Anxiety Disorders and Chronic Pain

Muscle tension, body soreness, headaches. For people with anxiety disorders, pain like this may be all too familiar. Pain can be a common symptom — and sometimes a good indicator — of an anxiety disorder, particularly generalized anxiety disorder (GAD). But beyond everyday aches and pains, some people will also suffer a diagnosed chronic pain disease such as arthritis or fibromyalgia. And a co-occurring chronic pain disease can make functioning even more difficult for someone with an anxiety disorder. But people can manage anxiety disorders and chronic pain to lead full and productive lives. Read on to learn more.

What is an anxiety disorder?

Anxiety disorders are a unique group of illnesses that fill people’s lives with persistent, excessive, and unreasonable anxiety, worry, and fear. They include generalized anxiety disorder (GAD), obsessive-compulsive disorder (OCD), panic disorder, posttraumatic stress disorder (PTSD), social anxiety disorder (SAD), and specific phobias. Although anxiety disorders are serious medical conditions, they are treatable. Click here to learn more.

What chronic pain conditions and diseases commonly occur with anxiety disorders?

Many chronic pain disorders are highly prevalent in people with anxiety disorders. These are among the most common:

Arthritis — Arthritis is a wide-ranging term that describes a group of more than 100 medical conditions that affect the musculoskeletal system and specifically the joints, which is where two or more bones meet. Arthritis-related joint problems include pain, stiffness, inflammation, and damage to joint cartilage and surrounding structures. Damage can lead to joint weakness, instability, and deformities that may interfere with even the most basic daily tasks. Some forms of arthritis are systemic, meaning they can affect the whole body and can cause damage to virtually any bodily organ or system.

The prevalence of anxiety and mood disorders (such as depression) is higher in individuals with arthritis than in the general population. Some studies have found anxiety disorders are even more strongly associated with arthritis than is depression. A co-occurring anxiety disorder or mood disorder is more often found in arthritis sufferers in younger age groups.

Fibromyalgia — Fibromyalgia is characterized by widespread musculoskeletal aches, pain, and stiffness, soft-tissue tenderness, general fatigue, and sleep problems. The most common areas of pain include the neck, back, shoulders, pelvic girdle, and hands, but any part of the body can be affected. People with fibromyalgia experience a range of symptoms that can vary in intensity. Symptoms may also include irritable bowel, headaches and migraines, dry eyes and mouth, rashes and other skin problems, vision problems, and poor coordination. The causes of fibromyalgia are unknown, and there is currently no lab test that can diagnose the condition.

In a recent study of 336 adults, published in the Journal of Clinical Psychiatry, those with fibromyalgia were almost seven times more likely to have suffered from an anxiety disorder than those without the disorder. They were also about three times more likely to have suffered major depression than those who had not experienced fibromyalgia. The study found the onset of an anxiety disorder or other mental illness in people with fibromyalgia preceded the onset of the fibromyalgia, suggesting that anxiety or depression may be more than just a reaction to the chronic pain. The researchers noted there may be a “shared vulnerability” between the psychiatric disorders and fibromyalgia, possibly genes or environmental factors such as chronic stress. However, the connection remains unknown and requires further study.

Migraine — A migraine is severe pain felt on one or both sides of the head. The pain normally occurs around the temples or behind one eye or ear. A migraine may also cause nausea and vomiting and sensitivity to light and sound. The pain can last a few hours or up to two days. In a classic migraine a person experiences an aura, or visual symptoms such as losing vision or seeing flashing lights 10 to 30 minutes before an attack. During a common migraine a person may have nausea, vomiting, or other symptoms, but does not experience an aura.
Migraines (and chronic daily headaches) are highly prevalent in people with anxiety disorders, as well as those with mood- and substance-abuse disorders. Many studies have found that generalized anxiety disorder and panic disorder are particularly associated with migraines or other types of headaches. Moreover, in people with a co-occurring anxiety disorder and migraines, the likelihood of major depression increases. As with fibromyalgia, researchers have suggested that there may be a common predisposition to anxiety disorders, depression, and migraines.

Back Pain — Anxiety disorders and back pain often co-occur; back pain is more common in people with anxiety and mood disorders than those without them. Illness, accidents, and infections are among the causes of back pain. According to WebMD, no matter the cause, back pain symptoms are the same, and they include persistent aches or stiffness anywhere along the spine; sharp, localized pain in the neck, upper back, or lower back, especially after lifting heavy objects or engaging in strenuous activity; and chronic ache in the middle or lower back, especially after sitting or standing for extended periods.

Does chronic pain complicate the condition of a person who also has anxiety disorder?

An anxiety disorder and a co-occurring chronic pain disease can make a person’s health more difficult to treat. But a variety of treatments and lifestyle changes can offer relief. Possible health complications are noted below:

• Increased disability or reduced functioning
• Poorer quality of life
• Poorer response to treatment
• Poorer treatment adherence
• Increased perception of disease severity

Chronic pain sufferers who also have an anxiety disorder may have lower pain tolerance or a lower pain threshold. People with an anxiety disorder may be more sensitive to medication side effects or more fearful of harmful side effects of medication than chronic pain suffers who aren’t anxious, and they may also be more fearful of pain than someone who experiences pain without anxiety.

What treatment considerations are made when someone has co-occurring conditions?

Because special treatment challenges exist when a patient has a co-occurring anxiety disorder and chronic pain disease, a doctor will usually take a different treatment approach than if a patient has just one of these conditions. Treatment will be based on the specific pain condition and anxiety disorder.

Considerations or actions a doctor may take include the following:

Dual effectiveness of medications. Sometimes a doctor may select a medication that is dually effective for an anxiety disorder and a type of pain condition; for instance, patients with fibromyalgia are sometimes treated with low doses of selective serotonin reuptake inhibitors (SSRIs), antidepressants that can reduce pain and improve sleep. SSRIs have not been found to be consistently effective for treating headache-associated pain, but some anxiolytics, tricyclic antidepressants, and monoamine oxidase inhibitors (MAOIs) can help with headache and migraine pain. These medications may be used to treat an anxiety disorder as well.

• Medication side effects. If a patient is treated with multiple medications (one for anxiety and one for headaches), a doctor will closely monitor any side effects to ensure that the anxiety medication is not making the headaches worse or vice versa.

• Treatment adherence and patient education. Adhering to a prescribed treatment is sometimes more of a problem for patients who have both conditions. But doctors often successfully improve treatment adherence with proper education, so that patients know what to expect regarding symptoms, side effects, and time frame for improvement, among other factors.

What specific treatments are available for people with an anxiety disorder and chronic pain?

Many treatments for anxiety disorders may also improve chronic pain symptoms. Usually a comprehensive plan with a number of treatment components is necessary. A doctor will work with a patient to develop a treatment approach tailored to specific conditions and symptoms. Below is more information about some treatment options for anxiety disorders and chronic pain.

• Cognitive-Behavior Therapy (CBT) — CBT helps patients identify, challenge, and change unwanted and unproductive thoughts and feelings, as well as modify and gain control over unwanted behavior. The patient learns recovery skills that are useful for a lifetime. CBT is used to treat anxiety disorders as well as chronic pain conditions.

• Medication —Very useful in the treatment of anxiety disorders and chronic pain, medication is often used in conjunction with therapy and other treatment techniques. Depending on the individual, medication may be either a short-term or long-term treatment option. The choice of medication should be discussed thoroughly between doctor and patient, and it will always depend on individual circumstances. Some people with an anxiety disorder and chronic pain may be able to find one medication that helps alleviate the symptoms of both conditions. Others may take one medication for anxiety and another for pain management.

• Relaxation Techniques — Relaxation techniques may help individuals develop the ability to cope more effectively with the stresses that contribute to anxiety and pain. Common techniques include breathing retraining, progressive muscle relaxation, and exercise.

• Complementary and Alternative Methods — Yoga, acupuncture, therapeutic massage, and biofeedback (controlling how the body reacts to stress to reduce its effects) are among the complementary and alternative techniques that relieve the symptoms of both anxiety disorders and chronic pain.

To find a professional who treats anxiety disorders in your area, click here.

What basic lifestyle changes are recommended for someone with an anxiety disorder and chronic pain?

Many lifestyle changes that improve the symptoms of an anxiety disorder also help the symptoms of chronic pain.

• Good Nutrition — Nutrition and diet can influence both anxiety and chronic pain symptoms. People with anxiety should limit or avoid caffeine and alcohol, which can trigger panic attacks and worsen anxiety symptoms. According to the National Fibromyalgia Association, certain foods aggravate some musculoskeletal conditions; they include dairy products, gluten (found in wheat, oats, barley, and rye), corn, sugar, and members of the nightshade family (potatoes, tomatoes, eggplant, peppers, and tobacco). The association recommends that individuals who experience pain reduce their intake of tea, coffee, alcohol, red meat and other acid-forming foods. A doctor can provide patients with more guidance on foods to eat regularly and those to avoid.

• Exercise — Regular exercise produces many positive effects for people with anxiety disorders and chronic pain. It strengthens muscles, reduces stiffness, improves flexibility, and boosts mood and self-esteem. Some people with chronic pain find exercising difficult to do, but because it often helps reduce overall pain, its benefits may be worth any temporary discomfort. All individuals, particularly those with chronic pain, should check with their doctors before beginning an exercise regimen.

• Sleep Management — Getting a good night’s sleep is key for anxiety disorders and chronic pain conditions. Symptoms of both types of conditions often become worse without proper or enough sleep. Consistent sleep and wake times, a good sleep environment (comfortable room temperature, no TV or other distractions), and avoiding caffeine late in the day and at night can help promote restful sleep.

References and Resources

American Chronic Pain Association

American Medical Network: Psychiatric Ills Common for Adults with Fibromyalgia

Arthritis Foundation

BMC Musculoskeletal Disorders 2006, 7:37: Mental Disorders in a Population Sample with Musculoskeletal Disorders

Headache. 2006;46(9):1327-1333: Psychiatric Comorbidity of Migraine

Joint Bone Spine. 2002 May;69(3):300-6: Is Anxiety a More Common Disorder than Depression in Rheumatoid Arthritis?

National Fibromyalgia Association

National Headache Foundation

National Institute of Neurological Disorders and Stroke: Chronic Pain Information Page

Psychosomatics 40:1, January-February 1999: Psychiatric Disorders in Patients with Fibromyalgia

WebMD: Back Pain Help Center