Can facial pain affect mental health?

For several reasons, the answer is yes it can. First, there is a ‘loss’ associated with a facial pain condition – a sense of loss of control over your life. Another reason is because facial pain can cause even small, daily decisions to become complex: Can I go on that vacation? Can I go out to eat with my friends tonight?  Will I be able to handle school (or work, or taking care of my kids)? In addition, for many, facial pain can be triggered by facial expressions. We use our face to communicate emotions and when this is impeded by pain, there is a psychological impact.

Your facial pain can have an impact on the relationships in your life that support your happiness, feelings of security, and mental well-being. In your relationships, there may be a lack of understanding about your facial pain that creates tension. You may withdraw from people and activities, deepening a sense of isolation.

Your enjoyment of hobbies and social time may also be affected by your facial pain; you may make life-changing decisions about family or work based on your facial pain. All of these factors can have a big impact on your mental health, and taking care of your mental health is just as important as caring for your physical well-being.

Here we will cover the following mental health topics:

• Depression
• Insomnia
• PTSD
• Cognitive Behavioral Therapy, Acceptance and Commitment Therapy
• Getting support

The chronic pain connection to depression

Clinical depression is a medical illness; it is more than feeling sad or ‘blue’. Clinical depression is a psychological state that affects how you feel, how you act, and the way you think. There is a strong link between chronic pain and depression. 

Interestingly, chronic pain affects your mental health, and depression affects your physical well-being. Symptoms of depression include both physical: pain, fatigue, appetite changes, weight gain or loss, sleep changes, and mental: feelings of sadness, helplessness, or emptiness, irritability, frustration, and angry outbursts, and others.

What is chronic pain? 

Pain becomes chronic when it goes on for many months or even years, whether it is constant or frequently occurring. People with chronic pain often experience mental and emotional distress in addition to their physical pain symptoms. Your facial pain may make you unable to do things you enjoy, negatively impacting your quality of life. Given that, it is not surprising that people who suffer from chronic pain also have recurrent clinical depression. Scientists estimate that as many as 85% of people with chronic pain are affected by severe depression.

It makes sense not only from the emotional aspect but from the physical perspective, as well. Your brain has to process every pain signal that is sent, which means it gets over-worked by chronic pain. Constantly processing pain signals can lead to dysregulation of certain neurotransmitters—the same neurotransmitters involved in depression.

How stress plays a role

One  reason chronic pain and depression are so interconnected is because of the way stress works in the body. Stressful situations, including episodes of pain, induce a flood of stress hormones that produce physiological changes. This is known as the “fight or flight” reaction- it is an evolved defense system. Your brain is sending signals to your body to prepare to fight off or run away from the cause of your pain, stress, and fear. Normally, when the pain goes away, those stress signals turn off and your body goes back to a relaxed state.

When you have chronic pain, though, the fight-or-flight signals never turn off, and the nervous system stays in a constant state of high alert. Over time, that constant stress wears your body down. So if you start out with chronic pain, it can lead to depression, which can increase your pain, which can deepen depression, and so forth. Finding ways to deal with stress and cope with your facial pain can give you a head start in the battle against depression. A silver lining to this situation is that you do have options for treatment, and some may target both pain and depression.

Antidepressants for depression and chronic pain 

The class of medications called antidepressants  is used for both depression and facial pain. This confuses a lot of people. They think their doctor believes their pain is psychological or “all in their heads”. In reality, the use of antidepressants for pain control is scientifically based and has been standard practice for decades.

Antidepressants cause chemical changes in the brain that alter the way pain is perceived to bring relief. So even if you are not depressed, your doctor may prescribe an antidepressant to treat your facial pain. In addition to treating the pain itself, taking antidepressants for pain can stop the cycle that leads to depression before it begins, or at least provide a running start.

Psychotherapy 

Therapy can help eliminate or  control troubling symptoms so you can function better and increase your well-being and healing. Psychotherapy is a common treatment for clinical depression, and it can be quite effective in helping you manage your chronic pain. An approach called cognitive behavioral therapy (CBT) has been shown to help people with chronic pain change their behavior and lifestyles in ways that help them manage and cope with their pain. It can also help them become less fearful of and demoralized because of their pain.

Psychodynamic psychotherapy is an evidenced-based treatment which relies strongly on the interpersonal relationship between the client and therapist as a means of understanding both known and unknown behavioral patterns. It can be truly transformative, as these well-worn patterns, once understood more clearly, can be reworked and modified. Psychodynamic psychotherapy is an approach which is based on a unique way of listening and bearing witness to feelings that can be difficult to put into words, in a setting of emotional honesty, safety and trust.

Psychodynamic psychotherapy is particularly helpful to chronic pain patients, who are often burdened in numerous ways by their pain, and the losses that go with it. Chronic pain can crowd out many things in life, but it doesn’t necessarily have to rule it.

Stress management 

With stress playing a role in both chronic pain and depression, learning to manage it can make a big difference. Methods that have been shown to help include:

• Mindfulness meditation
• Deep breathing
• Movement therapies, such as yoga and tai chi
• Hypnotherapy
• Guided imagery

Insomnia and pain: A chronic cycle 

Anyone can experience a sleepless night once in a while, but if you regularly have trouble falling asleep, staying asleep, or do not feel rested in the morning—and you also live with pain—you may be experiencing a double setback.

Insomnia is a common sleep disorder. About one-third of Americans have some form of insomnia, and 10% to 15% of adults report chronic insomnia (lasting 30 days or more) severe enough to impact their functioning the next day. Insomnia can cause fatigue and can also lead impaired decision-making, relationship problems, and a reduced quality of life.  Approximately two-thirds of individuals living with chronic pain have insomnia. Indeed, researchers recently demonstrated that short-term sleep deprivation amplifies pain reactivity in the brain and lowers pain thresholds; even modest nightly changes in sleep may increase the psychological impact of your pain.

Pain can interfere with your ability to fall asleep, can cause you to waken during the night, and can reduce overall sleep quality. Not sleeping well can make your pain worse. As with pain and depression, this can create a cycle that can be difficult to break. When pain and insomnia are impacting your life, it is important to speak with a healthcare provider—this may be your primary doctor, a psychologist, or a pain specialist. The good news is that, with the expertise of a knowledgeable caregiver, experts estimate that approximately 75% of chronic insomnia can be addressed successfully.

Post-Traumatic Stress Disorder (PTSD) 

People who live with chronic illness are at a greater risk of experiencing PTSD-like symptoms. The trigger for these symptoms is not a one-time event that occurred in the past; rather, chronic disease is a sense of ongoing threat to safety. Health consequences of PTSD include diminished mental and physical quality of life. PTSD produces neurobiological alterations including higher inflammation levels that negatively affect health. PTSD, like depression, can also affect how well you stick to your healthcare regime- taking your medication on schedule, eating well, getting physical activity, and keeping up with doctor appointments.

Pain as a triggering event

Most traumas come from experiencing an external event such as a natural disaster, or an attacker, or military conflict. When the trauma comes from within, in the form of chronic pain, your body is the source of ‘danger’. Feelings of fear, anxiety, shock, worry about the future can all take away your feelings of security. You may feel vulnerable and powerless against your pain.

Symptoms of PTSD

• Re-experiencing is a mental and emotional reliving of trauma. With chronic pain, re-experiencing can be connected with your experiences with hospitals and doctors. The idea of repeating procedures or tests can create extreme anxiety. Pain, negative experiences, and poor treatment outcomes of the past can impact your future feelings.
• Hyperarousal is when your body kicks into high alert when thinking about your illness. When focusing on your pain and feelings about your pain, you may become highly aware of your bodily sensations. Difficulty sleeping and irritability are also associated with hyperarousal.
• Avoidance is a way for someone with chronic pain of managing the intense anxiety that accompanies re-experiencing and hyperarousal. You may find ways to avoid the hospital, miss doctor appointments, or fail to schedule follow-up testing. The fear you may experience when you think about your facial pain and its impact is so great that avoiding anything to do with it seems like the only way to cope.

Treatment of illness-related PTSD

Treatment should focus heavily on developing coping skills. For some people, this will be pretty straightforward. For others, particularly those with additional past trauma, this will be more difficult. A good psychotherapist can help you build coping strategies that will help you feel safer and more in control. Some of these strategies include self-talk, support networks, and multi-step plans to see you through medical crises. As you feel more in control, PTSD symptoms should decrease.

Good psychotherapy also will help you to diminish re-experiencing symptoms by supporting you in developing a narrative of your illness experience. Those fragmented flashbacks need to be named, felt, and placed into the story of your life in order to be integrated. Finally, psychotherapy will address avoidance symptoms both behaviorally and emotionally.

Behavioral therapies

Pain management is always best provided as a multidisciplinary treatment. Pain impacts all domains of our lives, so the more life domains that are addressed in therapy usually leads to improved outcomes. Behavioral therapy seeks to identify and help change potentially self-destructive or unhealthy behaviors. It functions on the idea that all behaviors are learned and that unhealthy behaviors can be changed. The focus of treatment is often on addressing current problems and how to change them.

Cognitive behavioral therapy (CBT) and Acceptance and commitment therapy (ACT)

CBT is a practical, hands-on, goal-oriented psychotherapy treatment that aims to change whatever patterns of behavior and thinking are at the root of a person’s difficulties. ACT, which based on behavioral therapy, encourages mindful, values-guided action. Rather than focusing on symptom reduction, ACT encourages you to take actions that are based on your own values to enrich your life.

ACT is about accepting your distressing symptoms or situation and not trying to resist or suppress them. With ACT, you are taught to accept negative internal sensations, pain being one of them. CBT is more about cognitively reframing your distress that is a manifestation of cognitive distortions like ‘I’m a horrible person’ or ‘The world is a negative place’. With CBT, you are asked to think about the evidence for these cognitions as well as evidence to the contrary; that is, finding positive evidence. Then you are asked to “behave” as if that positive evidence is really true, even if your negative feelings and distorted thoughts would suggest otherwise.

Psychotherapists are not required to have special certification to provide CBT and ACT, although all clinical psychologists must have either a PhD or a PsyD degree, which allows them to provide psychotherapy to patients.

For people who are in pain and feeling demoralized, CBT and ACT can help with chronic stress, managing symptoms, decreasing anxiety, and improving problem-solving. With ACT and CBT, instead of ignoring or suppressing their symptoms, people are taught to focus on their goals and their values. They learn to make changes in their life and to move forward to regain life satisfaction.

Dialectic Behavioral Therapy (DBT)

The main assumption of DBT is that change and acceptance are intertwined. Its main goals are to teach people how to live in the moment, develop healthy ways to cope with stress, regulate their emotions, and improve their relationships with others. DBT incorporates a philosophical process called dialectics. Dialectics is based on the concept that everything is composed of opposites and that change occurs when there is a “dialogue” between opposing forces. The process makes three basic assumptions:

• All things are interconnected.
• Change is constant and inevitable.
• Opposites can be integrated to form a closer approximation of the truth.

In DBT, a patient and therapist work to resolve the apparent contradiction between self-acceptance and change to bring about positive changes in the patient. Through DBT, you can learn strategies to accept and tolerate your life circumstances, emotions, and yourself. You will also develop skills that can help you make positive changes in your behaviors and interactions with others.

Getting support

Research has shown consistent evidence that social support:

• Decreases morbidity and mortality rates
• Increases life expectancy
• Increases knowledge of a disease
• Improves self-efficacy
• Improves self-reported health status and self-care skills, including medication adherence
• Reduces use of emergency services

Even providers of social support report less depression, heightened self-esteem and self-efficacy, and improved quality of life.

The Facial Pain Association understands that support is a critical component of coping with your facial pain. Whether you are interested in group or one-on-one support, we can connect you to those valuable resources.