Chronic Pain, Anxiety, Depression, and the "Middle Path"

Beyond the physical pain that individuals with chronic conditions experience, there is often an emotional component to the nociceptive (tissue) and neuropathic (nerve) damage that causes chronic pain. In a general sense, any type of discomfort comes with an emotional response—for example, if you stub your toe on the coffee table, you may experience an emotional and intense response of immediate frustration. Chronic conditions are similar, though the emotional response is often deeper, more complex, and much more prolonged, becoming chronic along with the physical pain.

A 2023 study (Mullins et al.) concludes that “the presence of chronic pain in adults associated with significantly higher severity scores for both anxiety and depression as measured by validated surveys in a nationally representative sample.” Understanding how these feelings of anxiety and depression present themselves in individuals with chronic pain is important for cultivating adaptive means of coping with the emotional fallout of physical discomfort. With both anxiety and depression, looking at the disruption of an individual’s daily life and functioning is vital in measuring the sustained negative effect on psychological well-being.

The Anxiety of What If…

Anxiety is often an escalation of catastrophic thoughts, which creates an unpleasant and persistent cognitive feedback loop. For the individual with chronic pain, this might sound something like, What if it gets worse?... What if I never feel better?...What if I need surgery?...What if this makes me unable to walk?... Anxiety typically has a rational origin (in this case, physical pain) but becomes irrational as the thoughts snowball and become more and more catastrophic. When the thoughts of the person with chronic back pain leap from what if this keeps hurting to what if I can’t walk, anxiety takes hold and creates an untenable cognitive state that is flooded by these negatively biased thoughts, serving to disrupt the person’s daily life.

The Depression of What Has Been Lost

If anxiety is often a “what if” thought, depression takes on more of a tone of “what was” or “what could have been.” Because individuals with chronic pain are often forced to limit or restrict their previous capabilities, they are prone to feeling a sense of sadness and loss at their “new normal” and at the recognition of it being different and more challenging than it once was. A 2023 study (De La Rosa et al.) supports this, stating that “comorbidity in chronic spinal pain is significantly associated with role disability.” We can understand “role disability” to mean the limitations that an injury or illness places on a person’s ability to participate in their daily lives to the capacity that they did previously. Similar to grieving a physical death, individuals who suffer from chronic pain often experience a complex, nonlinear emotional process of letting go of the daily life they had previously been able to live. This process naturally comes with the depressive and hypoactive thoughts that accompany any type of loss.

How to Cope

Doctors, physical therapists, and others in the medical and kinesiology fields will stress that chronic pain is not curable, but it is manageable. The same goes for the emotional response to the pain: It is unrealistic to think we can completely eradicate it, but we can learn to manage it in a healthy and adaptive way. This begins with being realistic about the emotions that accompany chronic pain: They are neither eradicable nor ubiquitous. To assume either is to fully give ourselves over to either anxiety or depression. “The middle path,” a concept drawn from Buddhism, can help guide us to a healthy balance when we are living with chronic pain. In the middle path, we learn to embrace duality, to avoid extremes, and to find balance, all ideas that can assist with difficult emotions related to pain. In practice, this might look like:

• Making a concerted effort to avoid the extremes of “what if” (anxiety) and “what was” (depression), allowing us to feel more accepting of our circumstances without polarizing our emotions.
• Letting go of fixation on trying to make logical sense of the inherent and often confusing duality of life (i.e., being OK with not necessarily understanding why you are experiencing chronic pain but focusing instead on managing it and caring for yourself).
• Creating a realistic balance that allows you to participate in your daily life in a way that is healthy and reasonable. This might mean realigning priorities and expectations of yourself in order to ensure that you do not exacerbate either your physical or emotional discomfort.