedy would be effective. Hahnemann diluted the remedies in a process he named potentization. He would take an original natural substance and dilute it numerous times. Between each dilution, he would shake the remedy. Shaking supposedly released the cure’s healing energy.

A 1991 study in the British Medical Journal investigated 107 controlled trials of homeopathy. The researchers concluded: “At the moment the evidence of clinical trials is positive but not sufficient to draw definitive conclusions because most trials are of low methodological quality and because of the unknown role of publication bias. This indicates that there is a legitimate case for further evaluation of homoeopathy, but only by means of well-performed trials.”

A 1990 study published in Revue d’Epidemiologie et de Sante Publique investigated 40 randomized trials involving homeopathy. The researchers concluded that the evidence did not show homeopathy to be effective. In 1994 the National Council Against Health Fraud, a U.S.-based organization, advised consumers not to buy homeopathic products or to patronize homeopathic practitioners. In addition, they stated, “Basic scientists are urged to be proactive in opposing the marketing of homeopathic remedies because of conflicts with known physical laws. Those who study homeopathic remedies are warned to beware of deceptive practices in addition to applying sound research methodologies.”

A 2005 study published in Lancet analyzed 110 homeopathy trials and 110 conventional medicine trials. The researchers concluded “there was weak evidence for a specific effect of homoeopathic remedies, but strong evidence for specific effects of conventional interventions. This finding is compatible with the notion that the clinical effects of homoeopathy are placebo effects.”

Brien and colleagues (2010) conducted a study to assess whether benefits from adjunctive homeopathic intervention in patients with rheumatoid arthritis (RA) are due to the homeopathic consultation, homeopathic remedies or both. The researchers found that homeopathic consultations were associated with clinically relevant benefits for patients with active but relatively stable RA. Homeopathic remedies were not associated with benefits.

Very few studies validating homeopathy’s efficacy have appeared in major medical journals. Most positive studies have appeared in nonscientific journals, and have been subject to bias, or have had a poor research design. The overwhelming majority of data appearing in scientific journals shows that homeopathy is an ineffective treatment for any clinical condition.

Why Homeopathy?

Why do people turn to homeopathic treatment? In many cases they do not trust physicians or the expensive drugs that are often prescribed. Some people feel like physicians are not really interested in them personally, especially if they can’t find anything wrong with the patient, or if the diagnosis doesn’t match with what they think it should. Not hearing what the patient knows is right may be taken offensively. Physicians, generally, do not spend much time talking with the patient, which further supports the patient feeling the doctor’s lack of interest. If the physician doesn’t find anything wrong this may further offend the patient.

A visit to a homeopathy practitioner may take 45 minutes to an hour. The homeopathy practitioner asks numerous questions and appears to be genuinely concerned with the patient’s personal life. The homeopathy practitioner designs the remedy to suit the unique individual, which furthers the patient’s confidence in the remedy. Homeopathy is alluring to both the patient and practitioner. They become partners in fighting this terrible condition. The benefits of homeopathy are not the remedies, but the consultations (increasing placebo effects) associated with homeopathy (see Brien et al. above).

References

Brien, S., Lachance, L., Prescott, P., McDermott, C., & Lewith, G. (2010). Homeopathy has clinical benefits in rheumatoid arthritis patients that are attributable to the consultation process but not the homeopathic remedy: a randomized controlled clinical trial. Rheumatology (Oxford) Nov.13.

Hill, C. and F. Doyon. 1990. Review of randomized trials of homeopathy. Revue d’Epidemiologie et de Sante Publique 38 (2): 139–47.

Kleijnen, J. et al. 1991. Clinical trials of homeopathy. BMJ 302 (6772): 316–23.

National Council Against Health Fraud, Inc. NCAH F position paper on homeopathy. http://www.ncahf.org/pp/homeop.html (accessed November 25, 2010).

Shang, A. et al. 2005. Are the clinical effects of homeopathy placebo effects? Comparative study of placebo-controlled trials of homeopathy and allopathy. Lancet 366 (9487): 726–32.

Wagner, M. W. 2002. Is homeopathy “new science” or “new age”? Homeowatch. http://www.homeowatch.org/articles/wagner.html (accessed November 25, 2010).

It has recently become popular on a worldwide scale, they explain. But regular use “can have adverse outcomes.” They examined those of most interest for public health – dependence, risk of vehicle crashes, bronchitis and other airway diseases, heart disease, and effects on lifestyle and mental health.

It is estimated that 166 million adults worldwide used cannabis in 2006. Use was highest in the U.S., Australia and New Zealand, followed by Europe. It typically began in teenage years and declined after obtaining full-time employment, getting married, and having children.

The active component of cannabis is tetrahydrocannabinol (THC). Short-term side effects can include anxiety, changes in appetite, panic reactions and even psychotic symptoms. About nine percent of users will become dependent, compared with 32 percent for nicotine and 15 percent for alcohol. Withdrawal may trigger insomnia and depression.

Chronic bronchitis can develop, as cannabis smoke contains many of the same carcinogens as tobacco smoke. Heavy users are at higher risk of problems with verbal learning, memory, and attention. Use is also linked to poor educational attainment, but the experts say that the cause and effect of this relationship is unclear. It may be caused by pre-existing risk factors as well as cannabis use.

Because cannabis can slow reaction time and coordination, it brings an increased risk of road accidents. Its use in pregnancy could reduce birthweight, but does not seem to cause birth defects. Cannabis users are also more likely to go on to use other illicit drugs, including heroin and cocaine.

The potential link to schizophrenia causes widespread concern. Studies suggest the risk is more than doubled for people who have tried cannabis by age 18. An analysis published in the Lancet in 2007 found a 40 percent increase in risk of “psychotic symptoms or disorders” in people who had used cannabis, with the highest risk among regular users, particularly those with a vulnerability to psychosis. For depression and suicide attempts, the evidence is less clear.

The University of Queensland experts conclude that, “The most probable adverse effects [of cannabis] include a dependence syndrome, increased risk of motor vehicle crashes, impaired respiratory function, cardiovascular disease, and adverse effects of regular use on adolescent psychosocial development and mental health.”

In a separate study, the experts take an in-depth look at the possible risk of psychosis. They say that observational studies show “consistent evidence that cannabis is associated with an increased risk of schizophrenia, and more generally, psychosis.” But there is debate about whether cannabis is a true contributing cause.

Since 2004, there has been a great deal of research carried out regarding the link. Overall, these studies suggest that the association is unlikely to be due to chance. “The evidence suggests that it is more likely that cannabis use precipitates psychosis in vulnerable persons, which is consistent with other lines of evidence suggesting that there is a complex constellation of factors leading to psychosis,” they write.

“We argue that the evidence is as good as that for many other risk factors,” they add. “Psychotic disorders are associated with substantial disability, and cannabis use is a potentially preventable exposure.”

When the Australian team investigated whether cannabis is linked to higher overall risk of death, they found “insufficient evidence, mainly due to the low number of studies.” Some studies suggest that certain health outcomes may be elevated among heavy users, yet there is a lack of long-term research that follows cannabis users into old age, when harmful effects are more likely to emerge.

Conversely, cannabis has been tried as an experimental treatment for gastrointestinal conditions such as inflammatory bowel disease. Cannabinoid receptors are located throughout the gut, involved in the regulation of food intake, nausea and inflammation. Drugs based on cannabis that act on these receptors may have therapeutic potential, scientists believe.

Cannabis preparations are also used as a remedy for chronic pain. In a 2009 review, researchers state that cannabis is “moderately efficacious for treatment of chronic pain,” but the beneficial effects “may be partially (or completely) offset by potentially serious harms.” More evidence from larger trials is needed, they conclude.

References

Hall, W. and Degenhardt, L. Adverse health effects of non-medical cannabis use. The Lancet, Vol. 374, October 17, 2009, pp. 1383-91.

Degenhardt, L. et al. Should burden of disease estimates include cannabis use as a risk factor for psychosis? PLoS Medicine, Vol. 6, September 2009, e1000133.

Calabria, B. et al. Does cannabis use increase the risk of death? Systematic review of epidemiological evidence on adverse effects of cannabis use. Drug and Alcohol Review, Vol. 29, May 2010, pp. 318-30.

Martín-Sanchez, E. et al. Systematic review and meta-analysis of cannabis treatment for chronic pain. Pain Medicine, Vol. 10, November 2009, pp. 1353-68.

A team led by Dr. Camilla Bengtsson at the Karolinska Institute in Sweden used figures on 1,221 rheumatoid arthritis patients aged 18 to 65 years, and 1,454 similar healthy people.

Psychological job demands and job “decision latitude,” or personal control, were measured by questionnaire. Participants facing high demands with low control were defined as experiencing “job strain” as opposed to relaxed working conditions.

Earlier work has linked job strain with an increased risk of several diseases, including heart disease, because of a possible association with inflammation. But it has not previously been studied in relation to rheumatoid arthritis.

The team explains, “Data on environmental factors that may cause rheumatoid arthritis is scarce.” Results of their new study appear in the journal Psychotherapy and Psychosomatics.

Low decision latitude was linked to a 60 percent increase in risk of rheumatoid arthritis, but surprisingly, high psychological job demands were linked to a 20 percent lower risk. Job strain, a combination of the two, was linked with a 30 percent higher risk, compared with relaxed working conditions.

The team concludes, “The main new finding of this study was that low decision latitude was associated with an increased risk of developing rheumatoid arthritis. Furthermore, some evidence that those with high psychological job demands had a decreased risk of rheumatoid arthritis was found.”

Dr. Maurizio Cutolo of the University of Genoa, Italy, has looked into this link. He writes, “Stress is now recognized as an important risk factor in the pathogenesis of rheumatoid arthritis.”

He believes the mechanism can be explained by brain activity. “Activation of the stress response system influences the relationships between the hypothalamic-pituitary-adrenal axis, the sympathetic nervous system and the immune system,” he writes.

“The stress response results in the release of neurotransmitters (norepinephrine), hormones (cortisol) and immune cells. Major life events lead to an intense release of stress mediators, whereas in minor life events, only short-lived surges of neurotransmitters and hormones are expected.”

Long-lasting stress may lead to proinflammatory effects, because no adequate long-term anti-inflammatory responses are available, he states.

The Swedish team also investigated the possible influence of formal education and occupational class on risk of rheumatoid arthritis. Using figures on 930 rheumatoid arthritis patients and 1,126 similar healthy people, they calculated the risk of developing rheumatoid arthritis for different levels of formal education and occupational classes.

Those without a university degree had a 40 percent increased risk, compared with those with a university degree. Manual employees, and assistant and intermediate non-manual employees had a 20 percent higher risk than higher-ranking non-manual employees.

The researchers say that these increased risks were mainly confined to women, who constitute three times as many sufferers as men. They suggest that “as yet unexplained environmental or lifestyle factors, or both, influence the risk of rheumatoid arthritis, even in the relatively egalitarian Swedish society.”

In contrast to osteoarthritis, the more common form of arthritis caused by trauma or infection of a joint, rheumatoid arthritis is an autoimmune disease in which the body attacks itself.

Dr. Bengtsson believes that environmental factors are important, as the shared risk among identical twins is low, at only 12 to 15 percent. Evidence of the role of social class is crucial for understanding its causes, she writes. A limited formal education has been found to raise the risk of rheumatoid arthritis, but results are “somewhat inconsistent.” She thinks this inconsistency may be due to low participant numbers or the inclusion of other types of arthritis.

Because Sweden provides universal access to medical care, Dr. Bengtsson says it is unlikely that the links she found can be due to variation in treatment.

“Taking these considerations into account, the results from our study add to the likelihood that socioeconomic status indeed influences the risk of developing this disease even today, and even in Western Europe, including the highly egalitarian societies in Scandinavia,” she says.

“The lower risk in individuals with high education and less manual work may reflect fundamental factors that may have changed the overall pattern of rheumatoid arthritis in many Western societies toward a lower overall rate and a higher age of diagnosis,” she suggests.

References

Bengtsson, C. et al. Psychosocial Stress at Work and the Risk of Developing Rheumatoid Arthritis: Results from the Swedish EIRA Study. Psychotherapy and Psychosomatics, Vol. 78, April 2009, pp. 193-94.

Bengtsson, C. et al. Socioeconomic status and the risk of developing rheumatoid arthritis: results from the Swedish EIRA study. Annals of the Rheumatic Diseases, Vol. 64, November 2005, pp. 1588-94.

Cutolo, M. and Straub, R. H. Stress as a risk factor in the pathogenesis of rheumatoid arthritis. Neuroimmunomodulation, Vol. 13, 2006, pp. 277-82.

One of the fascinating segments of my job as a private tutor is my role as home school teacher. I take on referrals of students who can’t attend school. Sometimes the causes are physical (for example, a student with cancer undergoing radiation therapy). But far more commonly, I wind up home schooling students with emotional or psychological issues. And it’s remarkable to me how confusing and poorly identified and inadequately understood these issues can be.

Over the past two school years I’ve had three referrals that opened my eyes to how little I know, and how little even the school and mental health professionals seem to know, about the many faces of depression. I live and work in one of the most affluent and progressive suburban areas of this country; surely there is no better health care to be found. And yet, getting the right kind of information and help can be scarily difficult. In each case the professionals, the parents, the student and I all struggled to find answers and solutions. There never seemed to be a clear path to follow, and I wonder now if this is because depression never walks the same path twice.

Eva, diagnosed with chronic fatigue disorder, was also later identified as having depression (depression and CFD often go hand in hand). When I first met her, Eva could barely find the will to move her head off the sofa. One day I tried to encourage her to “just try one math problem,” and she shrieked as if I had stuck her with a pin. I was shocked and mortified; I had never imagined she was in such pain.

Molly has fibromyalgia (a chronic pain syndrome) and she then developed depression. Molly had always been a model student, and she was so determined to overcome the fog in her brain and the aches in her body and get her schoolwork done, that she’d push herself until she was wracked with migraines that would set her back for days. I learned to watch Molly carefully for signs of wincing and slow thinking and to stop our lessons before she pushed herself over the edge.

Caitlin would prop her head on her hand and stare at the book, or at me, or out the window. Was this ADD? Or, as too many teachers suspected, was it pure bratty defiance? Caitlin’s hostile glare and refusal to speak when spoken to were easy to misinterpret as insolence. The school year wore on, Caitlin was shuffled from one therapist to another to another (several therapists “fired” her because she refused to talk to them) and we dragged joylessly through our lessons. At one point Caitlin did receive a diagnosis of depression, though then none of the antidepressants seemed to help much.

These three girls were all so different, yet they each touched my heart in their own way and also made me feel so helpless. I always feel competent and effective to handle academic problems, but these cases were so out of my field of expertise. It was devastating to work with these girls every day and feel their pain and not really know what was wrong or what to do. Each suffered some version of depression, blended with other conditions in unique and confounding ways.

Perhaps one reason why depression can be hard to define or diagnose is because it can be a normal human response that has crossed a border into dysfunction. Eva points out that being trapped in what felt like a bottomless pit of fatigue, accentuated by her doctor’s cheery assurance that her CFS would hopefully improve “within two to four years” (an eternity to a teenager!) caused her to feel appropriately hopeless and depressed. Eva’s depression was very real, yet it was also “understandable.” Its cause seemed clear: the CFS caused the depression.

But then, curing Eva’s depression also cured her CFS! This, in any event, is how Eva herself reports it. Wellbutrin worked for Eva; she began to feel mentally better, and then physically better, until now she is almost completely recovered in all respects. And she no longer needs the Wellbutrin.

Molly’s outcome is also a happy one. Her fibromyalgia may never go away entirely, but antidepressants have helped Molly temper her perfectionist streak, allowing her to relax and therefore not aggravate her physical condition so much. She’s learned to set and respect physical and mental boundaries so as to preserve her health.

Caitlin’s situation remains unresolved. She appears to have several psychological issues, one of them being depression, all tangled together in ways that are difficult to sort out. Caitlin was a great reminder to me to never misinterpret a student’s “attitude.” The vast majority of kids I work with are warm and eager and cooperative right from the start. The very few, like Caitlin, who are seemingly cold or rude or otherwise resistant or poorly behaved have always turned out to be concealing tremendous internal pain. I know now to take that pain seriously, and resist any impulses to blame the victim.

Eva and I were talking the other day about how complex and diverse is depression, how depression is surely a different disease for each sufferer. Eva lately feels energetic enough to write, and she’s agreed to work on writing the tale of her chronic fatigue and depression. I hope I’ll be posting her story on my blog soon! The faces of depression need their voices heard.

Depression and other physical health conditions have separate but additive effects on well-being. For example, the combination of heart disease and depression can cause twice the reduction in social interaction than either condition alone.

Patients with both depression and physical health problems are at particular risk: The physical problem can complicate depression’s assessment and treatment by masking or mimicking its symptoms.

It can work the other way as well. People with any chronic physical disease tend to feel more psychological distress than do healthy people. Poor physical health brings an increased risk of depression, as do the social and relationship problems that are very common among chronically ill patients.

A 2009 study of patients with severe chronic obstructive pulmonary disease found that 22 percent of the participants had at least mild depression, defined as a score of 14 or more on the widely-used Beck Depression Inventory. Seventeen percent were taking antidepressants. The researchers say that for these patients, “depression is an independent determinant of health-related quality of life.”

Professor David Goldberg of the Institute of Psychiatry, London, UK, reports that the rate of depression in patients with a chronic disease is almost three times higher than normal. He explains, “Depression and chronic physical illness are in reciprocal relationship with one another: not only do many chronic illnesses cause higher rates of depression, but depression has been shown to antedate some chronic physical illnesses.”

He states that depression which occurs together with physical illness is less well diagnosed than depression occurring on its own. “Depression among those with chronic physical illnesses is likely to be missed by professionals who care for physically sick patients,” he writes in the journal World Psychiatry. “This is because health professionals are understandably concerned with the physical disorder which is usually the reason for the consultation, and may not be aware of the accompanying depression.”

Depressive illness can also precede a physical disease. It has been linked to coronary heart disease, stroke, colorectal cancer, back pain, irritable bowel syndrome, multiple sclerosis, and possibly type 2 diabetes.

Professor Goldberg believes that untreated depression causes much unnecessary suffering, whereas effective treatment can decrease disability, prolong survival and increase quality of life.

He suggests that treatment consist of giving “the least intrusive, most effective intervention first.” The primary care physician should have overall responsibility for the patient, but a case manager and a mental health specialist (psychiatrist or clinical psychologist) should provide further support.

Less severe depression may be helped by lifestyle advice on sleep and physical activity, modified to take account of any physical disabilities. Other treatments include cognitive-behavioral therapy, either as a self-help program, computer-based, or with a therapist in groups or individually.

“There is no good evidence that one antidepressant is superior to another in the treatment of depression among those with physical illnesses,” says Professor Goldberg, “and perhaps the most important consideration when choosing an antidepressant for these patients is the nature of the treatment being given for the physical illness.”

Certain antidepressants work better alongside beta-blockers, for example, and others work less well with serotonin receptor agonists prescribed for migraine, or monoamine oxidase inhibitors for Parkinson’s disease. Older antidepressants, such as tricyclics and St. John’s wort, should be avoided in physically ill patients, since they are each associated with a wide range of interactions with other drugs.

Although depression can be treated effectively, there is no clear evidence that this treatment improves the physical illness. But it does have other beneficial effects such as improvements in social and emotional functioning, perceived disability and fatigue.

A 2003 study found that the treatment of depression in arthritis patients led to improved arthritis-related pain intensity, less interference with daily activities due to arthritis, and better overall health status and quality of life.

Professor Goldberg concludes, “The weight of the evidence suggests that, in addition to reducing depressive symptoms, treatment of depression is effective in reducing functional disability. One of the reasons for persevering with active treatment for depression is that even if the outlook for survival is poor, quality of life may still be improved.”

References

Moy, M. L. et al. Multivariate models of determinants of health-related quality of life in severe chronic obstructive pulmonary disease. The Journal of Rehabilitation Research and Development, Vol. 46, 2009, pp. 643-54.

Goldberg D. The detection and treatment of depression in the physically ill. World Psychiatry, Vol. 9, February 2010, pp. 16-20.

Lin, E. H. et al. Effect of improving depression care on pain and functional outcomes among older adults with arthritis: a randomized controlled trial. The Journal of the American Medical Association, Vol. 290, November 2003, pp. 2428-29.

The best treatment approach for people with dysthymia appears to be a combination approach — psychotherapy combined with antidepressant medication. One large multisite study in the New England Journal of Medicine by Keller and colleagues (2000), for instance, had patients randomly assigned to one of three treatments: a depression-focused cognitive-behavioral therapy (CBT) program, the antidepressant Serzone (nefazodone), or to a combination of the two. About three-quarters responded to the combination, compared with about 48 percent for each individual condition.

“The combination of the two was whoppingly more effective than either one alone,” noted the researchers. “People suffering from chronic depression often have longstanding interpersonal difficulties, and the virtue of combined treatment in this case may be that it simultaneously targets both depressive symptoms and social functioning.”

Psychotherapy

There are many different types of psychotherapy available to help someone with dysthymia.

Before psychotherapy beings, a mental health professional will conduct a thorough evaluation to evaluate the individual’s current state of functioning, to assess mood type and severity, check for suicidal ideation and plan, etc. No matter which specific type of psychotherapeutic approach is utilized, a supportive, change-oriented environment and good rapport should be established by the therapist. A cognitive-behavioral therapy (CBT) that is client-centered should generally be considered, as it offers a therapy environment tailored to the patient’s need for unconditional acceptance and support. Non-specific factors will like be an important component of therapy. Therapy should be generally conducted with respect to the client’s pace and level of functioning. Attempts to focus on change too early in therapy could lead to early termination of therapy. This likely occurs because the patient feels the therapist didn’t respect or care enough about him or her to move at their rate.

Psychotherapy approaches for this disorder vary widely. Short-term approaches are preferred, however, because they emphasize realistic, attainable goals in the individual’s life which can usually bring them back to their normal level of functioning. This level, however, may be markedly less than what is expected in the average person. A person who suffers from dysthymic disorder has generally learned to live with a fair amount of chronic unhappiness in their lives. Realistic goals should be established early-on and the focus of therapy, instead of focusing on the person’s mood state.

Group therapy has been shown to be an effective modality for individuals suffering from this disorder. A group can be more supportive an individual than any one therapist can and help point out inconsistencies in the patient’s thinking and behavior. It should be considered, if not initially, then later on in treatment as the client regains his or her own self-confidence and can interact in a social context. Issues of self-esteem often accompany individuals who have dysthymic disorder, so care must be employed not to place the person into a group situation (where failure may be imminent) too soon. Family therapy may also be helpful for some individuals. Couples therapy can bring the individual’s spouse or significant other into the therapeutic relationship to create a therapeutic (and more powerful) triad.

Goals will vary according to type of therapy. Cognitive therapy emphasizes changes in one’s faulty or distorted way of thinking and perceiving the world. Interpersonal therapy focuses on an individual’s relationships with others and how to improve and strengthen existing relationships while finding new ones. Solution-focused therapy looks at specific problems plaguing an individual’s life in the present and examines how to best go about changing the person’s behavior to solve these difficulties. Social skills training focuses on teaching the client new skills on how to become more effective in social and work relationships. Usually, psychoanalytic and other insight-oriented approaches will be less effective because of their focus on the past and emphasis on lengthy therapy. While incorporation of therapy into a person’s chronic condition might be quite financially lucrative for the therapist, it is not the most change-effective and timely approach to help the individual overcome his or her difficulties.

Because the clinician must move at the client’s pace, progress with any type of therapy can be slow. Therapists should resist the temptation to try and “speed up” the process or force the client in a direction he or she is not yet ready to try. Closely related to this issue of the pace of therapy is being aware of the clinician’s frustration with lack of progress or boredom within the therapy session. It can be an emotionally draining experience for some therapists.

Medications

People with dysthymia often take an antidepressant medication, one that they find helps keep their energy levels up and keep them from reaching the lowest depressive moods. A class of antidepressants called selective serotonin re-uptake inhibitors (SSRIs) are the most commonly prescribed medication for chronic depression today. Prozac (fluoxetine), Paxil (paroxetine), Zoloft (sertraline) and Luvox (fluvoxamine) are the most commonly prescribed brand names. SSRI medications should not be prescribed in conjunction with the older MAOIs (more popular in Europe than in the U.S.).

The large-scale, multi-clinic government research study called STAR*D found that people with depression and who take a medication often need to try different brands and be patient before they find one that works for them.

Results from the STAR*D study indicate that if a first treatment with one SSRI fails, about one in four people who choose to switch to another medication will get better, regardless of whether the second medication is another SSRI or a medication of a different class. And if people choose to add a new medication to the existing SSRI, about one in three people will get better. It appears to make some — but not much — difference if the second medication is an antidepressant from a different class (e.g. bupropion) or if it is a medication that is meant to enhance the SSRI (e.g. buspirone).

The most commonly prescribed antidepressants generally take 6 to 8 weeks before a person will start feeling their therapeutic effects.

Self-Help

Self-help methods for the treatment of this disorder are often overlooked by the medical profession because very few professionals are involved in them. Adjunctive community support groups in concurrence with psychotherapy is usually beneficial to most people who suffer from dysthymic disorder. Caution should be utilized, however, if the person also suffers from social anxiety. A group like A.A. or N.A. may also be appropriate, if the underlying cause of the dysthymia is a substance abuse problem. Many support groups exist within communities throughout the world which are devoted to helping individuals with this disorder share their commons experiences and feelings.

Patients can be encouraged to try out new coping skills, assertiveness skills, cognitive restructuring, etc. within such a support group. They can be an important part of expanding the individual’s skill set and develop new, healthier social relationships.

Since this is a chronic disorder, your mental health professional should be sensitive to not using previous treatment approaches (especially medication) which have proven ineffective in the past. A careful and thorough history should be conducted at the onset of treatment to ensure this is evaluated. Specific attention should also be given to diagnostic issues, such as the existence of an alcohol or substance abuse problem, or social anxiety or other phobia, underlying or causing the dysthymic condition.

The Alexander Technique — developed in the late 1800s by a Shakespearean actor who lost his voice and discovered the cause to be a tightening of his upper torso — also can benefit those with chronic back pain, according to researchers.

The Alexander Technique aims to help each user develop lifelong skills that will aid their posture and coordination. Individual lessons involve assessing the patient’s musculoskeletal habits and focusing on the release of tension in the neck, head and spine. Teachers give verbal instructions and use hand contact to improve the student’s musculoskeletal use. The techniques are repeated at home between sessions.

British researchers recruited 579 patients with chronic or recurrent low back pain from 64 general practices in the south and west of England. The patients received either standard care, massage therapy, six Alexander Technique lessons, or 24 Alexander Technique lessons. A physician also told half of each group’s members to do specific exercises, and a nurse provided structured behavioral counseling.

The counseling was based on Ajzen’s theory of planned behavior, which says that a person’s attitude toward an action (in this case, exercise) and their perceived control are the most significant determinants of behavior.

After three months, and again at 12 months, the participants filled in disability questionnaires to record which activities were limited by their back pain. Limited activities could include having to walk more slowly than usual, or not leaving the house as often as usual.

The results showed that Alexander Technique lessons combined with the exercise program significantly reduced pain and improved functioning.

“Exercise and lessons in the Alexander Technique, but not massage, remained effective at one year, compared with standard care,” the researchers reported. The group that received six technique lessons achieved 72 percent of the effect of 24 lessons, and the researchers believe the results should apply to most patients with chronic or recurrent back pain.

Patients receiving Alexander Technique lessons also reported improved quality of life. The behavioral counseling provided only modest benefits.

However, Professor Maurits van Tulder from VU University in the Netherlands raises doubts. In an accompanying editorial, he warns that the study may not be generalizable to clinical practice because participants in this study were a random selection of patients who had attended primary care practices with chronic back pain in the past five years. “These people were not seeking care [at the time of the study] and may not be comparable to those who visit their primary care doctor for treatment of lower back pain,” he writes.

Professor van Tulder said that the evidence already strongly supports exercise therapy. For example, a large review found that exercise therapy “significantly reduces pain and improves function in adults with chronic low back pain.” But he warns that simply telling patients to exercise at home is ineffective; instead, the patients need expert supervision and guidance.

Van Tulder does not dismiss the Alexander Technique completely, but calls for further research to compare it with different types of exercise. He also wants to see further investigation into the effectiveness of cognitive behavioral therapy, acupuncture, yoga, and progressive relaxation for chronic back pain. “Patients’ preferences and expectations should also be considered,” he adds, “because these factors seem to influence outcomes.”

Cognitive behavioral therapy and supervised exercise therapy both are recommended, among other approaches, in the current medical guidelines in the US and in Europe for chronic low back pain.

References and other resources

Little, P. et al. Randomised controlled trial of Alexander technique lessons, exercise, and massage (ATEAM) for chronic and recurrent back pain. The British Medical Journal, 2008;337:a884.

van Tulder, M. Conservative non-pharmacological treatment for chronic low back pain. The British Medical Journal, 2008,337:a974.

Godin, G. and Kok, G. The theory of planned behavior: a review of its applications to health-related behaviors. The American Journal of Health Promotion, Vol. 11, Nov/Dec 1996, pp. 87-98.

Alexander Technique website

Research has shown us that family and friends can play a huge role in helping patients deal with a chronic illness.

When a person is suffering from a chronic illness, it’s important that they feel truly cared about. What matters most is how people interact with the sick person.

Here are some ways that patients and their families can get the kind of support they want from others:

• Put an end to family secrets. In other words, honesty is still the best policy. We often try to protect our families and loved ones from bad news, but hiding a person’s serious illness from the rest of the family can backfire. Communicate directly and be open with family members.
• Include your children. Although their understanding of the situation may be limited, children still appreciate being told what’s going on around them. Children can sometimes view themselves as the cause of problems or major events that happen around them. They may view a parent’s illness as being caused by something they did. Be open, honest, let children know it’s okay to ask questions. This will help relieve some of their anxiety. Remember, a child can be a great source of laughter and warmth for a sick individual.
• Be selective. Everybody under the sun doesn’t need to know about your illness or your loved one’s illness. Choose who you care to share your news with carefully. Some relationships will prosper and some will become strained. What’s important is that you feel that sharing the information with an individual will provide a stronger sense of support and strength.
• Be clear about how family and friends can help. People want to feel useful. Don’t be ashamed to ask for help or favors, such as cooking a meal or helping with the school carpool.

Finally, if someone you love if suffering from a chronic illness, learn about the disease, help out with daily errands and chores, and give emotional support. Sometimes we all need a shoulder to cry on.

Article courtesy of the American Psychological Association. Copyright © American Psychological Association. Reprinted here with permission.