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Allan Schwartz, Ph.D.Allan Schwartz, Ph.D.
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But, It Still Hurts: Pain-Depression-Pain

Allan N. Schwartz, LCSW, Ph.D. Updated: Sep 6th 2007

1. Introduction

There have been a number of recent articles discussing the fact that there are many people who go to their doctors with complaints about pain. Upon examination the doctor discovers that there is nothing physically wrong with these people. Rather than dismissing these patients doctors are being urged to refer them to psychiatry for the treatment of depression. It is also reported that large numbers of people consult their physicians for a variety of physical symptoms when, in fact, it turns out that they are suffering form one of the depressions or anxiety disorders. There is no doubt that it is correct for physicians to refer patients to psychiatry if tests prove that they are physically healthy. In fact, if the doctor is willing to ask a few questions of the patient it will usually be revealed that they are going through some type of life crisis that calls for psychotherapy and medication.

However, what of those patients who are already in treatment with a psychiatrist and a psychotherapist for depression and anxiety and whose pains persist? Unfortunately, there are a few individuals whose physical symptoms do not abate despite psychiatric and psychotherapeutic interventions. I am familiar with a number of these types of situations.

2. Clarification:

Before going any further it is important to clarify the fact that depressed and anxious patients with symptoms such as back aches, neck pains, upset stomachs, dizziness, headaches among many other types of maladies, are not imagining the symptoms. In other words, the symptoms are very real even though there is no disease process at work. It is not unusual for depression to express itself in the form of many of these medical complaints. There are now anti depressant medications that, along with alleviating depression, also diminish pain and discomfort. We now know as a matter of fact that there is a close relationship between mind and body. Trauma, grief, stress, worry and depression take their very real toll on our bodies, erode our immune systems and lead to very real sickness. This is why it is important for doctors to refer patients to mental health rather than simply dismiss them.

3. Dilemma:

To go back to the earlier question about those people who do not get relief despite being under psychiatric treatment, there is a serious dilemma developing in our medical system. The dilemma is this: once a patient has been referred to psychiatry there is a tendency to dismiss that individual's future physical complaints as "nothing more than a psychiatric problem." This happens even in the event that a person continues to experience a certain type of pain after years of taking anti depressant medication and attending psychotherapy sessions.

4. Hypothetical Case Example:

A man complains to his doctor that he is having difficulty breathing. This man is physically fit, working out in the gym every morning before going to work. In fact, the gym is something he enjoys and has been doing for many years. The doctor gives him a complete physical examination, including X-rays of his lungs and finds that there is no reason why he should be experiencing any breathing problems. Deciding that the patient must be having emotional difficulties in his life, he refers him to one of his associates who is a psychiatrist. Skeptical but willing to cooperate, the man goes to the psychiatrist and is diagnosed with ADHD and depression. He is prescribed medications and cooperates with the psychiatrist. His ability to focus his attention really does improve, as does his mood. However, this patient's breathing problems persist.

The man then goes to another doctor for a second opinion. The second physician reads the charts sent by the first MD and decides that this is a psychiatric case and tells him to return to his psychiatrist.

In order to shorten the story suffice it to say that the patient persisted until he found a top notch pulmonary specialist who diagnosed this man with a serious but rare lung problem. He was treated for the problem and vastly improved. By the way, he remained on his psychiatric medications and came to realize how ADHD had interfered with many aspects of his life. It is probably safe to guess that when he presented his case to his various medical doctors he did appear hyperactive and scattered, reinforcing the incorrect notion that his problems were "nothing more than mental."


5. Conclusions:

What is the moral of this story? The moral of this story is that now that physicians recognize the importance of diagnosing depression rather than just dismissing patients, it is important to not label patients just because they have a psychiatric diagnosis. The danger is that, by labeling and dismissing patients now under psychiatric care for anxiety and depression they may over look the presence of a real disease process just by dismissing the symptoms as one more psychiatric symptom.

An additional moral to this story is that patients who have persistent pain despite being on psychiatric medications, look more deeply into why the pain persists despite treatment. One of the rules I learned early in my training is that it is crucial that all possible medical causes for pain be fully ruled out before going into the area of psychiatric diagnosis.

A third moral to this story is to seek another opinion if any medical practitioner behaves in ways that are insulting or dismissive or impatient. Unfortunately, in the cases with which I have been familiar, too many doctors were unkind to these patients, acting as though their complaints were just so many deliberate lies. As patients we have the right to demand respect at all times.

What are your comments and experiences?

Allan Schwartz, LCSW, Ph.D.

Readers who live in the Boulder, Colorado metro area, or in Southwest Florida may contact Dr. Schwartz for face-to-face consultation. He is also available for psychotherapy through Skype video for those who are not in Florida or Colorado. He can be reached via email at for details.

Reader Comments
Discuss this issue below or in our forums.

Chest pains due to acid reflux, not merely depression - 39-year old male, Dallas, TX - Sep 21st 2007

Eight years ago, when I was first diagnosed with major depression, I complained about having frequent, recurring chest pains since my teen years. I asked my psychiatrist if I should go for additional testing and he said that it was not likely to yield any useful information. He was wrong. I believe this was a case where the diagnosis of depression created a sort of "professional myopia" regarding all the presented symptoms. I contributed to the problem by timidly accepting his opinion in the matter. <br/><br/>

Two years ago, while getting treatment for an unrelated gastro-intestinal problem, I mentioned the chronic chest pain to the attending specialist. He started me on a clinical trial for acid reflux disease, with positive results. Marvelous! For the first time in over twenty years I experienced relief for pain that I always associated with depression. Perhaps I would have experienced better results with my treatment of depression if my perception hadn't been distorted by the chronic acid reflux pain. <br/><br/>

As a patient, what I've learned from this is to build a relationship with my doctor(s) in which we can freely discuss every aspect of my health. Too many healthcare professionals behave as though they are in a hurry and that dialogue isn't as important as writing a prescription. There are some very good doctors out there and I've learned to go elsewhere if I don't feel like I'm getting competent and caring service.

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