Chronic Pain Management: The Role of Your Mental Health

While there’s little doubt that chronic pain can reduce mobility, strength, and endurance—it’s not only the physical side effects that may lower performance. Research suggests pain can also be a significant factor mentally and emotionally, leading to issues like reduced motivation and even higher risk of depression and anxiety.

For example, a study in Science noted that chronic pain changes circuitry in the brain around goal completion, which means it's harder to motivate yourself and to successfully reach goals when you do feel motivated to go at it.

Those brain changes affect mental states as well. Research in the journal Neural Plasticity suggests there’s a strong link between depression and chronic pain, and that their coexistence tends to further aggravate the severity of each. Other research in the journal Pain shows that those with chronic pain are five times more likely to have depression or anxiety than those who are pain-free.

The relationship goes in the other direction as well, because how you perceive pain can worsen the intensity of that pain, research suggests. When your mindset is affected in that way, it can be an ugly cycle—pain changes your brain, and the way you think about the problem can make the pain more frequent or debilitating.

Adding to all that, there’s an indirect effect of chronic pain that may also lead to mental health issues. Most notably, chronic pain can reduce sleep quality—which can then make pain even worse, setting up another ugly cycle—and research has linked poor sleep with higher risk for mental health challenges.

“Pain that’s present for longer than three months is considered chronic, and the longer it continues, the more likely it is that you’ll experience difficulties with both physical and mental effects,” Medhat Mikhael, M.D., pain management specialist at MemorialCare Orange Coast Medical Center in Fountain Valley, California, tells Bicycling.

This sounds like a lot of bad news for chronic pain sufferers who want to keep riding and up their performance. But chronic pain management may simply come down to a different approach. Here’s a look at how pain may be taking a toll, and even more importantly, what you can do about it.

The Mental Side Effects of Chronic Pain

Let’s say you have a dodgy knee and you overdo it while riding—you’ll know right away that you’ve created more injury thanks to swelling, pain, and tightness. But the mental aspects of chronic pain aren’t always so easy to spot, says Mikhael. They may be showing up more in your behaviors than in your frame of mind. The organization Mental Health America notes that signs can include:

More sensitivity or reactivity to stressors
Reduced productivity or function at work or at home
Disinterest in social activities
Lower self-esteem
Sleep problems like insomnia or waking frequently
Decreased appetite
Trouble concentrating
Overall sense of fatigue and daytime sleepiness
Higher level of irritability or frustration
Sudden mood changes

When you’re starting to see signs like these, it can imply deterioration in your quality of life, says Mikhael. When pain goes unaddressed, that can worsen the issue, similar to any health problem that isn’t well managed.

For example, a study in the journal PLOS ONE suggests chronic pain may have long-term health effects even decades later, including poor sleep, mental health struggles, and job loss.

When you notice these signs, it’s time to get help—and that includes working on the mental side of your chronic pain.

How to Address the Mental Side of Chronic Pain

Addressing the source of chronic pain should be the first step toward alleviating any mental and emotional struggles that may come up, says Mikhael. That can be done at the same time as assessing the type of mental toll pain may be having.

“Pain management can be complex and takes many factors into account, not just trying different medications to see if your pain can be alleviated,” he adds. For example, your health team may include physical therapists, as well as social workers or psychologists, so that both the physical and mental aspects of pain can be addressed at the same time. Research even backs this up, showing promising results for back pain relief when you pair cognitive behavioral therapy and physical therapy.

Another strategy for reducing chronic pain is to take a step back on your own and look at all parts of your life, particularly those where stress might be playing a role. Because stress involves the release of specific hormones like cortisol and adrenaline—which have been shown to worsen pain due to increased inflammation—making this a priority is crucial, says Mikhael.

A good place to start may be your work: In a research review published in the journal BMC Musculoskeletal Disorders, involving more than 19,000 individuals, researchers found higher levels of chronic lower back pain among those who reported psychosocial work issues, such as an overwhelming workload, little social support at the workplace, and lack of control over their daily tasks.

They found that these issues made people much more likely to report lower back pain, which could have ramifications for productivity, healthcare costs, and more absences from work, according to the study’s lead author, Gabriele Buruck, Ph.D., of the Dresden University of Technology’s department of psychology.

“Chronic low back pain is usually thought to be related to incorrect posture or sitting for too long,” she tells Bicycling. “But we were able to show that factors like workload, job control, and social support significantly contribute to the development of chronic pain as well.”

While mental health therapy is smart for those with chronic pain, even just acknowledging that pain is playing a part in your mental distress can be profound, adds Yoni Ashar, Ph.D., assistant professor in the department of medicine at the University of Colorado Anschutz. He tells Bicycling that in his research, participants who take time to understand how anxiety, fear, or stress might be affecting the severity of their pain tend to reduce the intensity of that pain.

“Seeing the connection between chronic pain and mental and emotional processing may even help reduce pain enough that it becomes much more manageable,” he says. “That can be incredible for the next step, which is adopting behaviors that can reduce that pain even more.”

The Role Exercise Plays in Chronic Pain Management

One of the most notable of the behaviors that can help control pain and reduce its mental effects is exercise, Ashar says.

In fact, a research review in Cochrane Library looking at a number of pain conditions, from rheumatoid arthritis to fibromyalgia and low back pain, found that consistent physical activity not only improved physical function but also showed a boost in psychological wellbeing in many of the studies evaluated.

Another research review, in PLOS ONE, notes exercise is so beneficial for the treatment of nearly all forms of chronic pain that researchers suggest it should be considered a first-line treatment, similar to medication—and given concerns about some drugs like opioids, physical activity might be considered before those meds are prescribed, they add. This research also highlights the significant effect of physical activity on mental health for those with chronic pain, and it doesn’t matter what form that exercise takes.

No matter how much pain is affecting you, and in what way, if you’ve been dealing with it for longer than a couple months, Mikhael suggests speaking with your doctor about a chronic pain management plan that includes lifestyle habits like exercise—tailored to your specific needs. Also, paying attention to any mental or emotional shifts and letting your doctor know of them is another crucial part of treatment, he says.