Pain and Affective Disorders

Daniel M. Rockers

Scott Fishman

Happiness is not being pained in body or troubled in mind.

—Thomas Jefferson, 1743–1826

Most patients in chronic pain have comorbid psychiatric conditions, ranging from mild (e.g., anxiety, adjustment, and dysthymic disorders) to severe (e.g., delusional and psychotic disorders). The chronology of these conditions often makes it difficult to determine whether the pain caused the psychiatric condition or the psychiatric condition caused the pain, or whether the condition and the pain occurred simultaneously. Depression and anxiety are known to enhance perceptions of pain and may be a predominating component of some pain syndromes. Some psychiatric conditions may even manifest as pain or painlike symptoms. For example, it has been suggested that complex regional pain syndrome (CRPS) is a conversionlike disorder (Ochoa and Verdugo, 1995). Many psychiatric conditions are caused by or are accompanied by neurochemical abnormalities. These abnormalities may help determine what type of pain medication is prescribed and may have a significant affect on the pain condition. For example, serotonin is considered an important factor in pain as well as mood states. The extensive overlap of drugs used to treat pain with those prescribed for psychiatric disorders suggests that common mechanisms may be at work in the two conditions. Because of this, comprehensive pain management requires an understanding of basic principles of psychiatric diagnoses and how they might affect or be affected by pain.

I. MOOD DISORDERS

Mood disorders are often split into two general categories: unipolar and bipolar disorders. Unipolar disorders include major depression and dysthymia (a less severe variant of depression); bipolar disorders include bipolar I (combination of manic and depressive episodes), bipolar II (combination of depressive and hypomanic episodes), and cyclothymia (a less severe variant of bipolar disorder).

1. Major Depression

(i) Description

Depression is the psychologic issue most frequently associated with chronic pain. Major depression is found in 8% to 50% of patients with chronic pain, and dysthymia may be seen in more than 75% of patients with chronic pain. At particular risk for major depression are women—those of lower socioeconomic status, those separated or divorced, those with a family history of depression, those with negative stressful events, those not having a confidant, and those living in urban areas.

For a clinical diagnosis of depression, the following are required: (a) at least 2 weeks of either depressed mood or the loss of interest or pleasure in nearly all activities, and (b) any four of the following additional symptoms: changes in appetite or weight, sleep difficulties, changes in psychomotor activity, decreased energy, feelings of worthlessness or guilt, difficulty in thinking, recurrent thoughts of death, or suicidality. In addition, these symptoms must substantially impair an individual’s social, occupational or other functioning.

It is important to distinguish between clinical depression and naturally occurring mood states such as bereavement or normal sadness. The use of rapid assessment instruments such as the Beck Depression Inventory or the Hamilton Rating Scale for Depression (HAM-D) augments and documents interview impressions but does not replace them. Collateral information can be used as well; patients themselves may be poor historians or may not recognize when these feelings began to emerge—some of the symptoms include an inability to think, concentrate, or make decisions—and these feelings may impair their ability to recall. Depression may manifest in a number of various symptom constellations; for example, children may experience depression more in terms of somatic complaints, social withdrawal, or irritability.

(ii) Concerns

Suicide risk is greatest for those depressed patients with psychotic functioning, a history of past suicide attempts, a family history of suicides, or concurrent substance abuse. The astute practitioner is aware of when a depressed patient exhibits a loss of impulse control or when cognitive faculties are compromised to the point of poor judgment. When patients are judged to present a significant risk of suicide, standard precautions should be taken, such as having them sign a written contract promising not to harm themselves, determining appropriate social support, and helping elucidate reasons to continue living. For patients who cannot be left alone, family or friends’ assistance should be secured or hospitalization should be considered. When treating those in imminent danger of harming themselves or others, one should remain mindful that most state laws mandate that any treating clinician, including a pain specialist, must take action to ensure safety, as well as formal psychiatric evaluation.

(iii) Course and Treatment

Symptoms of depression may develop over days or weeks; there may be a prodromal phase characterized by slight anxiety or mild depressive symptoms. The duration of this stage is variable. An untreated depression typically lasts 6 months or longer, regardless of age of onset. Although most patients experience remission, a significant minority (20% to 30%) continue to have symptoms over a period of 1 to 2 years. In addition, two out of three will experience a recurrence.

There are many contemporary models of depression, including cognitive, learned helplessness, reinforcement, biogenic amine, neurophysiologic, and final common pathway. Cognitive or psychologic models suggest cognitive and behavioral treatments, whereas biologic models tend to suggest pharmacologic treatments. Beck’s cognitive triad characterization of depression is that the self is seen in a negative light, the current situation is viewed negatively, and the future is viewed negatively. These cognitions are very common in a chronic tormenting condition such as pain. According to Seligman’s learned helplessness model, the depressed person views his or her responses to the environment as ineffective—they will not bring relief.

Many patients with chronic pain experience depressive hopelessness about their pain condition, and it is easy to experience negative thoughts or feelings of helplessness when faced with ceaseless pain. The pain seems to (and frequently does) control life. The experience is one of a tormenting, unremitting taskmaster. Psychosocial treatment of unipolar depression consists of behavioral therapy, cognitive-behavioral therapy, or interpersonal therapy. These treatments are discussed in Chapter 15 and can result in significant reduction in depressive symptoms and can maintain their effect after treatment is terminated. The goal in these treatments is for the patients to (a) accept the chronicity of their pain condition, (b) restructure negative beliefs, and (c) experience a sense of self-efficacy in life. Acceptance is crucial, and without it, forward progress out of the depressive state is unlikely.

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