We experience depression not just in our minds but with physical symptoms as well. Recognizing headaches, joint pain, and GI trouble associated with depression is key for optimal treatment.
Inexplicable Physical Symptoms & Depression
Dichelle was sure she had the flu last fall. She felt exhausted and had a constant headache, and her muscles ached. She took some over-the-counter meds, curled up under a blanket, and waited for it to pass.
After a few weeks, she felt worse, not better. When a sinus infection hit, Dichelle made an appointment to see her doctor.
“I was as sick as a dog and had no idea what was wrong,” recalls Dichelle, an esthetician in North Carolina.
The doctor prescribed antibiotics, but the sinus infection and flu-like symptoms continued to plague Dichelle long after she’d finished the pills. Around the same time, she developed a twitch in her left eye that was so intense she found it difficult to do routine tasks like driving, watching TV, or reading. Her ophthalmologist found no medical reason for the twitching.
It was only when Dichelle complained about her various ailments to her psychologist that she learned all of the physical symptoms she’d been experiencing—from the headaches and intense fatigue to muscle twinges and eye twitches—were linked to depression.
Dichelle was shocked. She’d been diagnosed with depression in the past, but she hadn’t experienced such physical effects in the intervening years.
“[The therapist] said, ‘You’ve been through a lot of stress and trauma, and this is probably your body’s way of responding,’” says Dichelle, who suffered from three miscarriages in a single year, just months before she got sick. “It made complete sense to me when I started thinking about it. If your brain is responding to some sort of trauma, it makes sense that your body will, too.”
The Body’s Response to Trauma & Stress
When discussing depression, it’s typical to focus on the emotional dimension. Common depression checklists target mood and mind, glossing over potential physical ills. Yet downplaying the physical side of depression can make it difficult to find a wholistic treatment that addresses both emotional and physical symptoms. Conversely, emphasizing physical symptoms while ignoring emotional problems can make it next to impossible to get an accurate diagnosis of depression.
In the journal Psychosomatics, researchers from Massachusetts General Hospital and Harvard Medical School noted that headaches, chest pain, stomach pain, backaches, and general musculoskeletal complaints have gained increased recognition as an aspect of major depressive disorder, or MDD. The authors estimated that up to 76 percent of those who had the emotional symptoms associated with MDD also reported physical symptoms (known as somatic symptoms in medical terminology).
Meanwhile, an international team of researchers who analyzed data from a World Health Organization (WHO) report found that an average of 69 percent of the patients who met the criteria for major depression reported only physical symptoms as the reason for their visit to a primary care physician.
“Masked Depression”
Keith S. Dobson, PhD, a professor and director of clinical psychology at the University of Calgary in Alberta, uses the term “masked depression” to describe depression that is experienced more in terms of physical suffering than through emotional indicators.
“In some cases, people are not as well tuned to their emotional state but are in touch with how they’re feeling physically and those are the symptoms they choose to focus on,” Dobson explains.
Even though depression is experienced differently from person to person, physical and emotional symptoms may spring from the same cause. The neurotransmitters serotonin and norepinephrine regulate both pain and mood, which is the reason why someone who is suffering from depression can experience both emotional and physical symptoms.
For this reason, a class of widely prescribed medications known as selective serotonin reuptake inhibitors or SSRIs, which increase the availability of serotonin in the brain, and newer antidepressants known as SNRIs, which affect both serotonin and norepinephrine, are often effective in treating patients who experience depression with physical symptoms.
“The circuits in the brain that mediate emotional pain are right next to the circuits that mediate physical pain and they share a lot of the same pathways,” explains Stephen Ilardi, PhD, associate professor of clinical psychology at the University of Kansas whose recent research has focused on neurological and cognitive underpinnings of depression. “[That’s why] someone who is in intense emotional pain can also begin to feel a sense of physical agony.”
Diagnosis Difficulties
One of the biggest issues for patients who complain of physical symptoms like chronic joint and muscle pain, gastrointestinal issues, and headaches is getting an accurate diagnosis—and thus, appropriate treatment.
Doctors prescribed antinausea medications for Nielle and suggested she change her diet in order to deal with headaches, muscle aches, loss of appetite, and stomach problems. She was in and out of doctors’ offices near her home in Lakewood, Colorado, dozens of times, struggling to find out what was wrong with her.
“I would go to see the doctors in tears, telling them, ‘I can’t live like this, I need help,’” recalls Nielle, 36. “The doctors were treating the problems like isolated instances and each time I got a different treatment.”
Even Nielle believed her problems had different causes. She attributed the pain in her neck and shoulders to her work as a web designer, which kept her sitting in front of the computer for long periods. She thought her frequent headaches could be linked to her menstrual cycle.
Nielle continued to take various prescription and over-the-counter medications in hopes of relieving the problems, but had no luck.
It was a series of emotional symptoms, including low mood and feeling weepy, that led Nielle to see a therapist this spring. When the therapist gave her a diagnosis of depression, Nielle learned her physical symptoms were likely triggered by her emotional state.
“Now that I know the cause, I have a game plan for feeling better,” explains Nielle, who credits regular sessions with her therapist, medications, meditation, a good diet, and regular exercise with alleviating both her emotional and physical symptoms.
Research published in the Journal of Family Practice found that family physicians were accurate in diagnosing depression in 67 percent of patients who reported only emotional complaints but were accurate just 29 percent of the time when patients complained of multiple medical concerns.
Part of the blame lies with patients who talk to their doctors about their physical health while ignoring or refusing to discuss their emotional health. The WHO report found that of the patients who sought medical care for multiple physical symptoms and were later diagnosed with depression, 11 percent denied experiencing any psychological symptoms of depression even when doctors asked specific questions about their emotional health.
Stigma makes many patients reluctant to discuss emotional symptoms with their doctors, says Gregory Simon, MD, MPH, a psychiatrist at the Group Health Research Institute in Seattle, Washington, and lead author of the WHO report on somatic symptoms. The body-mind dichotomy in the medical profession further complicates matters, he adds.
“Patients who are seeing their primary care doctors are going to talk about how they’re feeling physically and patients who are seeing mental health professionals are going to talk about how they’re feeling emotionally,” says Simon.
The corollary, says Keith Dobson, is that practitioners naturally ask about issues in their own fields.
“It’s not that doctors are ignoring obvious complaints,” says Dobson. “It’s more a case that they tend to ask more about the physical signs of illness because that’s their focus as family doctors.”
The flip side, Dobson adds, is that mental health professionals tend to focus on psychological symptoms and don’t inquire about physical conditions.
Both Dobson and Simon stress the need for primary care doctors to perform thorough medical exams that go beyond just assessing physical health, encouraging patients to express their full range of symptoms. In some cases, Simon explains, practitioners have to be alert to what’s left unspoken.
“Doctors need to ask questions that’ll help distinguish [between] what people are feeling and what they’re talking about,” he says.
Culture & Stigma
When it comes to talking to the doctor about illness, culture plays an important role in how patients relate their symptoms.
Andrew Ryder, PhD, associate professor of psychology at Concordia University in Montreal, Quebec, studies how culture affects the experience, diagnosis, and treatment of depression. “Understanding culture is essential to understanding depression,” he explains. “Cultures differ in what’s appropriate and inappropriate to talk about and it’s the culture that informs the diagnosis and treatment.”
A study for the Centre for Addiction and Mental Health (CAMH) in Canada examined cultural differences in the expression of the physical and emotional symptoms of depression. Ryder was among the researchers who found that participants in East Asia were more likely to emphasize physical complaints while participants in North America focused on their psychological symptoms.
“It’s not that [the participants in East Asia] aren’t feeling emotions, it’s that they’re not focusing on them to the same extent,” he explains. “Some cultures think it’s appropriate to go to the doctor and complain about appetite loss or pain but it’s not appropriate to talk about feelings of guilt. In some cultures, a physical complaint will get you medication and time off of work but an emotional complaint could get you labeled as lazy.”
Researchers who have studied depression in Hispanic communities have reported similar findings. A study at the University of California–Los Angeles School of Medicine, published online in General Hospital Psychiatry last year, found that low-income Hispanic Americans with depression were less likely to take medication and keep scheduled medical appointments, in part because mental health conditions like depression are stigmatized in their culture.
African Americans also face barriers to getting an accurate diagnosis of depression. A study published in the Journal of Family Practice found that African Americans are more likely to report physical symptoms of depression, which can complicate the diagnosis of depression, and less likely to use outpatient mental health services, which can inhibit treatment.
According to Ryder, the CAMH research shows that, in general, those who have lower socioeconomic status and those from rural areas are less willing to talk about their emotions and more apt to focus on physical complaints.
Men also are more likely to talk about physical rather than psychological symptoms of depression.
“In all of these cases, there’s a danger of not receiving a diagnosis or taking longer to diagnose, and that makes it more difficult to get treatment,” Ryder says.
Treatment for Mental, Emotional, & Physical Symptoms
Michael knows firsthand how an accurate diagnosis is essential to appropriate treatment.
Though he was diagnosed with depression many years ago, Michael, 53, didn’t link his painful headaches to his moods for nearly a decade. After paying close attention to when the headaches were most intense, the sports journalist from Toronto learned to distinguish between a run-of-the-mill headache that can be treated with an over-the-counter pain reliever and the kind of dull ache that accompanies depression.
“The headaches don’t go away until the depression goes away,” he says. “I’ve learned that I can’t just treat the headaches, I have to treat the depression, too.”
Research shows that somatic symptoms often disappear—or at least dissipate—once depression is treated. Since emotional indicators and physical maladies are triggered in the same part of the brain, it makes sense that treatments that are effective for depression will alleviate the aches and pains, too.
For Dichelle, physical pain has brought an unexpected benefit: She has become more in touch with her emotions and a better advocate for her health. Now, when she feels a twinge in her back or a dull ache behind her temples—symptoms that other people might ignore—she immediately tunes in to her mood.
“It’s helped me to be more self-aware, to really ask myself, ‘What’s happening to trigger the feelings? Did I sleep badly or move in an awkward direction, or is there something emotional that I need to deal with?’” she explains. “I’m more proactive about addressing the symptoms and that’s improved my overall health.”
Symptom or Trigger?
There are times when pain is more than just a symptom of depression, it’s the trigger. Patients with chronic illnesses such as cancer, arthritis, and migraines have twice the risk of being diagnosed with depression as individuals who don’t suffer from chronic pain. Depression is often more severe in those with chronic pain, and depressive episodes last longer.
Both doctors and patients often attribute symptoms of depression to the medical illness, making it much more difficult for those with chronic pain to get an accurate diagnosis of, and timely treatment for, depression.
The best course of action, according to Gregory Simon, MD, a psychiatrist at the Group Health Research Institute in Seattle, is for patients with chronic pain to stay attuned to their emotional state and report any changes to their doctors.
Printed as “Hear Your Body Talk,” Fall 2010
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