Mental Health Issues in Teens With Chronic Pain

According to a worldwide survey conducted in 2019 that included data from over two-hundred thousand children and teens from 42 countries, 44.2 percent reported experiencing chronic pain. In addition, data from 2008 shows that among children and teens who experience chronic pain, 5.1 percent reported pain so severe it prevented them from participating in regular daily activities.

The research on chronic pain among adolescents in the U.S. shows a broad range of results. However, the most recent reliable meta-analysis of chronic pain among adolescence – the data we’re about to share – is ten years old. Since then, the body of research has grown considerably, but no new population-level data is available – yet. A new meta-analysis of these results is currently underway, scheduled for publication with the next year.

The new study will contain updated information on the prevalence of chronic pain among adolescents, using the same categories of chronic pain the initial study used. Here’s the prevalence data and chronic pain categories from 2011.

Prevalence of Chronic Pain Among U.S. Teens

• Headache: 8-83%
• Stomach/gastrointestinal pain: 4-53%
• Spine/back pain: 14-24%
• Musculoskeletal pain: 4-40%
• More than one pain: 4-49%
• Other pains: 5-88%

The authors of this study reported that chronic pain was higher among adolescent girls, and the incidence of chronic pain increased with age. A conservative interpretation of this data – meaning that when we look at percentages towards the low end of the reporting spectrum – we see that at minimum, millions of teens in the U.S. experience chronic pain. When we think about the worldwide data on chronic, severe pain – 5.1% of children from 42 countries – we understand that chronic pain is more common than most people realize.

Another thing people know is that there’s a relationship between chronic pain and mental health disorders such as depression and anxiety.

We’ll discuss that relationship now.

Chronic Pain and Mental Health

First, though, let’s make sure we’re on the same page with what we mean by chronic pain. Pain is what we experience when something hurts. There are two primary categories of pain: acute and chronic.

Acute pain appears quickly and has a specific identifiable cause. It’s typically sharp and does not last long. Acute pain disappears when the cause of the pain disappears, whether through treatment or time. The most common causes of acute pain are:

• Broken bones
• Surgery
• Typical cuts, burns, scrapes, or bruises
• Dental work

As mentioned, acute pain goes away when the cause goes away. But it may take more than a couple of hours. For instance, the pain caused by a small cut on the finger may disappear in less than a day, while the pain caused by a visit to the dentist may take a week or more. However, in both cases, the pain disappears when the cause disappears.

Chronic pain is different. It’s ongoing and typically lasts longer than six months. Unlike acute pain, chronic pain does not always disappear when the injury that initially caused it heals. The neural pathways carrying the brain signals may remain active for years. Types of chronic pain among the general population include:

• Headache
• Nerve pain
• Back pain
• Arthritis-related pain
• Cancer-related pain

The physical discomfort associated with chronic pain is not the only problem people with chronic pain experiences. Research shows that chronic pain can lead to:

• Depression
• Anxiety
• Fear of additional pain or re-injury
• Anger

In adolescents, researchers identify a variety of factors that explain the relationship between chronic pain and mental health disorders. These factors include family relationships, personal attitudes toward pain, neural pathways associated with both pain and mental health disorders, stress, insomnia, and inflammation related to immunity compromised by chronic pain.

Chronic Pain and Mental Health in Adolescents: Prevalence

We’ll discuss the factors that contribute to the relationship between chronic pain and mental health issues in a moment. First, we’ll talk about the prevalence of mental health disorders among teens with chronic pain.

In addition to the mental health disorders mentioned above, we should report that studies link “persistent and debilitating pain” with “poor academic achievement and significant disruptions in coil functioning.”

With those big-picture factors in mind, it’s important to know that several large studies identify the presence of specific mental health disorders among adolescents with chronic pain. We collated the following statistics from data published here, here, and here. Here are the numbers:

Mental Health Disorders, Chronic Pain, and Teens

• The first study, which included close to 4,000 youth and teens with chronic pain, showed:
  • 44% had a mental health condition
  • 28% had a mood disorder
  • 18% had an anxiety disorder
  • 6% had somatization (a.k.a. psychosomatic) disorders
  • 4% had post-traumatic stress disorder
• The second study, which included close to 1,400 youth and teens, found that chronic pain during adolescence predicted the presence of the following disorders:
  • 24.4% developed a depressive disorder between age 19-26
  • 21% developed an anxiety disorder between age 19-26
• The third study indicated chronic pain during adolescence doubled the likelihood of developing:
  • Depressive disorders during adulthood
  • Anxiety disorders during adulthood

At face value, all this data makes perfect sense. Researchers are hard at work identifying the underlying factors that mediate the relationship between chronic pain and mental health disorders. We’ll share the results of that research in a moment.

A Quick Reality Check

Before we go any further, let’s take a simple, logical, laypersons look at this phenomenon. We’re talking about pain. As we all know, pain hurts. And chronic pain – defined as pain that persists over six months and doesn’t go away when the cause goes away – hurts a lot for a long time. Therefore, it makes perfect sense that chronic pain would be, to use the word in a non-clinical way, depressing. And when pain that should go away but does not, it’s not surprising that teens who experience that phenomenon develop, to use this word in non-clinical way as well, anxiety.

We shouldn’t lose track of these basic ideas as we discuss chronic pain and mental health. At the same time, being depressed and anxious about chronic pain is not the same thing as developing a depressive disorder or an anxiety disorder that meet(s) clinical criteria. A mental health disorder is a separate medical condition that develops in addition to the physical pathology that caused the pain in the first place.

Not to put too fine a point on this, but what we’re talking about now is more that being bummed out about a broken leg and worried it might happen again. These are very real mental health disorders that teens and families must address in addition to the cause of the chronic pain.

With that said, we’ll move on.

Chronic Pain, Depression, and Anxiety: Understanding Underlying Causes

Scientific research on the relationship between chronic pain and mental health disorders shows there are three broad categories of factors that begin to explain why a significant percentage of teens with chronic pain also develop depression and anxiety:

1. Physiological Factors

• Neural Networks. Data shows that chronic pain and the two mental health disorders most commonly associated with chronic pain share a common neurological network: the hypothalamic-pituitary-adrenal axis, a.k.a. the HPA axis. Prolonged activation of the HPA axis, also called the stress axis, can lead to the development of both depressive disorder and anxiety disorders
• Data shows individuals with chronic pain have decreased levels of serotonin – sometimes called the feelgood molecule – in the area between neurons in brain areas associated with pain, anxiety, and depression. Research implicates a genetic mutation that results in decreased serotonin production. This, in turn, can increase the experience of pain. It can also increase the likelihood of experiencing symptoms of anxiety and depression.
• The Inflammation Response. Preclinical research shows that chronic pain can lead to inflammation in the brain areas related to symptoms of anxiety and depression. The same research shows that brain regions that regulate behavior – the reward system and the prefrontal cortex – display increased negative activity, called excitotoxicity, in response to pain-related inflammation. Also, decades of research confirms that childhood stress/pain can lead to dysregulation in the immune system, including the type of neuroinflammation related to symptoms of anxiety and depression.
• This is a direct connection that’s easy to understand. Chronic pain can make falling and staying asleep difficult. Chronic lack of sleep – i.e. insomnia – leads to a host of negative physical and psychological consequences, including depression and anxiety. Therefore, insomnia among teens with chronic pain can cause and exacerbated symptoms of depression and anxiety.

2. Interpersonal Factors/Family Relationships

• Miscarried Helping. Yes – we find that an odd phrase, too. But when we think about it, it makes sense. Miscarried helping is when someone tries to help, but the help they provide ends up having the opposite effect. It exacerbates the situation in need of remedy, as opposed to improving it. A study on parenting and teens with chronic pain shows that “…parents who reported miscarried helping were more likely to report greater family conflict and less family cohesion,” and that “…teens who reported miscarried helping were also more likely to report poorer family functioning.”
• Confounding Findings. The same study showed that parent and teen perceptions of miscarried helping did not always match expectation. Meaning that the teens of parents who said their helping caused harm did not always report family conflict, and the parents of teens who said their parents helping caused harm did not always report family conflict, either.
• Family Conflict. The confounding evidence notwithstanding, it’s well known that family conflict and reduced family cohesion can increase risk of both depression and anxiety in teens. Therefore, researchers identify miscarried helping – by way of increasing family conflict in some cases – as a contributing factor to the mental health consequences of chronic pain in adolescents.

3. Intrapersonal Factors

• Catastrophizing Pain. The dictionary of the American Psychological Association (APA) defines catastrophizing as “…when [people] think that the worst possible outcome will occur from a particular action or when they feel as if they are in the midst of a catastrophe [when they aren’t]. The tendency to catastrophize can unnecessarily increase levels of anxiety and lead to maladaptive behavior.” When teens apply this type of thinking to the pain they experience, it increases the likelihood of developing a depressive disorder and/or an anxiety disorder.
• Avoidance Behaviors. Some teens with chronic pain develop a type of anxiety called post-traumatic stress disorder (PTSD). A common maladaptive thought pattern associated with PTSD is avoidance. This behavior has unintended negative consequences: research shows it amplifies pain sensation, which in turn amplify avoidance thought pattern, which in turn re-amplify pain sensations. This negative cycle exacerbates both the initial pain experience and the anxiety that can develop as a result of chronic pain.

Based on our current scientific understanding, those are the three factors that explain the relationship between chronic pain and mental health disorders among teens.

We know the connection is real, and researchers are beginning to understand why it’s there.

But are there any treatments available that can help teens that experience chronic pain and a mental health disorder?

Mindfulness, Cognitive Behavioral Therapy, Mental Health Disorders, and Chronic Pain

In 2016, a group of researchers conducted and published the results of a randomized control trial (RCT) on the efficacy of a mindfulness-based intervention on female adolescents with chronic pain. The primary goal of the study was to measure the impact of mindfulness on levels of pain. However, the researchers measured life satisfaction, depression, anxiety, and psychological distress as well.

When we read the results, we were surprised.

The study showed the opposite of what your average, science savvy, open-minded skeptic might expect: the mindfulness intervention succeeded in only one of the five metrics listed above.

Can you guess which one?

Pain.

We admit that we expected the mindfulness intervention to help with the mental health components measured in the study. But it didn’t. It helped reduce pain. That helps us understand why many mental health experts with experience working with adolescents are confident that a traditional approach to mental health disorders – cognitive behavioral therapy (CBT) – might work for teens with chronic pain and/or anxiety/depression when combined with complementary mindfulness techniques like yoga, mindful exercise, and meditation.

Hope Ahead for CBT + Mindfulness

We say might because as of now, there are several clinical trials underway to test this hypothesis, but there is no clinical data available supporting this assertion. Here’s why mental health practitioners think this combination can work:

1. Decades of data show CBT is effective in treating depression and anxiety.
2. Specifically, CBT helps with maladaptive thought processes such as avoidance and catastrophizing. Research shows these two factors increase chronic pain and anxiety/depression.
3. The data from the trial on mindfulness and chronic pain in adolescent girls showed clear improvements in their levels of pain.

When we combine these three things we know, we’re cautiously optimistic that new data will show CBT + mindfulness will help teens living with chronic pain and mental health issues. The data are there, separately. If skilled clinicians can develop a working protocol that combines the two approaches into one successful, unified intervention, then there’s hope that help and relief are on the way.