CHAPTER 29 PSYCHOLOGICAL SYNDROMES
1. Which psychiatric disorders are associated with chronic pain?
Pain may be the chief complaint in a number of psychiatric disorders; conversely, pain can lead to disturbing psychological symptoms. Pain is often the presenting symptom in somatoform disorders. Most patients experiencing chronic pain report depressive symptoms at some point during the course of their condition. Pain is rarely the presenting symptom of a delusional disorder. Individuals with chronic pain secondary to accidents, often motor vehicle accidents, may exhibit symptoms of posttraumatic stress disorder. Whereas anxiety is the most common concomitant of acute pain, depression is the overriding symptom in chronic pain. Anxiety may also contribute to fixation on symptoms.
2. What is the DSM-IV?
The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition—DSM-IV—is the official manual of the American Psychiatric Association. Its purpose is to provide a framework for classifying disorders and defining diagnostic criteria for the disorders listed. A multiaxial system is employed to foster systematic and comprehensive assessment of the various clinical domains. Five axes are described; the first three relate to clinical diagnoses.
Axis I: Clinical disorders and other clinical conditions that may be the focus of clinical attention
Axis II: Personality disorders and mental retardation
Axis III: General medical conditions
Axis IV: Psychosocial and environmental problems
Of note is the fact that the DSM has recently undergone revisions, and some changes are relevant to the field of pain.
DEPRESSIVE DISORDERS
3. Is there an association between chronic pain and depression?
Depression is considered to be the most common emotional response to persistent pain. However, accurate assessment may be difficult. Significant depressive symptoms are present in 30% to 87% of patients with chronic pain, and about 35% of chronic pain patients meet criteria for a major depressive episode. Insomnia, difficulty with concentration, and generalized fatigue are reported in 34% to 53% of patients not meeting stringent criteria for a major depressive disorder. Patients most often ascribe such symptoms as secondary to their pain, rather than as true depression, leading to false negatives in the statistical analysis of incidence of depression.
4. What is the cause-and-effect relationship between pain and depression?
The cause-and-effect relationship between pain and depression is undetermined. Rates of depressive symptoms are consistently higher among populations of chronic pain patients (CPP). However, there have been few studies comparing the incidence of depressive symptoms in CPP with incidence in other populations of chronically ill medical patients.
Clinicians and researchers continue to debate which comes first, depression or chronic pain. Those adhering to a “pain prone” or “masked depression” (see Question 6) orientation have proposed that underlying depressive symptomatology is expressed through pain behavior. Proponents of the diathesis-stress perspective believe that the physical and psychological stress of the chronic pain experience contributes to the development of depressive symptoms.
One fact is certain: it is difficult to assess depression in patients with pain.
5. Name some impediments to the accurate assessment of depression in chronic pain populations
Several issues lead to underdiagnosis of depressive symptoms. Physicians and patients often ascribe the loss of energy, decreased interest, disrupted sleep pattern, appetite disturbance, and social withdrawal to a normal reaction to severe pain and disability. Prolonged duration of these symptoms, however, may be indicative of a depressive syndrome. Patients may become defensive talking about their feelings because of societal stigmas regarding mental illness and may be reluctant to portray themselves as “weak.” Finally, shifting the focus to psychological issues may be threatening for the patient, because of fear that the examiner will conclude that the pain complaints are secondary to depression and not “organic” in nature.
6. Are chronic pain syndromes a physical manifestation of a “masked depression”?
Traditional psychoanalytic theory postulated that pain could be a face-saving means of expressing underlying depressive symptomatology; hence, a masked depression. Individuals with such interpsychic dynamics had been labeled as “pain-prone personalities.” This has been a pervading construct, and it continues to have supporters.
However, more recent research and literature reviews point to depressive symptoms emerging as a consequence of the experience of chronic pain. The day-to-day burdens of chronic pain have been described as “major fateful events” that result in great psychological distress and significant, negative changes in lifestyle. Individuals with a biological predisposition for depression (the “scar hypothesis”) may be more vulnerable to the development of depressive symptoms as their condition worsens. In short, there is movement away from the idea of pain-prone personalities.
7. Is there a possible physiological construct that would explain the diathesis-stress hypothesis?
In animal models, chronic pain paradigms are associated with activation of the hypothalamo-pituitary-adrenal axis. Chronic pain acts as an “inescapable stress.” The inability to avoid or escape from stress promotes learned helplessness and is associated with depressive symptoms.
8. What are the diagnostic criteria for a major depressive disorder?
To be diagnosed with a major depressive disorder, the patient needs to have experienced five of the following over at least a 2-week period, and occurring nearly every day: depressed/sad mood, markedly diminished interest or pleasure, significant weight loss or gain, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue, feelings of worthlessness or excessive or inappropriate guilt, diminished cognitive abilities, recurrent thoughts of death, or suicidal ideation. These symptoms should not be better accounted for by another psychiatric disorder, medical illness, or reaction to medication. There is no history of a manic episode. These symptoms should represent a change from the patient’s previous affective state.
9. How does the DSM-IV address psychological symptoms in patients with physical illness?
In DSM-III-R the focus was on psychological disturbance, and symptoms “clearly due to a physical condition” were not included. This stipulation has been eliminated from the DSM-IV. Therefore, more individuals with chronic pain syndromes may meet criteria for specific psychiatric disorders.
10. What is the relationship between chronic pain and suicide risk?
The relationship between chronic pain and suicide risk is multifaceted. Consider the following:
Chronic pain and illness contribute to depressive symptoms.
Chronic medical illness has been labeled a motivating factor in approximately 25% of all suicides. The experience of chronic pain is likely to be a significant factor in promoting suicide ideation and attempts.
Depressive symptoms and suicide are strongly associated.
45% to 70% of completed suicides have a history of mood disorder.
Concomitant psychiatric syndromes can impair adjustment to the impact of chronic pain.
25% of patients with at least one general medical illness report suicidal ideation, and 9% are reported to have made a suicide attempt.
Some surveys have suggested that up to 50% of patients with chronic nonmalignant pain have contemplated suicide at some point.
Pain that is either inadequately controlled or poorly tolerated further increases risk.
The duration of pain may increase risk.
Lack of social supports also increases vulnerability to suicidal ideation and attempts.
A personal and/or family history of substance abuse puts the patient at greater risk.
Passive and other maladaptive coping strategies are reflective of, and contribute to, a greater sense of helplessness and hopelessness.
Because many pain patients view themselves as disabled by their pain, often with little hope for improvement, they are at risk for affective disorders and suicidal potential.
Good work status decreases suicidal risk, whereas the loss of employment increases vulnerability.
11. Do chronic pain patients acknowledge their depression and suicidal feelings?
Willingness of any individual to confide depression, suicidal feelings, or other disturbing emotions depends on a variety of factors. One survey, conducted by a pain self-help organization, found that patients with nonmalignant pain reported that depression was among the most disturbing aspects of the chronic pain experience. Fifty percent of these individuals commented that profound feelings of hopelessness had led them to consider suicide.
Clearly, the development of trust within the doctor-patient relationship is a key factor in providing the patient with a sense of personal safety to acknowledge feelings of desperation. The degree of depression will mediate both suicidal intent and willingness to disclose. Research has documented that suicide intent among chronic pain patients is relatively low in comparison to psychiatric populations. Should a patient express intent, it is essential that immediate action be taken to prevent self-injury.
12. Are there data on suicide completion within the chronic pain population?
Although it is generally felt that the chronic pain population is at significant risk for suicide, there is a dearth of literature on the subject. White men and women, aged 35 to 64 years and receiving workers’ compensation for pain, were shown to be at two to three times greater risk for suicide than the general population. However, this rate was significantly lower than that seen in a psychiatric population. Despite the study limitations, the authors concluded that CPP are at significant risk for suicide.
13. What depressive symptoms are seen in patients with chronic pain, even without true depression?
CPPs commonly experience a significant decrease in their level of energy. Pain is physically and psychologically wearing, and analgesic, antidepressant medications and a more sedentary lifestyle can contribute to fatigue. Sleep disturbances are also quite common, with individuals experiencing difficulty falling asleep or being awakened during the night because of pain. Pain and/or medication may impair concentration and decrease energy. Irritability, frustration, and dysphoria can parallel the level of pain.
14. What is dysthymia?
Dysthymic disorder refers to persistent, low-level, depressive feelings. It appears to be fairly common among chronic pain patients. These individuals tend to view the “glass as half empty” and describe their mood as “blue” or “down in the dumps” more often than not. Characteristics of dysthymia include long-standing lack of interest in anything, low self-esteem, and a propensity for self-criticism. Dysthymic patients describe their pessimistic outlook as normal for them (egosyntonic). Major depressive episodes are a marked departure from the patient’s normal euthymic mood. Depressed patients describe their pessimistic outlook as abnormal (egodystonic).
15. List the diagnostic criteria for dysthymic disorder
The following are the diagnostic criteria for dysthymic disorder:
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