Major depressive disorder secondary to chronic low back pain
Chronic back pain × 4 years; opioid taper completed; depressed, withdrawn, identity collapsed around 'disabled.'
Presenting concern
Referred by pain medicine. PHQ-9: 17. Withdrawn from former hobbies (cycling, woodworking), gained 30 lbs, marital strain. Off opioids 6 months, now on duloxetine. Pain still present but more manageable.
History
Workplace back injury 4 years ago. Cascade: surgery → opioid dependence → taper → depression. Previously highly active. No prior psychiatric history.
- Identity loss around physical capability
- Deconditioning compounding pain
- Marital strain
- Pain-related fear avoidance
- Off opioids
- Engaged with pain medicine team
- Wife still supportive
- Has prior identity to draw on
Conceptualization across modalities
Pain catastrophizing + fear-avoidance + life narrowing = chronic pain depression. Treatment is not to eliminate pain but to expand life despite it. Values clarification + willingness + committed action.
- Defusion from 'I can't until pain is gone' thinking
- Values clarification
- Graded behavioral activation in values direction
- Willingness to feel pain in service of meaningful action
Behavioral withdrawal from valued activity drives depression independent of pain. Cognitive distortions ('I'm broken,' 'I'll never get my life back') maintain hopelessness. Graded activation + cognitive work targets both.
- Graded activity scheduling (paced, not pain-contingent)
- Thought records on pain-related cognitions
- Sleep hygiene
- Address fear-avoidance behaviors
Treatment plan
Engage (1–4)
Formulation, values clarification, pacing introduction.
Activate (5–14)
Graded activity, willingness work, marital re-engagement.
Identity (15–20)
Reconstruct identity beyond 'former athlete / disabled.'
PHQ-9 to 8 by session 16. Returned to modified cycling. Identity shift in progress, ongoing.