Pain Management Series – Part 2: Pain, Depression, PTSD, and the Silent Wounds of War

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An estimated 76.5 million Americans suffer from chronic pain, affecting more people than diabetes, heart disease, and cancer combined. Pain is a serious public health issue that does not discriminate based upon age, race, gender, or occupation. Since 2001, over 1.5 million servicemen and women have served in Iraq and Afghanistan, with nearly 33,000 sustaining severe wounds from roadside bombs and improvised explosive devices (IEDs). These very visible wounds include traumatic amputation, some forms of traumatic brain injury, burns, and shrapnel damage, resulting in chronic—or lifelong—pain.

Pain is the number-one cause of disability in returning veterans from Iraq and Afghanistan. Thousands more soldiers will endure the often invisible wounds of war, including high rates of depression, post-traumatic stress disorder (PTSD), and chronically painful injuries of the spine, joints, and muscles due to combat.

In a culture that values strength and determination and relies on persistence under adversity, reporting pain, depression, or the symptoms of PTSD is often seen as a sign of weakness or an inability to perform expected duties. Silent suffering of pain, depression, and PTSD can exacerbate the problem and intensify the symptoms. When left untreated or undertreated, these invisible wounds can impact not only the person who suffers, but their family members, other loved ones, and caregivers as well.

Pain and Depression: What Is Their Relationship?

Statistically, pain and depression occur together as often as 40 to 60 percent of the time, complicating treatment, especially if either the pain or the depression goes unrecognized or untreated. Alarmingly, veterans who participated in an American Pain Foundation online veterans survey reported they had depression with chronic pain almost 95 percent of the time.

Matt Bair, MD, MS describes pain and depression as a “reciprocal relationship.” Persons who suffer from chronic pain often develop depression, and persons who suffer from depression often develop chronic pain. Because pain and depression can often go hand in hand, treating both issues at the same time is often required to improve the function and quality of life of individuals affected. Pain and depression are both perceived and experienced by similar chemistry in the brain—sometimes creating a vicious cycle. The mechanisms by which individuals experience pain and emotion or depression are located in the same area of the brain and are influenced by the chemicals serotonin, norepinephrine, and dopamine. When pain is increased or decreased, depression can be increased or decreased as well. Both pain and depression can also be affected by psychosocial factors like stress, family relationships, spiritual connections, friends, and community.

Pain and Post-Traumatic Stress Disorder

In civilian populations, 15 to 35 percent of patients with chronic pain also meet the criteria for post-traumatic stress disorder, which can be experienced following natural disasters, horrific motor vehicle accidents, and violent crimes such as rape or murder. For servicemembers wounded in combat, the experience of PTSD, or a milder form of stress known as “combat stress,” can occur with varying severity. Estimates show that 25 percent of returning veterans from Iraq and Afghanistan have been diagnosed with PTSD.

Combat stress can be characterized as a normal reaction to an abnormal event or experience and in some individuals can be experienced with the more severe and intense symptoms of PTSD, a clinical diagnosis and condition that can be very disabling. Exposure to the trauma of war, possibly multiple times in succession, can be very overwhelming for some. Individuals can experience a range of symptoms, from mild anxiety, restlessness, sleeplessness, irritability, and hyperarousal, to nightmares and flashbacks to the trauma, reexperiencing the traumatic event in their mind. Oftentimes, PTSD may not occur for months or even years following the traumatic event. The trauma of combat can be exceptionally horrifying, and the experience of surviving serious combat injury or seeing others seriously injured is very real and lasting. PTSD can be overwhelming, especially when it occurs in combination with chronic pain and depression. With suicide rates increasing among returning veterans from Iraq and Afghanistan and the rates of substance abuse increasing, the necessity of treating these often silent and invisible, yet co-occurring illnesses, could not be more urgent.

How to Recognize Pain, Depression, and PTSD

All of these conditions—pain, depression, and PTSD—can occur silently and invisibly, experienced internally only by the individual who suffers, until he or she is no longer able to cope or manage. The level of impact from each of these chronic conditions can be reflected on a sliding scale, from mild, to moderate, to severe. The symptoms of each will often depend on the severity. Because the experience of each of these conditions is individual, it can be a daunting task to recognize what is happening and seek appropriate care and treatment.

Oftentimes, it is a family member or caregiver who notices that something is different. The affected individual may have increased difficulty moving, or facial grimaces or wincing that indicate pain—or other signs of pain such as moodiness and irritability, difficulty sleeping, and changes in eating habits. Caregivers or family members will often use phrases like the following to describe loved ones who may be battling depression: “They don’t have any energy,” “My mom used to be so active—she loved to walk outside and now she sleeps,” “I try to talk to him, but he isn’t paying any attention,” “She seems irritable, sad—she just wants to be left alone,” “He has no patience with our children—everything seems to make him angry.”

PTSD is particularly challenging, because so many veterans still feel that there is a stigma attached to reporting mental health-related symptoms. And with PTSD, as with pain and depression, it is family members who often notice the symptoms, such as irritability, sleeplessness, nightmares, feelings of anxiety, and depression. They’ll report, “He wakes up in the night disoriented, screaming,” “She just stares like she’s a thousand miles away,” “He just wants to be alone in his room—he doesn’t want to do anything he used to enjoy.”

Like pain and depression, PTSD can be very isolating, leaving the person with a hopeless and helpless feeling. Left unrecognized and untreated, PTSD can complicate pain and depression, and can contribute to increased rates of substance abuse and addiction, undermining the quality of life for the individual, their family, and their community.

Treatment Options

Pain, depression, and PTSD, when occurring together, should be treated together, with a multidisciplined approach that addresses the needs of the whole person. Such a comprehensive approach to care works best to improve function, decrease symptoms, and improve quality of life.

First, a complete evaluation, including a thorough medical history and physical exam should be performed by a trained professional who has experience with these illnesses. There are several questionnaires that are used to measure pain and depression together, and also to evaluate the severity of combat stress and PTSD. Documenting symptoms in a diary—paying attention to how pain, feelings, mood, sleep, or stress have impacted daily activities—can be a good way to open a discussion. A pain notebook can be helpful to document the impact that persistent pain, depression, and PTSD have on daily activities. (One resource for recording pain is the Target Chronic Pain Notebook from the American Pain Foundation, available at   http://www.painfoundation.org/Publications/TargetNotebook.pdf.) Once this is completed, a plan of care can be discussed and agreed upon between the individual and the provider, with the support of family members and caregivers.

Treatment options might include cognitive behavioral therapy and/or individual or family counseling. There are many new Vet Centers, run by the Department of Veterans Affairs (VA), or drop-in centers for peer-to-peer counseling. Sharing the experience with someone who understands can often be very helpful, whether the issue is pain, depression, or PTSD. Behavioral therapy, including relaxation techniques and stress reduction, biofeedback, or meditation might be part of the plan of care. Physical therapy, with stretching and massage, or aquatic/pool therapy can be useful. Exercise—even a small amount of physical activity such as walking—can be helpful to keep brain chemistry in balance and help decrease the symptoms of pain, depression, and PTSD. Acupuncture, from use on the battlefield to treating the wounded at Walter Reed Army Medical Center, is gaining acceptance and validity as an option for treating the painful wounds of combat. Research is ongoing to develop a variety of other helpful options.

Too often, family members also experience some sort of apprehension, anxiety, and confusion when their loved one experiences pain, depression, or PTSD. However, family member or caregiver involvement adds much to the treatment process. Enlisting the help of family members to ensure that the individual is following up on recommendations can be very helpful. Educating those who care for individuals who suffer chronic pain, depression, and PTSD about the symptoms to look for and the importance of getting treatment can improve the outcome for the individual. Providing information, resources, and support to caregivers can empower them to advocate for their loved one and become active participants in the plan of care. (Editor’s Note: In a future installment in this series, the topic of “Caring for the Caregivers of Servicemembers Who Have Chronic Pain” will be discussed. The article will offer timely information, resources, avenues for support, and strategies to caregivers on a vital issue—the importance of addressing and caring for their own needs for support and respite so that they can be in the best position possible to care for a loved one.

Barriers to Care for Pain, Depression, and PTSD

For wounded servicemembers, perhaps one of the biggest barriers to care for pain, depression, and PTSD is fear of being perceived as weak or unable to perform one’s duty. Many injured and wounded will suffer silently and invisibly, delaying treatment that could prevent the onset of more chronic and disabling conditions. Eliminating the stigma attached to reporting symptoms of pain or mental health concerns needs to occur—from the commanding officers to the soldiers in the field, and for wounded veterans returning home to their communities. Education about the symptoms of combat stress and PTSD would assist in recognizing those who might be affected. Improving programs that provide treatment in a nonthreatening and nonjudgmental environment, such as peer counseling, could be helpful as well.

Finding available, effective, multimodal options for treating pain, depression, and PTSD can be a challenge, especially for veterans who live away from the larger VA facilities and in rural areas. Additionally, finding support for the family members and caregivers of these Wounded Warriors can be difficult. Programs that reach out to these families to offer information, resources, and support can help to reduce feelings of isolation.

Mapping Out a Plan

As more soldiers survive combat injuries, the complexity of these wounds has increased. New options for diagnosing and treating the painful wounds being inflicted on today’s battlefields need to be researched and developed. This includes the often invisible wounds of combat stress, pain, depression, and PTSD, as well as the very visible wounds of traumatic amputation, some forms of TBI, shrapnel damage, and other combat-related injuries.

The experience of combat injury and the resulting pain, depression, and PTSD can forever change the lives of those who are affected. Recognizing the impact of silent suffering or invisible wounds can allow for those who need treatment and care to seek the comprehensive services needed to improve their ability to function and to increase the quality of their lives. Calling attention to the magnitude and impact of untreated or undertreated pain, depression, and PTSD can serve to decrease the stigma involved in reporting and seeking treatment. Assisting the families of those who suffer from pain, depression, and PTSD by offering programs to provide information, resources, and support for spouses and caregivers will improve the outcomes for individuals and families.

For additional information, education, support, and resources to manage pain, depression, and PTSD, visit the American Pain Foundation Web site at http://www.painfoundation.org and the National Center for PTSD Web site at http://www.ncptsd.va.gov/ncmain/index.jsp.

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Sidebar 1

Tips For Recognizing PTSD

1. Individuals may be irritable, anxious, fearful, or depressed.
2. Oftentimes, they feel that no one understands them or what they have experienced.
3. They may become withdrawn or prefer to be left alone.
4. They may react to smells, sounds, or images that remind them of the traumatic event.
5. Sleeplessness or nightmares are common.
6. Hypervigilance or hyperarousal is common, a feeling that they have to be alert or are in danger.
7. They may have intrusive thoughts—remembering traumatic events—while stopped in traffic or in crowds.
8. They may feel emotionally “numb” and avoid others or situations that will remind them of the trauma.
9. They may relive the experience in their mind and seem to be unaware of their surroundings, acting irrationally.
10. Self-medicating and substance abuse may be used to escape the experience of PTSD.

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Sidebar 2

Tips For Coping with Depression

1. Think positively and surround yourself with others who think positively.
2. Be kind to yourself and set small, attainable goals.
3. Get plenty of sleep.
4. Eat a balanced diet with lots of fruits, vegetables, whole grains, and lean protein.
5. Relax with soothing music, meditation, scented candles, slow, deep breathing, and/or in a quiet setting outside.
6. Talk things out with a friend or family member, so small things don’t become big things.
7. Exercise—even small increases in activity can be helpful.
8. Express yourself—remember, it’s okay to cry.
9. Laugh—it’s equally important, so look for the humor in situations and make time to have fun.
10. Seek professional help and guidance if symptoms of pain, depression, combat stress, or PTSD worsen.
    

Brenda Murdough, MSN, RN-BC currently serves as the American Pain Foundation’s coordinator of the Military/Veterans Initiative where she advocates for pain management needs of veterans and military personnel and their family members and caregivers. Brenda has a Master of Science degree in nursing and is board certified in pain management.