• Smile
• Look for the positive
• Get outside in nature
• Take 5 minutes each to remember the positive
• A daily act of kindness
• Enjoy the happiness of others
• Practice compassion
• Using your senses to help with pain: sight
• Using your senses to help with pain: smell
• Using your senses to help with pain: hearing
• Using your senses to help with pain: taste
• Using your senses to help with pain: touch
• Using your senses to help with pain: taste
• Using your senses to help with pain: thermoception
• Using your senses to help with pain: kinesthetic sense

We know that 2 types of thinking can make your pain worse and cause greater disability: 1) catastrophizing and 2) fear avoidance. Fear avoidance is a tendency to:

• Be fearful of physical activity or work
• Avoid doing things that may increase your pain
• Fear that physical activity or work may cause more damage
• Believe that physical activity or work causes your pain

With fear avoidance, these questions and thoughts may run through your mind:

• I shouldn’t / can’t do things that might make my pain worse.
• Doing this might cause more damage in my body.
• Physical activity or work makes my pain worse.
• I shouldn’t / can’t do any physical activity or work with my present pain.
• I can’t do any physical activity or work until my pain is treated.
• I don’t think I’ll ever be able to go back to work.

It’s important to recognize that many people with chronic pain do have physician-prescribed physical limitations. Or, you might have limitations from your physical therapist or rehabilitation doctor. And it’s imperative that you follow those guidelines! What we’re addressing here is a fear or an avoidance of activity that’s physically ok for you to do. (If that difference between what you can and can’t do isn’t clear for you, please talk with your doctor about what is ok for you to do. And if you haven’t been doing activities, please discuss how to safely increase your activity level with your doctor.)

For many people with chronic pain, (unfortunately) you’ll have pain whether or not you do activities or work. So not doing anything won’t prevent discomfort. But, by not doing anything, you’ll miss out on all the positive aspects of activities, hobbies, work, and physical exercise. The important concept is balance. It’s very important that you do as much as you can, while also keeping your pain under control.

How do you minimize this “fear avoidance” type of thinking?

1. From your doctor, learn which activities are ok and which ones you shouldn’t do. With this information, you can then do as much as possible. Use Activity Logs. These chart how much you can do, rather than how bad your symptoms are.

2. Emphasize the positive aspects of activity.

While activity may indeed increase your pain, it may be worth it for the wonderful, positive things that come with activities, hobbies, work, and physical exercise.

3. Modify activities as needed.

Be creative in modifying your activities, so you can do them, while at the same time minimizing any increases in pain. Can you walk for several shorter periods instead of one long walk? Can you garden in containers on your front porch instead of doing the whole yard? Can you use voice recognition on your computer, instead of a keyboard?

Likewise, you may choose to do a longer walk one day when friends from out-of-town visit, recognizing that you may need to rest more for the next 2 days. Overall balance is what you’re trying to achieve.

4. Chronic pain often doesn’t mean body damage.

Acute pain often means you’re hurting your body. For example, touching that hot stove is causing a burn, so pain signals you that you’re hurting your body and makes you to pull your hand away. Chronic pain, on the other hand, often doesn’t mean that you’re hurting your body. So by limiting activities, you’re not avoiding damage.

5. Don’t let your pain get out of control.

You certainly don’t want to do activities to the point that your pain is getting worse and worse, or doesn’t subside when you rest. Be mindful of this balance between activities and pain levels, and don’t let either side completely dictate what you do.

6. Gradually add activities.

If you’re adding activities you haven’t done in a while, or doing more of an activity, do so gradually and under the supervision of your health provider.

7. Emphasize your ability to manage your pain.

Practice your skills to lower your pain levels. Practice your skills to cope with your pain. This will let you do more of what you enjoy and what’s important to you.

* * * * *

The emphasis here is on a balance in your life. Don’t let your pain dictate your life. Live your life as fully as possible, despite having chronic pain.

Your pain is bad enough, but yes, some types of thinking can make it feel worse and cause greater disability. 2 types of thinking can make your pain worse, 1) catastrophizing and 2) fear avoidance. Today we’ll look at catastrophizing. This is a tendency to:

• focus more so than necessary on sensations of pain
• focus on how bad the pain is
• not try to reduce or manage pain

Catastrophizing comes from catastrophe – you’re looking at your situation as a catastrophe. Do thoughts like these run through your mind?

• Is my pain getting worse now?
• How bad is my pain now? And now? And now?
• This is so bad, I can’t stand it.
• This is the worst pain I’ve ever had.
• This will never go away.
• I can’t do anything to help myself.
• That relaxation exercise didn’t help yesterday, so I’m not trying it today.

Before we go further, let’s acknowledge that you may actually be having your worst pain ever. And at times, of course you feel discouraged. Looking at this type of thinking is not meant to minimize your difficult experience or to say you shouldn’t have this type of thinking.

How do you minimize this type of thinking?

1. Avoid focusing on your pain

Focus on other things instead, as much as this is possible. Use distraction. Get involved with activities. Don’t let your pain be a repetitive topic of discussion.

One caution: Pain Logs, which are charts or forms on which you are asked to chart your pain levels daily or even several times a day, can actually cause you to pay more attention to your pain, which can then feel worse. Do these only when really needed, and then for the minimal mount of time they’re useful, e.g. evaluating a new medication.

Use Activity Logs instead! These chart how much you can do, rather than how bad your symptoms are.

2. Emphasize the positive

Saying, This is so bad, I can’t stand it, actually reinforces in your mind that you can’t stand it. Change these statements to a positive perspective. For example, My pain is bad, but it’ll get better. Or, I’m tough. I can tolerate this a little while longer.

3. Emphasize your ability to cope

Practice your skills to lower your pain levels. Practice your skills to cope with your pain.

Catastrophizing is a type of thinking that most of us fall into at one time or another. Recognizing these types of thoughts is important, so you can, instead, focus on something else, change to more positive thoughts, and practice, practice, practice your coping skills.

The information offered here is not intended as advice for any particular patient; as such, no doctor-patient relationship is created or implied. I do not endorse any specific product, service or treatment. Likewise, I do not specifically endorse any product advertised on this site.

Clinical descriptions discussed here are based on composites from many occurrences, patients, and conversations that have been a part of my medical training, residency, and practice as a physician. Confidentiality in everything I write is always maintained. To maintain your own privacy, please include only your first name or an alias when writing on this site. As well, although to my knowledge I have never had a breach of privacy because of the internet, you agree that the internet is not 100% secure and a breach is theoretically possible when you post something to this website or blog.

If you think you have a medical emergency, call your doctor or 911 immediately.

With this website, and when I worked in my medical practice with patients with chronic pain, my goals include:

1. To decrease pain as much as possible
2. To decrease suffering
3. To improve functioning – to live fully despite pain

I hope you find your visit valuable. As the information on this site is constantly evolving, I hope you’ll come back to visit again. As with any medical information, please discuss with your physician anything from this website that you’d like to add to your treatment.  You agree to read and abide by the disclaimer when you use this website.

I’m was Board Certified Psychiatrist in practice for 27 years in Pennsylvania. I had a private practice, working mostly with patients in chronic pain. I also taught psychiatry residents and did research in chronic pain. My guiding principle in practicing as a physician was to help patients in all areas of their lives – medical, psychological and spiritual. Chronic pain is a challenge to your spirit, but a challenge that can always be faced and your situation improved.

I also know the challenge of chronic pain first-hand, having experienced a chronic pain condition myself for many years. Thankfully, my situation has improved, though is hasn’t been cured. I used my personal understanding of what it’s like to live with chronic pain in my work as a pain management physician.

Thanks for visiting!

1. Use your bedroom only for sleep (and sex). This is so your mind associates your bedroom with sleep, rather than work, TV, reading, etc.

2. Develop a getting-ready-for-sleep routine. Again, this helps your mind and body know you’re getting ready for sleep. Do relaxing, calming activities the hour or 2 before bed. Then brush your teeth, wash your face, and turn off the lights. Even doing activities in the same order every night can help.

It’s crucial to turn off all screens – TV, phone, computer – because the light these devices emit keeps your brain awake and you up.

3. Go to bed only when you’re sleepy. It’s more likely you’ll be able to fall asleep, and you’ll avoid tossing and turning in bed because you’re not sleepy. But remember, you have to spend the hour or 2 before your bedtime slowing down your body and mind, so you naturally become sleepy. It’s unlikely you’ll begin to feel sleepy if you’re engrossed in a book, doing an online search, etc.

4. If you can’t fall asleep, get out of bed. The average time it takes to fall asleep is 5 to 30 minutes. To keep your bedroom associated with sleep, you don’t want to lie in bed unable to sleep (which can also make you start worrying about when you’re going to fall asleep). So if you’re unable to fall asleep after 20 minutes or so, get out of bed and do a quiet activity – perhaps a relaxation exercise or quiet reading – and then return to bed when you begin to get sleepy. You may then fall asleep, but if not, get out of bed again, and do this as many times as you’re unable to fall asleep. Again, the first few nights you do this, you may not sleep very much at all, but keep at it. You’re working on establishing good sleep habits! And the next night, you’ll be more likely to fall asleep sooner.

5. Get up at the same time every morning. This helps to establish a sleeping routine. You might be tired, or even very tired, the first few days you do this, but you’ll then be ready for bed at night. On weekends and vacations, you can change this a little bit, but get up no more than 1 hour later than your usual getting-up time, and don’t do this until you’re sleeping well.

6. No naps. Naps go against the sleep routine you’re trying to establish of sleeping at night. If you find yourself tired, try exercise, getting fresh air, or some other alerting activity. After you’re sleeping well, if you still find you get tired, a brief – 1/2 hour – nap in the early afternoon may be ok, especially for older adults.

7. No alcohol before bed. No caffeine within 8 hours of your bedtime. No tobacco within 3 hours of your bedtime. This isn’t to take away things you might enjoy – it’s because all of these disrupt your sleep! Caffeine and nicotine are stimulants – what you don’t need at bedtime. Alcohol disrupts your sleep cycles, especially deep sleep. While is may help you get to sleep, you’ll wake up more often.

8. Exercise regularly, but not right before bedtime. Exercise tires your body and decreases anxiety, in addition to all the other good reasons to exercise. Just don’t do it right before bedtime, when it can wake you up.

9. Make your bedroom a good place to sleep. Be sure your bedroom is not too hot or cold. Make sure it’s dark enough, even as the sun starts to come up. And make sure sounds don’t disturb your sleep – you can try a fan or white noise machine.

Remember, everyone experiences occasional sleep problems. But if you regularly have sleep problems, try these techniques all together. If after trying them, you’re still unable to sleep better, talk to your doctor about other options. Good sleep is very important – for your mood, for healing, and to reduce your pain.

• Pain. Falling asleep can be difficult because pain keeps you awake, or pain can wake you up in the middle of the night.
• Decreased activity. If you aren’t able to do very much during the day, you might not be tired as night.
• Anxiety and worry. These 2 notorious culprits can make falling asleep difficult if you worry about things when your head hits the pillow. Or, if you wake up during the night, you might start worrying about things and not be able to get back to sleep. Things unfortunately often look worse in the wee hours of the morning. You might wake up earlier than you’d like to and not be able to fall back to sleep.
• Depression. This often accompanies anxiety and worry. And actually, one of the symptoms we look for to diagnose depression is sleep problems, especially waking up earlier than you’d like.
• Sleep problems as part of your medical disorder. For example, difficulty sleeping or sleep that doesn’t refresh you (“non-restorative sleep) is part of the disease of fibromyalgia.
• Medication. Although most of the medications that are used to treat chronic pain are sedating, a few can cause sleep problems.

How to Get Better Sleep

Here’s a quick way to start on your way to reducing stress:

1. Choose only 1 idea

My one idea is: ____________________________

For example:

The one idea I’ll do is: Exercise more

2. Identify obstacles

One thing that may get in the way of me doing #1 is: _________________________

For example:

One thing that may get in the way of me doing #1 : Rain. If it’s raining, I can’t exercise outside.

3. How will you handle that obstacle?

I’ll deal with this obstacle by: ____________________________

For example:

I’ll deal with this obstacle by: I’ll get some exercise videos, so I can exercise inside.

4. Make your goal specific

Instead of “exercise more”, write “exercise 2 times a week”.

Instead of “eat better”, write “eat 2 servings of fruit a day”.

My specific goal is: ____________________________

Here are 2 examples, with all 4 steps:
Example #1:
1. My one idea is: Get better at time management.
2. One thing that may get in the way of me doing #1 is: I’m always running behind.
3. I’ll deal with this obstacle by: Leave 5 minutes earlier than I think I have to.
4. My specific goal is: Give myself 5 extra minutes to get to work each morning this week.

Example #2:
1. My one idea is: Say yes to people who offer to help me.
2. One thing that may get in the way of me doing #1 is: I’m embarrassed that I need help.
3. I’ll deal with this obstacle by: View this as an experiment. I don’t need to continue if it’s too embarrassing.
4. My specific goal is: Say yes to 2 offers of help this week.

Go through this exercise right now for yourself.
1. My one idea is: _________________________________________________
2. One thing that may get in the way of me doing #1 is: ________________________
3. I’ll deal with this obstacle by: ________________________________________
4. My specific goal is: _______________________________________________

List of Stress-reducers:

• Exercise
• Eat a balanced diet
• Time management
• Leave extra time in your schedule to get things done or get to places
• Reduce the number of things on your to-do list
• Schedule in relaxation and fun
• Practice assertiveness skills
• Take a walk
• Practice saying no to requests you don’t have time to do, can’t do, or don’t want to do
• Practice saying yes to offers of help
• Have at least 1 positive activity each day
• Spend time with family
• Plant something
• Spend time with friends
• Schedule time just for yourself
• Do something for others regularly
• Practice deep breathing or meditation regularly
• Repeat positive phrases to yourself, like “things will work out all right”
• Write in a journal
• Spend time on a hobby – gardening, reading – whatever you enjoy
• Laugh at something each day
• Have a favorite place to go, either physically or in your mind

List of Stress-reducers:

• Exercise
• Eat a balanced diet
• Time management
• Leave extra time in your schedule to get things done or get to places
• Reduce the number of things on your to-do list
• Schedule in relaxation and fun
• Practice assertiveness skills
• Take a walk
• Practice saying no to requests you don’t have time to do, can’t do, or don’t want to do
• Practice saying yes to offers of help
• Have at least 1 positive activity each day
• Spend time with family
• Plant something
• Spend time with friends
• Schedule time just for yourself
• Do something for others regularly
• Practice deep breathing or meditation regularly
• Repeat positive phrases to yourself, like “things will work out all right”
• Write in a journal
• Spend time on a hobby – gardening, reading – whatever you enjoy
• Laugh at something each day
• Have a favorite place to go, either physically or in your mind

Pick a Specific Way to Reduce Your Stress

Does this mean my doctor thinks the pain is in my head, or I’m crazy? No. Chronic pain is real. Often, it is also very hard to treat, so having a team work with you to treat the pain from different angles can help. A mental health person can often help you decrease your pain levels, as well as cope better with the pain you have.

How can a psychiatrist help me? There are several ways a psychiatrist can help. These include:

1. Support and problem-solving, as you face this great challenge. Just having someone to talk to about how you’re doing and what problems you’re facing is helpful. I also help patients figure out how to deal with problems that come up because of pain. Pain can affect all areas of your life, including work and relationships. Talking about these other areas and solving problems that come up in them is helpful.
2. Teaching skills that can decrease your pain, such as relaxation, visualization and guided imagery exercises. Hypnosis is sometimes a helpful addition.
3. Helping you figure out what activity is helpful, and what activity hurts in your present condition. Pacing, which is monitoring your activity level, to do as much as possible while keeping your pain under control, is a helpful skill. You may learn to replace activities you can no longer do with other ones you enjoy. Or you might learn to modify activities so you can still do them. For example, someone who used to like to garden for hours at a time may no longer be able to do that because of pain. But she may be able to garden over several shorter time periods (pacing), or garden in raised containers instead of her garden (modifying), or take up knitting instead (replacing).
4. Figuring out with you which of your usual coping skills are helpful to you and which ones may be getting in your way. For example, some people respond to difficulty by working harder. This may be helpful if you work hard to find information on your condition, but it could get in the way if you apply this to physical therapy exercises, doing 100 when you were instructed to do 10. In contrast, some people immediately give up and think the worst will happen to them. A psychiatrist would help you examine which of your thoughts interfere with functioning, and help you replace them with more realistic thoughts.
5. Medication. A psychiatrist is a doctor who can prescribe medication to help decrease pain or increase your ability to handle your situation. These medications can be helpful even if you don’t have depression or anxiety. These medications include antidepressants, anti-anxiety medications, anticonvulsants, and others. Some psychiatrists prescribe narcotics.
6. Evaluate if you have depression or anxiety that is contributing to your pain. A psychiatrist can diagnose and treat conditions like depression or anxiety that often come along with pain disorders. Treatment may include both therapy and medications.
7. Help you sleep better. Many patients with pain have a difficult time falling asleep or staying asleep. Psychiatrists can treat this problem by teaching you skills to help with sleep or by prescribing non-addicting medication if needed.