A woman sits on a bench in a park.

A Complete Guide to Chronic Pain & Mental Health

Chronic pain isn’t just a physical battle; it’s an all-out mental marathon too.

If you’re among the millions grappling with persistent aches, you know it’s not only about sore joints or throbbing headaches – it can cloud your mood and cast a shadow over your state of mind.

You’re not alone in feeling like each day is an uphill struggle against both discomfort and emotional turmoil.

Here’s something to think about: studies show that people with chronic pain are three times more likely to develop symptoms of anxiety or depression.

This article is crafted to unravel this complex tie between enduring pain and mental wellness.

We’ll explore what keeps these conditions intertwined, how they impact daily life, and most importantly, ways to manage them for better health harmony.

Are you ready to find some relief?

Please note: We have pioneered a novel injection technique to resolve chronic pain.

It uses platelets from your blood to provoke an immune response to stimulate self-healing.

Surprisingly, this technique works without any additional drug or chemical added.

Don’t get addicted to pain meds trying to get rid of chronic pain!

Watch a quick video about Platelet Rich Fibrin Treatments here.

Key Takeaways

  • Chronic pain not only causes physical discomfort but also has a significant impact on mental health, increasing the risk of anxiety and depression.

  • Common chronic pain conditions such as arthritis, migraines, fibromyalgia, and multiple sclerosis can exacerbate psychological challenges like stress or emotional distress.

  • Managing chronic pain effectively involves a combination of strategies including medication, psychotherapy, low-impact exercises, mindfulness practices, anti-inflammatory diets, improved sleep habits, social support systems, and pet therapy.

  • Self – help tips like engaging in physical activity and practicing relaxation techniques can reduce symptoms of both chronic pain and associated mental health issues.

  • Professional treatment options tailored to individual needs are essential for addressing the intertwined aspects of chronic pain and mental well-being.

Understanding the Link Between Chronic Pain and Mental Health

Transitioning from a broad overview, let’s now delve into how chronic pain intertwines with mental health.

Living with persistent discomfort often triggers psychological distress, as the struggle to manage pain can lead to feelings of frustration and helplessness.

This emotional burden may increase the risk of developing mental health disorders such as anxiety or depression.

The brain pathways that process physical sensations of pain overlap with those that regulate mood, which explains why individuals suffering from conditions like arthritis or back pain frequently experience mood disorders too.

Recognizing this connection is crucial for effective treatment, as managing one aspect can positively affect the other.

Health care providers look at both symptoms and coping strategies since untreated mental health problems can intensify the perception of pain.

Conversely, successful pain relief brings about an improvement in overall well-being and reduces depressive episodes or anxious feelings associated with chronic ailments.

It’s a complex relationship where both factors—physical and emotional—significantly impact each other, underlining the importance of integrative medical care approaches which address all facets of a patient’s experience with chronic pain.

Prevalence of Mental Health Conditions in Those With Chronic Pain

A young woman looking out a window.

The connection between chronic pain and mental health sets the stage for a deeper dive into how often individuals with persistent pain conditions face psychological challenges.

Studies reveal that people experiencing chronic pain are at a higher risk for developing mental health conditions, particularly anxiety disorders and major depressive disorder.

The presence of continuous discomfort can trigger feelings of hopelessness, leading to severe depression in some cases.

Moreover, ongoing distress from conditions like arthritis or back issues can contribute to sleep disturbances and fatigue, exacerbating emotional distress.

Evidence points to a significant overlap between chronic pain sufferers and those diagnosed with psychiatric disorders.

Mental health concerns do not discriminate; they affect individuals regardless of their age or type of chronic pain condition—be it cancer pain, fibromyalgia, or neuropathic pains stemming from multiple sclerosis (MS).

Somatic symptoms such as tingling or acute pain can amplify the severity of these psychological ailments.

This confluence necessitates comprehensive care strategies encompassing both physical ailment treatment and support for associated mental disorders to optimize overall well-being.

Common Chronic Pain Conditions and Their Association with Mental Health

Back and neck issues, arthritis, cancer, migraines, fibromyalgia, multiple sclerosis (MS), and premenstrual syndrome (PMS) are some of the common chronic pain conditions that are often associated with mental health challenges.

To learn more about how these conditions impact mental health and effective management strategies, continue on.

Back/Neck Issues

Back and neck issues are some of the most common chronic pain conditions that people experience, affecting an estimated 80% of the population at some point in their lives.

These problems often stem from a variety of factors such as poor posture, degenerative diseases like osteoarthritis, or accidents causing injury to the spinal column.

If left unaddressed, they can lead to major depression and generalized anxiety due to ongoing discomfort and disruption of daily activities.

Effective pain management for back and neck issues usually involves a combination of physical activity, treatments from health care professionals, and sometimes medication.

Low-impact exercises can help strengthen muscles supporting the spine while psychotherapeutic treatments address emotional fallout from long-term pain.

Ensuring quality sleep is also critical in this context; insomnia worsens both physical pain and mental health symptoms.

Individuals suffering may seek primary care providers’ advice on interventions ranging from improved ergonomics at work to specialized psychopharmacology approaches tailored for managing chronic stress affecting the central nervous system.

Arthritis

Arthritis affects millions of people, causing pain and inflammation in the joints.

Rheumatoid arthritis is an autoimmune disease that can lead to joint damage and deformities.

Osteoarthritis, on the other hand, occurs due to wear and tear of the joints over time, often affecting weight-bearing joints like knees and hips.

The impact of arthritis on mental health cannot be overlooked. The chronic pain associated with arthritis can contribute to depression and anxiety symptoms.

Additionally, managing daily activities becomes challenging for individuals living with this condition.

Understanding these implications is crucial for providing comprehensive care to those with arthritis.

Cancer

Moving on from arthritis, another chronic pain condition with a significant impact on mental health is cancer.

People diagnosed with cancer often experience physical discomfort and distress, which can lead to heightened emotional and psychological challenges.

The combination of managing the symptoms of cancer while dealing with the associated mental health issues can be overwhelming for individuals and their loved ones, impacting various aspects of daily life.

The treatment process for cancer also involves its own set of challenges, including side effects from medication, invasive procedures, and lifestyle adjustments.

These factors contribute to the complexity of managing both physical pain and mental well-being in individuals affected by cancer.

Migraine

Cancer can cause severe pain, and its treatments often contribute to chronic pain conditions.

Another common condition that significantly affects both physical and mental health is migraine.

Migraine attacks are characterized by intense headaches, often accompanied by nausea, vomiting, and sensitivity to light or sound.

These debilitating symptoms can have a profound impact on an individual’s quality of life and mental well-being.

Migraines are known to be comorbid with various psychiatric disorders such as depression, anxiety, and sleep disorders.

The intensity and frequency of migraine attacks can lead to heightened levels of stress and emotional distress in individuals experiencing them.

Fibromyalgia

Fibromyalgia is a chronic pain disorder characterized by widespread musculoskeletal pain, fatigue, and tenderness in localized areas.

It affects the muscles and soft tissue, often leading to sleep disturbances, mood issues, and memory problems.

Individuals with fibromyalgia might also experience comorbid conditions such as anxiety disorders or depression.

Research suggests that fibromyalgia may be linked to abnormal levels of certain chemicals in the brain that amplify painful sensations.

The exact cause of fibromyalgia is still unknown; however, it’s believed that factors such as genetics and infections may play a role in its development.

Management often involves a combination of medication (like antidepressants), physical therapy, exercise programs tailored to individual needs, stress reduction techniques like mindfulness meditation or yoga, and patient education aimed at improving coping strategies for dealing with chronic pain.

Multiple Sclerosis (MS)

Multiple Sclerosis (MS) affects the central nervous system, leading to various physical and cognitive challenges.

Individuals with MS commonly experience chronic pain, which can significantly impact their mental health.

Studies have shown that nearly half of people with MS report experiencing chronic pain, contributing to increased anxiety and depression symptoms.

Various types of pain can accompany MS, including neuropathic pain, muscle spasms, and musculoskeletal pain.

These symptoms often lead to sleep disturbances and reduced quality of life for those affected by the condition.

Premenstrual Syndrome (PMS)

Premenstrual Syndrome (PMS) affects many women, with symptoms like mood swings, irritability, bloating, and fatigue.

These physical and emotional fluctuations can impact mental health, leading to increased stress or anxiety during the premenstrual phase.

Management options may include lifestyle adjustments and professional treatment interventions.

Understanding PMS is vital for recognizing its potential impact on mental health and overall well-being.

Effective strategies for managing PMS related symptoms can significantly improve a person’s quality of life while promoting better mental health outcomes as they navigate through their daily activities.

How Chronic Pain Affects Your Mood

Chronic pain can significantly impact mood, often leading to symptoms of depression and anxiety.

It can cause feelings of frustration, irritability, and hopelessness.

Patients may experience a decreased interest in activities they once enjoyed due to the constant discomfort.

The stress of managing relentless pain can exacerbate existing mental health conditions or trigger new ones such as generalized anxiety disorder or obsessive-compulsive disorder.

The persistent nature of chronic pain might lead to sleep disturbances, affecting mood regulation.

Additionally, the reliance on medication for pain management could result in adverse side effects that further affect emotional well-being.

Social support plays a crucial role in mitigating these impacts, providing comfort and understanding during challenging times.

Causes of Chronic Pain

After understanding how chronic pain affects your mood, it’s crucial to explore the various causes behind this persistent condition.

Chronic pain can stem from a multitude of sources such as injuries, nerve damage, arthritis, infections, and fibromyalgia.

Additionally, conditions like endometriosis and back or neck issues could also contribute to long-term pain experiences.

Furthermore, genetic factors and certain medical procedures may play a role in the development of chronic pain.

Chronic Pain often arises from numerous contributing factors that include nerve damage due to injury or surgery; underlying diseases such as osteoarthritis; infections like shingles or post-herpetic neuralgia; fibromyalgia; endometriosis in women; and structural problems like disc herniation causing back or neck issues are all known contributors.

Moreover, genetic predispositions alongside psychological influences can exacerbate the persistence of chronic pain symptoms throughout an individual’s life.

Self-Help Tips for Managing Chronic Pain

In managing chronic pain, individuals may benefit from performing low-impact exercises, practicing mindfulness, following an anti-inflammation diet, improving sleep, building and maintaining social support, and trying pet therapy.

These self-help tips can help alleviate symptoms and improve overall well-being for those living with chronic pain.

Performing Low-Impact Exercises

Engaging in low-impact exercises like swimming, yoga, or walking can help alleviate chronic pain and improve mental well-being.

These activities promote blood flow, strengthen muscles, and release endorphins – natural painkillers enhancing mood and reducing stress levels.

Low-impact exercises also provide an opportunity for social interaction which is crucial for managing chronic pain conditions while fostering a sense of community support.

Engaging in physical activity can also lessen depressive symptoms, contribute to better sleep quality, and increase overall functionality.

Practicing Mindfulness

Transitioning from engaging in low-impact exercises, another effective self-help tip for managing chronic pain is practicing mindfulness.

Mindfulness involves maintaining a moment-by-moment awareness of thoughts, feelings, bodily sensations, and the surrounding environment with a gentle and accepting attitude.

This practice aims to reduce stress and promote relaxation by focusing on the present moment without judgment or attachment to specific outcomes.

Incorporating mindfulness meditation into daily routines can help individuals with chronic pain develop coping strategies, improve emotional regulation, and enhance overall well-being.

Engaging in mindfulness activities such as deep breathing exercises, body scans, or progressive muscle relaxation can aid in alleviating physical tension while fostering mental clarity.

By cultivating heightened self-awareness through mindfulness practices, individuals may experience reduced reactivity to pain sensations and greater resilience when facing challenging circumstances related to their chronic condition.

Following an Anti-Inflammation Diet

An anti-inflammation diet focuses on consuming foods that help reduce inflammation in the body.

Emphasizing whole foods like fruits, vegetables, nuts, seeds, and oily fish can aid in managing chronic pain by reducing inflammation.

Incorporating keywords such as “inflammation,” “foods,” and “reducing” helps to highlight the importance of nutrition in addressing chronic pain and mental health.

In addition to decreasing inflammation, an anti-inflammation diet may also contribute to improved overall health and well-being for individuals dealing with chronic pain.

Integrating a variety of nutrient-dense foods while minimizing processed and sugary options can play a significant role in alleviating symptoms associated with chronic pain conditions.

Improving Sleep

Improving sleep is crucial for managing chronic pain and promoting mental well-being.

Establishing a consistent sleep schedule, creating a relaxing bedtime routine, and ensuring a comfortable sleep environment can help alleviate pain symptoms and improve overall mood.

Engaging in calming activities before bed, such as reading or listening to soothing music, can aid in winding down the mind and body for restful sleep.

Additionally, practicing relaxation techniques like deep breathing or progressive muscle relaxation can further enhance the quality of sleep while reducing discomfort associated with chronic pain.

To optimize one’s sleep patterns when dealing with chronic pain conditions, considering using mindfulness meditation or guided imagery methods that focus on addressing both physical discomfort and mental stressors.

Such approaches may contribute to better sleeping habits while helping manage pain levels effectively.

Building and Maintaining Social Support

Building and maintaining social support is crucial for managing chronic pain and associated mental health challenges.

Engaging in regular communication with friends, family, or support groups can provide emotional reassurance, reduce feelings of isolation, and offer practical help when needed.

Participating in social activities can also improve mood and alleviate stress, contributing to a more balanced mental state amidst the difficulties of chronic pain.

Developing a strong social network helps individuals feel understood and validated while enhancing their overall well-being.

Whether through sharing experiences with others who are facing similar struggles or seeking encouragement from loved ones, establishing and nurturing social connections can significantly impact coping mechanisms and resilience in the face of chronic pain.

Trying Pet Therapy

Engaging with pet therapy involves spending time with animals to improve mental and physical well-being.

Interacting with pets like dogs or cats can reduce stress, boost mood, and provide companionship.

Engaging in activities such as walking a dog or grooming a cat can encourage physical activity and help manage chronic pain.

Pet therapy is linked to reduced levels of anxiety, depression, and loneliness, offering a comforting presence that promotes relaxation and distraction from pain symptoms.

Positive interactions with animals trigger the release of oxytocin, dopamine, and endorphins in the brain, which are natural chemicals responsible for improving mood and reducing pain perception.

Professional Treatment Options for Chronic Pain and Associated Mental Health Issues

Professional treatment options for chronic pain and associated mental health issues include medication, such as opioid analgesics and psychopharmacological drugs, as well as psychotherapies like supportive psychotherapy and anxiolytic treatments.

These interventions aim to address the physical and psychological aspects of chronic pain conditions and improve overall quality of life for individuals experiencing these challenges.

Medication

Medication prescribed for chronic pain often includes opioid analgesics, which help alleviate moderate to severe pain by interacting with the brain and nervous system.

Anti-inflammatory drugs such as nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroids are commonly used to reduce inflammation and relieve pain associated with conditions like arthritis.

However, it’s crucial to balance potential benefits against risks, being mindful of potential side effects, dependency concerns, and individual responses to these medications.

Considering psychiatric symptoms in patients with chronic pain, psychopharmacological interventions using anxiolytics, neuroleptics, or sedative-hypnotic drugs may be indicated for managing comorbid disorders such as anxiety or sleep disturbances.

Psychotherapy

Psychotherapy involves talking with a trained mental health professional to address the emotional and psychological aspects of chronic pain.

It aims to help individuals develop coping strategies, manage stress, and improve their overall well-being.

Therapists may use various techniques such as cognitive-behavioral therapy (CBT) or mindfulness-based approaches to assist individuals in understanding and changing negative thought patterns related to their pain experience.

Engaging in psychotherapy can also aid in identifying any underlying mental health conditions that may be exacerbating the experience of chronic pain.

By addressing these issues, individuals can learn how to better manage their symptoms and improve their quality of life, reducing the impact of both physical discomfort and emotional distress.

How to Help Someone in Chronic Pain

Helping someone in chronic pain begins with understanding and empathy. Firstly, offering a sympathetic ear can make a significant difference.

Additionally, assisting them with daily tasks or errands that may exacerbate their pain can be incredibly helpful and alleviate some of their burdens.

Encouraging them to seek professional guidance and providing emotional support through the highs and lows is crucial for their mental well-being.

It’s also essential to respect their boundaries when discussing treatments or lifestyle changes but expressing your willingness to assist wherever needed.

Supporting someone in chronic pain involves being patient, understanding, and willing to accommodate their unique needs.

Offering practical assistance and emotional support can have a positive impact on their overall quality of life, aiding them in managing both physical discomfort and mental health challenges.

The Impact of Chronic Pain on Depression and Anxiety

Transitioning from understanding how to help someone in chronic pain, it’s essential to recognize the impact of chronic pain on mental health.

Chronic pain significantly contributes to depression and anxiety, often exacerbating existing conditions or triggering new ones.

The persistent discomfort and challenges associated with chronic pain can lead individuals to experience feelings of hopelessness, sadness, and fearfulness.

This not only affects their emotional well-being but also influences their ability to engage in daily activities and maintain social connections.

Recognizing this connection between chronic pain and its impact on depression and anxiety is crucial in providing comprehensive support for individuals dealing with these intertwined struggles.

The Role of Lifestyle Changes in Managing Chronic Pain and Mental Health

Engaging in regular low-impact exercises, such as walking or swimming, can help alleviate chronic pain and improve mental well-being.

Incorporating mindfulness practices into your daily routine, like deep breathing or meditation, may reduce stress and enhance overall quality of life.

Adapting to an anti-inflammatory diet rich in fruits, vegetables, whole grains, and lean proteins has the potential to decrease inflammation and manage chronic pain.

Prioritizing good sleep habits by establishing a consistent bedtime routine can also contribute to better pain management and mental health.

The Effect of Chronic Pain on Quality of Life and Daily Activities

Chronic pain significantly impacts the quality of life and daily activities of individuals.

It can limit mobility, impair concentration, and disrupt sleep patterns, leading to fatigue and reduced productivity.

Simple tasks such as cooking, cleaning, or driving may become arduous or even impossible for those experiencing chronic pain in their bones or muscles.

Furthermore, chronic pain often leads to social isolation and diminished participation in enjoyable activities due to the constant discomfort it causes.

This not only affects the individual’s physical well-being but also contributes to emotional distress and a sense of helplessness.

Consequently, addressing the effect of chronic pain on quality of life is crucial for both physical and mental well-being.

A woman is walking down a path in the mountains.

The Importance of Mental Health Screening for People with Chronic Pain

Mental health screening for individuals with chronic pain is crucial to identifying and addressing underlying psychological issues.

Screening can help healthcare providers understand the extent of a person’s mental health condition and develop an appropriate treatment plan.

It also allows for early intervention, preventing the escalation of mental health challenges in those experiencing chronic pain.

Effective mental health screening ensures that both physical and emotional aspects of chronic pain are addressed, leading to improved overall well-being.

Early identification of mental health concerns can guide personalized care, ultimately enhancing the quality of life for individuals battling chronic pain conditions.

The Connection between Chronic Pain and Psychiatric Disorders

Chronic pain is often linked to psychiatric disorders such as depression, anxiety, and somatoform disorders, highlighting the intricate relationship between physical and mental health.

Understanding this connection is crucial in providing comprehensive care for individuals experiencing chronic pain.

Chronic Pain, Depression, and Anxiety

Chronic pain often coexists with depression and anxiety, exacerbating the overall burden on individuals.

Managing chronic pain can be emotionally taxing, impacting mental well-being and quality of life.

Depression and anxiety are common comorbid conditions among individuals experiencing chronic pain, presenting a complex challenge that requires holistic approaches for effective management.

Anxiety associated with chronic pain can heighten the perception of discomfort and contribute to a cycle of increased pain sensitivity.

Similarly, depression may lead to decreased motivation in managing physical symptoms or engaging in pleasurable activities.

Integrative treatment strategies focusing on both physical and mental health aspects are crucial for addressing the interconnected nature of chronic pain, depression, and anxiety.

Optimizing care by considering these interrelated conditions is essential for improving overall well-being.

Chronic Pain, Depression, and Somatoform Disorders

Chronic pain often coexists with mental health conditions such as depression and somatoform disorders.

Those experiencing chronic pain may also struggle with unexplained physical symptoms that lead to distress and impairment in daily functioning.

Depression, characterized by persistent feelings of sadness and hopelessness, can exacerbate the impact of chronic pain on an individual’s overall well-being.

Depression can manifest in various physical symptoms as well, intensifying the subjective experience of pain.

Somatoform disorders involve a pattern of symptoms that suggest a physical illness or injury but cannot be fully explained by a medical condition, leading to significant distress or impairment.

The Role of Psychotherapeutic Treatments in Treating Chronic Pain

Psychotherapeutic treatments play a vital role in managing chronic pain.

They help individuals develop coping strategies and reduce the emotional impact of persistent pain.

Cognitive-behavioral therapy, a common psychotherapeutic approach, aims to change negative thought patterns and behaviors associated with pain, leading to improved quality of life and reduced distress for those experiencing chronic pain.

In addition to cognitive-behavioral therapy, other forms of psychotherapy such as mindfulness-based stress reduction can also be beneficial in alleviating the psychological burden of chronic pain.

Engaging in these therapies can empower individuals with chronic pain to better manage their symptoms and improve overall well-being without relying solely on medication.

Potential Risks and Side Effects of Medication for Chronic Pain

Transitioning from the role of psychotherapeutic treatments in chronic pain management to potential risks and side effects of medication, it’s essential to understand that although medications can provide relief, they may also pose certain risks and side effects.

Opioid use for chronic pain control is associated with several potential risks, including substance use disorders and opioid misuse.

Other drugs used for pain modulation such as benzodiazepines and barbiturates pose the risk of addiction and may exacerbate symptoms of depression and anxiety in individuals with chronic pain conditions.

Furthermore, hypnotics prescribed for improving sleep quality could lead to dependency issues if not carefully monitored.

On the other hand, non-opioid medicines like NSAIDs carry a risk of gastrointestinal bleeding or kidney damage if used in excessive doses over prolonged periods.

It’s crucial to weigh these potential risks against the benefits when considering medication options for chronic pain management.

The Relationship Between Chronic Pain and Personality Factors

After considering the potential risks and side effects of medication for chronic pain, it’s essential to explore the relationship between chronic pain and personality factors.

Research suggests that certain personality traits can influence an individual’s experience of chronic pain.

Factors such as neuroticism, extraversion, and conscientiousness have been linked to how individuals perceive and cope with ongoing pain conditions.

Moreover, individuals with high levels of neuroticism may be more likely to experience greater distress from chronic pain.

On the other hand, those with higher conscientiousness may display better adherence to treatment plans and engage in healthier lifestyle choices that could positively impact their experience of chronic pain conditions.

These findings support the notion that understanding an individual’s personality traits can play a crucial role in tailoring treatment approaches for managing chronic pain effectively.

Recent Research on Psychiatric Aspects of Chronic Pain

Recent research on psychiatric aspects of chronic pain has shed light on the intricate relationship between physical and mental well-being.

Studies have indicated a strong association between chronic pain and conditions such as obsessive-compulsive disorder (OCD), bipolar disorder, and premenstrual dysphoric disorder (PMDD).

This emerging data underscores the significance of holistic treatment approaches that address both the physical symptoms of chronic pain and the associated psychiatric disorders to ensure comprehensive care for individuals experiencing these co-occurring conditions.

Furthermore, ongoing studies have revealed potential correlations between chronic pain and personality factors, shedding light on how individual traits may influence one’s experience of persistent pain.

These findings offer valuable insights into personalized treatment strategies aimed at addressing not only the physical manifestations of chronic pain but also considering an individual’s unique psychological makeup in developing effective management plans.

Conclusion

In conclusion, managing chronic pain and mental health requires a multi-faceted approach.

By implementing low-impact exercises, mindfulness practices, and an anti-inflammatory diet, individuals can expect practical and efficient relief.

These strategies hold the potential to significantly improve quality of life and daily activities for those dealing with chronic pain.

For further guidance and support, consider seeking professional treatment options or exploring psychotherapeutic treatments to address both physical and mental well-being.

Ultimately, taking proactive steps towards managing chronic pain can lead to profound improvements in overall wellness and resilience.

FAQs

How does chronic pain affect mental health?

Chronic pain, like ongoing low back pain or osteoarthritis (OA), can lead to mental health issues such as stress and depression because it makes day-to-day life harder.

What is comorbidity in relation to chronic pain and mental health?

Comorbidity means having more than one illness at the same time, so someone with chronic pain might also have a mental health condition, and doctors need to treat both.

Can chronic pain lead to problems with thinking or memory?

Yes, people dealing with long-term pain sometimes face challenges like dementia which can make it hard for them to think clearly or remember things well.

Are there conditions where people feel pain differently due to their mental state?

There are cases like malingering where a person might pretend to have pain for some benefit, while in factitious disorder they actually create symptoms just because they want the role of being sick.