When Chronic Illness Feels Like Depression

Am I depressed or just sick? Am I depressed because I am ill? Am I ill because I am depressed?

The National Institute of Mental Health provides the following list as signs of depression:

  • Feeling sad, irritable, or anxious;
  • Feeling empty, hopeless, guilty, or worthless;
  • Loss of pleasure in usually-enjoyed hobbies or activities, including sex;
  • Fatigue and decreased energy, feeling listless;
  • Trouble concentrating, remembering details, and making decisions;
  • Not being able to sleep, or sleeping too much. Waking too early;
  • Eating too much or not wanting to eat at all, possibly with unplanned weight gain or loss;
  • Thoughts of death, suicide or suicide attempts; and/or,
  • Aches or pains, headaches, cramps, or digestive problems without a clear physical cause and/or that do not ease even with treatment.

Think about that list. Most of the items, with possible exceptions of the final two, are fairly common in cases of chronic disease or illness. For the individual, this can create uncertainty regarding mental, or even physical, health. If the root cause is unclear, so too is the treatment plan.

What does this mean for the individual? I think it means that those of us dealing with chronic illness need to take it easy on ourselves when we can’t maintain a positive mental state. It doesn’t mean we should give up, but we shouldn’t feel so guilty.

What does this mean for caregivers? Patients with chronic conditions may need treatment for depression or they may need to be reassured that these feelings don’t necessarily mean clinical depression. Caregivers may need to spend more time talking to patients to get at the psychological and emotional issues, and maybe be prepared for some tears, or guilt, or anger.

What does this mean for family and friends? The person you care for may not be able to be as fun as you want, even during times when the illness seems to be under relative control. Your loved one may need you more mentally or emotionally than physically, but simultaneously may feel an abundance of shame about that. And you may, in turn, be angry or frustrated and need to find someone else to talk to about it.

The interaction between chronic illness/disease and mental wellbeing is complicated, like people are. We can’t expect it to be simple or easy, whether we are the patient or those offering support.

It “Shouldn’t” Hurt, But Sometimes It Does

Image by Remara Photography on Flickr

If it hurts, come out of the pose.

Effort is fine, but you should not feel pain.

These are words that I have heard, and even said, in yoga classes many times. The basic idea is a very sound, because awareness of where the edge between effort and pain is prevents injury in yoga, as it does in other sports and activities. Additionally, it seems like pain is counter-productive to the more psychological or spiritual elements of yoga. However, as someone with a chronic pain issue, there is a little voice in my head that always says “but…” when I hear or say these instructions.

For me, a person with rheumatoid arthritis, yoga asana hurts. How much it hurts varies from week to week (or even day to day) and from one joint to another. But, it always hurts somewhere. The degree of pain can range from relatively unpleasant to the sort of pain that prevents me from practicing asana at all. But, there is almost always pain that is beyond a sensation of discomfort.

In class last night, every pose that involved pressure on my hands or wrists produced some degree of sharp pain. As you can imagine, this is a significant portion of the poses in a vinyasa class. However, I worked through it, because if I didn’t do vinyasas that caused pain, I would not be doing much vinyasa, and that’s not a place I want to be right now. I felt ok about having that pain while I was practicing, because this week it hurts to open an envelope, so I wasn’t surprised or alarmed to feel pain in downward dog. While I have read about pain-free yoga, I have never experienced it. I don’t say this to be dramatic or as a plea for sympathy. It’s just a reality for me in everything I do and thus it is part of my yoga practice.

I know I’m not alone. Many people experience chronic pain in one form or another, and some of those people are doing yoga (some do it as a way of dealing with chronic pain). Staying completely away from any sensation we might characterize as pain can be detrimental to achieving the benefits of yoga that can be gained for someone who has pain. But, that has to be qualified with a “within reason.” Working through some types of pain can result in exacerbation of the underlying conditions. It’s complicated.

You might be surprised to hear that I don’t have an answer to this issue (but not if you read here often, because I frequently don’t have a clear answer  – sarcasm alert).

I think the answer partly depends on what kind of yoga it is, and what the goal is. For a gentle yoga asana class or a class focused on relaxation, any level of pain or intensity might be too much. For a more physically active vinyasa class, or a yin class that can produce intensity for many people, we may need to expect that some students are feeling sensation they might characterize as pain and that this is ok, as long as the pain is not extreme, is not unusual, is not unbearable, does not produce dizziness or nausea, and is not in areas of the body that are very easily injured (e.g. knees) or where injuries could be quite dangerous (e.g. neck).

It also depends on the person. If the pain experienced causes the individual to clench up, to move a joint in an unsafe manner in an attempt to avoid the sensation, or to come “out of” the practice, then it is likely not advantageous to continue doing the poses that create that pain.

I think that part of the key here, as it is with so many things, is knowing the body. If I know my body well, then I’m better able to see where my edge is. It isn’t something that another person can ascertain for me. Some of that learning happens by going a little past that edge and feeling it after. Some of it happens by going a little past where you think the edge is and finding out that it isn’t really there. Some of it happens by learning to relabel some pain as sensation, or becoming more of a connoisseur of your own body sensations and thus knowing what feels like “normal” pain and what feels like “abnormal” pain, or what feels like a muscle or ligament pulling instead of some tension on a previously damaged joint. Yoga helps us to gain this kind of body knowledge.

The bottom line, for me, is that sometimes yoga asana hurts. That can be the sign of a problem, or it can be just a reality of the particular body doing the asana. As we can’t assume that anything will be experienced in the same way from person to person, we can’t assume that yoga shouldn’t hurt if it’s being done correctly.

Chronic Pain and Yoga – A Few Facts

Note: WordPress doesn’t like it if I try to put quotation marks in a title, but understand that by “facts” I mean generally agreed upon beliefs about reality.

Recently, I taught a 3 week series about yoga and chronic pain.  I posted last week about the conversation we had regarding the relationship between chronic pain and the klesas.  What follows in this post are some of the basic points we considered in the first week about the connection between chronic pain and yoga.

About pain

  • Pain has a function – when we experience sensation that is perceived as pain, the body ramps up the sympathetic nervous system, which prepares us to fight or flee.  This is utterly functional in some situations (you are being chased by an angry rabid badger), but less when the threat is your everyday bodily experience.
  • 75-90 million Americans are believed to experience chronic pain.
  • Chronic pain is the # 1 complaint of older Americans (1/5 on painkillers regularly).
  • Woman have higher rates of chronic pain, but they seek help more and respond more quickly to interventions.
  • Men have (or report) lower rates, but they get worse before seeking help and are less likely to seek multiple ways to manage pain.
  • Estrogen seems to somehow be related to pain, with some studies suggesting it might increase our ability to “recognize” pain.
  • Studies suggest that chronic pain may decrease the immune response, effectively causing those who are in pain to also become ill more frequently.
  • When one has chronic pain, the process of neuropasticity (nervous system “learning” to respond to a stimuli more effectively) creates a wind-up effect whereby the body increases the intensity of pain signals and responds to smaller/lesser stimuli more strongly.
  • Additionally,  when pain is ongoing, the brain actually undergoes neuronal changes that permanently change pain response. This creates a situation where boundaries between sensation, stress, pain become blurred.

Common co-morbid issues with chronic pain

  • Insomnia/sleep disturbance (over 65% of people with chronic pain report sleep problems)
  • Lower endorphins (meaning less feeling of happiness, peacefulness)
  • Depression
  • Allodynia – pain from stimuli not normally painful
  • Side effects from pain medications – addiction, nausea, constipation, respiratory depression

Yoga can help!

Benefits of meditation

  • Through meditation, we learn to engage in svadyaya (self study) and are better able to see the difference between suffering and  pain.
  • Mindful meditation helps us increase awareness of all physical sensation, including feelings of comfort and ease which are always being experienced by some part of the body, even if it’s just the little toe on the left foot.
  • Meditation appears to increase activation of left prefrontal cortex, which is the area of the brain associated with happiness and equanimity.
  • Meditation has been shown to reduces transmission of pain signals from thalamus to higher brain centers.
  • Because meditation can change our response to sensation, and because of the idea of neuroplasticity, we can teach the brain a new response to sensation.

Benefits of pranayama

  • Deep and regular breathing increases parasympathetic nerve response, thus reducing the sympathetic response and shifting the body away from flight/flight.
  • Pranayama can increased oxygenation.  Decreased oxygenation of the body is a problem for individuals experiencing stress, like chronic pain.
  • Pranayama brings our focus to the breath over pain or other body sensations, and this can provide space for meditation and calm.  As we are able to get some distance from pain, we might be able to understand our responses better.

Benefits of asana

  • Exercise, including asana, lowers stress. Since stress creates muscle spasms and increases pain, it follows that exercise can decrease pain.
  • Asana promotes flexibility in muscle, reducing pain due to tightness.
  • Asana can strengthen muscles, providing better support for joints.
  • Attention to alignment in asana helps us reduce pain due to compression/alignment issues.
  • Exercise creates an increase in endorphins, and thereby happiness, equanimity, and pain relief.
  • Regular exercise improves sleep.
  • Asana practice can change our relationship with sensation, such that we don’t automatically evaluate all uncomfortable sensations as pain.
  • Ongoing work with asana can help us to revise our understanding of body, seeing what it is capable of doing and how amazing it is, rather than focusing on what it can’t do or how bad it feels.

Go yoga!