How to Deal Emotionally with the Uncertainties of Pancreatitis: For Family Members and Patients

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On this page, below our introduction section, we will discuss the following topics:

•  anxiety;
•  depression;
•  antidepressants;
•  stress management; and,
•  breathing exercises (for relaxation).

Introduction

One of the most difficult parts of learning to live with pancreatitis is the many uncertainties associated with the chronic form of the disease. Often folks have been ill and not diagnosed with their pancreatic illness for several months, or even years before they come to us. The MUSC Digestive Disease Center hear over and over again, "I'm sick and tired of feeling sick and tired."

"I can't plan my life, and neither can my family."

"I just wish this pain or nausea were more manageable."

"I wish I could eat some of my favorite foods without getting an attack."

"I never know when I'll end up in the emergency room in the middle of the night and be labeled as 'drug seeking.'"

There is probably no one affected by pancreatitis who hasn't felt either anxious or depressed at one time or another in dealing with the troublesome symptoms of pancreatitis. We find that a fair number of the people who come to our support and education group have begun taking either anti-anxiety medications or antidepressants, in addition to pain medications and other medications for symptom management. These folks may be the patient, a caregiver or family members.

Feeling powerless to help a loved one who is feeling miserable over a long period of time may lead to anxiety or depression. The stress of trying to adapt graciously to the forced life style changes which often accompany chronic pancreatitis may also contribute to folks having trouble with symptoms of anxiety and/or depression. Most people who benefit from treatment find considerable improvement from both medication and talking about their worries and fears with a counselor or therapist.

Much of the anxiety of pancreatitis comes from uncertainty and unpredictability about quality of life and treatment options. Problems with depression tend to come from the chronic or long term nature of the illness. While a certain amount of worry, concern, or feeling "down" is "normal" in living with a chronic disease, sometimes these feelings cross over from being an expected and manageable emotional response, to being a bonafide treatable mental illness. We tell folks "that's the good news," because both Anxiety Disorders and clinical or Major Depression are treatable.

The most common treatments prescribed by doctors and nurses are medications, behavioral therapy, and talking therapy. Some unconventional, complementary medicine, or alternative healthcare treatments which may be useful for allaying bothersome symptoms associated with pancreatitis include relaxation techniques and breathing exercises, guided imagery exercises, hypnotherapy, acupuncture or acupressure, prayer, and Therapeutic Touch or other "hands on" therapies, such as massage therapy.

Let's look at one important difference between medications for anxiety and medication for depression. The anti-anxiety medications may be prescribed to be taken on a regular basis if one is diagnosed with a true anxiety disorder, but they can also be taken on an "as needed" (or "PRN") basis. Most of the anti-anxiety drugs (anxiolytics) in common use today have a fairly short life span in the body so can be used for short term relief. This is important because these useful medications may be habit-forming. In that case, although people may become dependent on the medications, this should not be an immediate concern. Usually a physician or nurse will decide if addiction seems to be becoming a problem for that person, and recommend special treatment for medical dependence on the substance. Some drugs commonly prescribed for anxiety are lorazepam (Ativan), clonazepam (Klonopin), buspirone (BuSpar), alprazolam (Xanax), and oxazepam (Serax).

Antidepressants, on the other hand, should be taken on a regular basis whether you feel depressed or not. All antidepressant drugs need to reach and maintain a steady therapeutic blood level to do their work. One usually has to take them for one to three weeks before they begin to be effective. This is an important distinction from anti-anxiety drugs. The newer antidepressants, called serotonin reuptake inhibitors (SSRIs) or atypicals, usually work more quickly than the older ones. Some drugs commonly prescribed for depression are fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), trazedone (Desyrel), fluvoxamine (Luvox), bupropion (Wellbutrin), and venlafaxine (Effexor). Some tried and true antidepressants are amitriptyline (Elavil), desipramine (Norpramine), doxepin (Sinequan), and nortriptyline (Pamelor). Some of these medications help people manage pain better and to sleep better and are often taken at bedtime. Two newer antidepressant drugs are mirtazepine (Remeron) and citalopram (Celexa).

If a physician or nurse practitioner orders an anti-anxiety medication for you to help you cope – say up to 3 times a day – and you don't feel you need it at a particular time - OK, don't take it that often. But be sure to tell your health care provider how often you are taking "as needed" medicines, especially if you are admitted to the hospital. It is very important not to stop anti-anxiety medicines all at once, as this can lead to withdrawal symptoms and possible seizures. There are also some antidepressants which should be gradually tapered down in dosage. Never stop any medication "cold turkey" without checking with your doctor or nurse first.

One of the things we tell folks to help them understand the difference between anti-anxiety and antidepressant drugs is that taking anti-anxiety drugs is like taking aspirin or Tylenol for a headache. You get the headache; you take the medicine, and the symptoms go away. You don't need to take the medicine again unless you get more symptoms (for most people). But depression is not an acute event—it is an on going process. So one takes the antidepressant every day, whether you feel that you need it that day or not, as one takes the full dose of an antibiotic. You need to take an antibiotic drug until the prescription is finished, otherwise you may not get the effect you require.

To recap, it is normal to feel a certain amount of anxiety or depression when you or a loved one has a severe or recurring medical illness, such as pancreatitis. However, if symptoms persist and are bothersome to you or your family, talk with your doctor or nurse or other health care provider and ask him or her to assess or refer you for special help. Both anti-anxiety and anti-depressant medications may come from your general practitioner or your pancreatic physician, or they may be ordered through your referral to a therapist or psychiatrist.

If you think you or a loved one may be suffering from untreated depression or anxiety, tell your doctor or nurse. Long periods of pancreatic pain or nausea, and feeling out of control and unable to help a loved one who is hurting can deplete a person's inner resources and the nerve hormones that help regulate emotions. Depression and Anxiety are treatable. They don't just go away on their own and a truly depressed person cannot "snap out of it" by will power or sheer faith.

Anxiety

Common medical treatments for anxiety disorders and/or major depression:

• Talking therapy (counseling or psychotherapy - individual, family, or group)
• Medication therapy
• Combination of talking therapy and medication

Other treatments to complement the above treatments or to try using first:

• Physical exercise program
• Light therapy
• Therapeutic massage
• Balanced diet, if possible
• Relaxation exercises
• Guided imagery
• Prayer
• Hypnosis
• Hatha Yoga exercises
• Acupuncture or acupressure
• Stress management techniques
• Dancing or Martial Arts classes
• Certain herbal remedies (check on their possible side effects)

Depression

• One out of every four women, and one out of every ten men, will get depression in a lifetime.
• A person with a major or "clinical" depression cannot "snap out of it," be strong, or "pull themselves up to their bootstraps."
• Depression is a mind/body disease, not a weakness. It is not a moral weakness nor punishment. And there is no need to feel embarrassed or ashamed.

Antidepressants

Some commonly used antidepressant medications are the selective serotonin reuptake inhibitors (SSRI’s) and their successors. Some generic names are paroxetine, sertaline, fluoxetine, fluvoxamine, buproprion, venlafaxine, trazodone, and mirtazapine. The brand names of these are, respectively, Paxil, Zoloft, Prozac, Fluvor, Wellbutrin SR, Effextor SR, Desyrel, Remeron. Tricyclic antidepressants Amitriptyline (Elavil) and, more recently, nortriptyline (Pamelor) are often used in conjunction to other antidepressants in the treatment for chronic pain. Sometime pain management services will add other medications to augment narcotic or other strong pain medications for treating the chronic pain of pancreatitis, such as neurontin or Gabapentine. Often chronic pain is lessened when depression from having a chronic illness is treated with adequate doses of antidepressants. Medications for depression are not addicting but should not be stopped without telling your doctor or nurse! Most medicines prescribed for anxiety can be addicting.

Stress Management

When we as humans are stressed our body's built in mechanisms respond to stress and protect us via a response called the Fight or Flight reflex. Hans Selye developed a stress model in the 18th century, and Herbert Benson, MD later used this model to describe the Relaxation Response. One of the classic examples is the parable of the caveman and the saber tooth tiger. When this primitive person saw the danger (stressor) the body automatically—the autonomic nervous system—prepares itself to either run away from the danger or to go forward and fight it.  He starts pumping adrenaline, his blood pressure will rise, his heart rate will increase, muscles become tense, hands become cold and clammy and his stomach is tense. Now say the tiger just walks away and does not attach this person, then the autonomic nervous system turns off and the muscles relax, the heart goes back to normal, blood pressure goes down to normal, and the hands regain blood pressure again becoming warm and dry. That's a normal response and all of us do that when we are stressed. If we have so many stressors at one time or if we have trouble letting go or not seeing that the real or imagined danger has passed that autonomic system gets stuck on and our muscles stay tense, our blood pressure stays up and we have trouble digesting our food. So if we get in that state of chronic stress the biological response becomes abnormal. It's still not necessarily an anxiety disorder, but when you're constantly tense you manifest a number of physical symptoms.

There is a difference between positive and negative stress. In the example above, if the caveman gets his stone axe out and prepares to fight, the physical responses to that stress helps to protect him. If we are driving a car and a child runs out in front of us and we must slam on brakes, our stress response prepares us to react in a positive way and take care of it. Negative stress is when your body doesn't go into "relax" mode. Anxiety which goes on and on without that break can be treated with an anti-anxiety medication, but because stress is normal and there can be side effects as well as addiction, there are many other things that people can do first to try to relax without taking a pill. Some examples are deep breathing, reading or finding a diversion, walking or any physical exercise, prayer, talking with an understanding friend, listening to soft music, being out in nature, or yoga. There are also relaxation exercises including guided imagery. These are just a few of the many relaxation options open to everyone.

Breathing Exercises (for Relaxation)

Exercise #1 (Deep breath [tense], exhale [relax], yawn)

1. Clench your fists, breathe in deeply and hold it a moment.
2. Breathe out slowly and go limp as a rag doll.
3. Yawn for quick relaxation. Yawning becomes spontaneous.  It is also contagious, so others may begin yawning and relaxing, too.

Exercise #2 (Slow rhythmic breathing and relaxation)

1. Breathe in slowly and deeply.
2. As you breathe out slowly, feel yourself beginning to relax; feel the tension leaving your body.
3. Now breathe in and out slowly and regularly, at whatever rate is comfortable for you. You many wish to try abdominal breathing.  If you do not know how to do abdominal breathing, ask your nurse for help.
4. To help you focus on your breathing and breathe slowly and rhythmically:  Breathe in as you say silently to yourself, "in, two, three." Breathe out as you say silently to yourself, "out, two, three," or each time you breathe out, say silently to yourself a word such as "peace" or "relax."
5. You may imagine that you are doing this in a place you have found very calming and relaxing for you, such as lying in the sun on the beach.
6. Do steps (a) through (d) only once or repeat steps (c) and (d) for up to 20 minutes.*
7. End with a slow deep breath. As you breathe out, say to yourself "I feel alert and relaxed."
   
   *Note:  If you do intend to do this exercise for more than a few seconds, try to get in a comfortable position in a quiet environment and either close your eyes or focus on an object. This technique has the advantage of being very adaptable in that it may be used for only a few seconds or for up to 20 minutes.