Psychological and Social Aspects of Chronic Pain

Steven Stanos, DOCenter for Pain Management

Rehabilitation Institute of ChicagoDept. Physical Medicine & Rehabilitation

Northwestern University Feinberg School of Medicine

Outline

Evolution of pain psychology

Diagnoses

• Pain disorder ,Depression

• Health Anxiety, Hypochondriasis

• Somatization disorder, PTSD

Losses and Gains

Chronic Pain Interrupts

• Behavior

• Function

• Identity

• Cognition

Harris S et al. Pain. 2003;105:363-370.

Gate Control Theory

Melzack R. In: Cousins MJ, Bridenbaugh PO, eds. Neural Blockade in Clinical Anesthesia and Management of Pain. 3rd ed. Philadelphia, Penn: Lippincott Williams & Wilkins; 1998.

Gate Control Theory

A. Sensory

B. Affective

C. Evaluative

Melzack et al. Pain. 1982;14:33-43.

Body Self NeuromatrixINPUTSCognitive

Evaluative

Sensory-

Discriminative

Motivational-

Affective

OUTPUTSPain Perception

Action Programs

Stress-Regulation

Programs

C

A

S

Time Time

Melzack R. J Dent Education 2001;65:1378-82.

The PAIN Patient

• Demoralized from continued quest for relief• Cascade of ongoing stressors• In a state of “medical limbo”• Inactivity leads to preoccupation with “the body

in pain”• Change from active to more passive coping with

the pain

“First off, you’re not a nut. You’re a legume.”

“Yellow Flags”

• Maladaptive beliefs• Expectations and pain

behavior• Reinforcement of pain• Heightened emotional

activity• Job dissatisfaction• Poor social support• Compensation

Cairns MC, Spine 2003; 28(9):953-59

Pain and Mood Disorders: Community Sample

0

5

10

15

20

25

30

35

40

MDD Panic GAD

Arthritis

No arthritis

Migraine

No Migraine

LBP

No LBP

Per

cent

age

McWilliams LA, et al. Pain 2004: 111(1-2).

Psychodynamic Theories

• Deep rooted personality conflicts

• Pain & underlying emotional conflicts

• Freud: “pain” emotional response to an actual loss or injury

• “pain” as “mourning”

Developmental Theory George Engel, MD

• “Psychogenic pain”• “Library” of pain experiences• Pain acquires “meaning”• Pain used unconsciously to resolve

developmental conflicts

1. Absolving one of guilty feelings

2. Focus on pain enables individual to displace attention

3. Enables role of victimization

Engel GL. Am J Med. 1959;26:899-918.

“Conversion V”

Neurotic triad

Hypochondriasis (Hs)

Depression (D)

Hysteria (Hy)

Hs

D

Hy

Hanvik. J Consult Psychol 1951;15.

Richard Sternbach/ Learning Theory

• Trait theory

• Personality factors predispose patients to CP

• Pain predispose one to neuroticism and hypochondriacal worries

• CP no purpose

Sternbach RA, 1974.

Cognitive Revolution: Dennis Turk, PhD

• Attributions, efficacy, expectations

• Personal control, problem solving within cognitive-behavioral perspective

• BioPsychoSocial approach

Turk DC, Flor H. Pain 1984;19:209-33.

Diathesis-Stress

DIATHESIS COPING

STRESS

Turk DC, Flor H. Pain 1984;19:209-33.

Gatchel’s 3-Stage Model

Stage I: Normal emotional reaction during acute phase

Stage II: Behavioral and psychological reactions and problems

Stage III: Acceptance or habituation to “sick role”

Gatchel RJ, 1991

PAIN

Biological

Psychological Social

ACCEPTANCEACCEPTANCE“Living with pain without reaction, disapproval, or attempts to reduce or avoid it . . .

A disengagement from struggling with pain.”McCracken LM, Pain; 1998.

McCracken LM, J Back Musculoskel Rehab; 1999.

depression

• Costs (1990 vs. 2000)• Treatment increased

50%• Costs increase 7%• 2000

– $26 billion (direct medical costs)

– $5 billion (suicide)– $51 billion (workplace

costs)

• Psychiatric

• Behavioral

• Physical

Greenberg PE, et al. J Clin Psychiatry 2003;64:1465-75.

Cassano eta l, J of Psychosom Research, 2002

Depression: Common Behavioral & Physical Symptoms

Behavioral• Interpersonal friction• Anger• Avoidance• Reduced productivity• Substance use/abuse• Victimization• Social withdrawal

Physical• Fatigue• Insomnia/

hypersomnia• Appetite changes• Pains and aches• Muscle tension• Gastrointestinal upset

From DSM-IV, American Psychiatric Association, 1994.

Major Depressive DisorderA. 5 or > of following symptoms, present during same 2-week period

– Depressed mood most of the day– Diminished interest or pleasure– Weight loss– Insomnia/hypersomnia– Psychomotor agitation or

retardation– Fatigue or loss of energy– Feelings of worthlessness guilt– Diminished ability to think/

concentrate, or indecisiveness– Recurrent thought of death

B. Symptoms cause clinically significant distress or impairment

C. Symptoms not caused by effects of a substance or general medical condition

D. Not better accounted for by bereavement, marked functional impairment, morbid preoccupation with worthlessness, SI, psychotic symptoms or psychomotor retardation

Depression: DSM-IV

Emotional– Guilt– Suicide– Lack of interest– Sadness

Physical– Lack of energy– Sleep disturbance– Appetite change– Change in psychomotor

function– Decreased concentration

Associated Symptoms– Pain– Worry– Irritability– Obsessive rumination– Anxiety– Brooding– Tearfulness

Predictors of Depression in Chronic Pain

• Pain intensity• Frequency severe pain experienced• Number of painful areas• Psychosocial factors

– low self efficacy– poor coping– poor problem solving

• Functional disability

Sullivan, Turk. Bonica’s Management of Pain.2001.

DSM / Pain Disorder History

DSM II ’68: No diagnosis

DSM III ‘80: “Psychogenic Pain Disorder”

Pain “grossly in excess”

Etiological Ψ Disorder:

1. temporal relationship

2. pain allows avoidance

3. promotes emotional support & attention

DSM III – R ’87: “Somatoform Pain Disorder”

“Preoccupation with pain for at least 6 months”

DSM IV ’94: “Pain Disorder”

DSM-IV Pain Disorder

• Pain in 1 or > anatomical sites is predominant focus of clinical presentation and of sufficient severity to warrant clinical attention

• Pain causes significant distress or impairment in social, occupational, or other areas of functioning

• Psychological factors judged to have important role in onset, severity, exacerbation, or maintainment of pain

• Symptom or deficit is not intentionally produced or feigned

• Not better accounted for by mood disorder, or psychotic disorder

Pain Catastrophizing

Pain-related Anxiety and Fear

Helplessness

Increased:

Pain

Psychological Distress

Physical Disability

Self-efficacy

Pain Coping Strategies

Readiness to Change

Acceptance

Decreased:

Pain

Psychological Distress

Disability

Keefe FJ, et al. Annu Rev Psych, 2005.

ANGERANGER

Fernandez, Turk.

Pain 1995;61.

Okifuji A.

J Psychsom Res

1999;47.

ANXIETYANXIETY

McCracken, Gross. McCracken, Gross.

J Occ RehabJ Occ Rehab 1998;8. 1998;8.

FEARFEAR

Health AnxietyChronic pain patients• Convinced disease present and

less able to accept medical reassurance1

• Believe pain was caused by a physical condition2

• 47% of patients unsure of diagnosis and 20% disagreed (linked to affective distress)3

• Chronic pain sample4: 51% severe disabling health

anxiety37% hypochondriasis

1. Pilowsky,et al,1976; 2.Keefe,et al,1986;3.Geisser,et al.1998 4. Rode, et al, 2006.

Hyopochondriasis

• Preoccupation with fears of having, or the idea that one has, a serious disease based on the person’s misinterpretation of bodily symptoms.

– Prevalence between 5% and 9%– Coexist with anxiety, depressive, or somatoform

disorders– Hostility, antagonism, and dissatisfaction with medical

care.

Noyes R, et al. J Nerv & Mental Dis 1997.

Why doesn’t my patient want to get better ?”

Dersh, Polatin, Leeman. J Occ Rehab 2004;14.

Secondary Gain

Internal• Gratification preexisting unresolved

dependency & revengeful strivings• Attempt to elicit care-giving• Ability withdraw from unpleasant or

unsatisfactory life roles• Adoption of “sick role”• Convert socially unacceptable disability to a

socially acceptable one

Secondary Gain

External• Financial awards

– Wage replacement– Settlement– Debt protection

• Protection from legal and other obligations• Job manipulation• Vocational retraining and skill upgrade

Dersh, Polatin, Leeman. J Occ Rehab 2004;14.

Secondary Losses

• Economic• Meaningfully relating

to society via work• Work social

relationships• Meaningful and

enjoyable family roles• Respect • Community approval

• Negative sanctions from family

• New role not comfortable

• Social stigma of being “disabled”

• Guilt over disability

Tertiary gains and losses

Gains1. Gratification of

altruistic needs

2. Change in role

3. Decrease family tension

4. Resolve marital difficulties

Losses1. Increased

responsibilities

2. Emotional effect

3. Disturbance within the relationship

4. Guilt created by the ill individual

5. Financial hardship

A discrete period of intense fear or discomfort, in which four of the following symptoms developed abruptly and reached a peak within 10 minutes

Panic Attack

• Palpitations, accelerated heart rate

• Sweating• Trembling or shaking• Sensations of shortness of

breath or smothering• Feeling of choking• Chest pain or discomfort• Nausea or abdominal pain• Feeling dizzy, lightheaded,

faint• Depersonalization

• 10. Fear of losing control or going crazy

• 11. Fear of dying• 12. Paresthesias• 13. Chills or hot flushes• 14. Persistent concern about

having additional attacks• 15. Worry about implications• 16. Significant change in

behavior related to attacks

From DSM-IV, American Psychiatric Association, 1994.

Somatoform disorders

• Somatization disorderSomatization disorder

• Pain disorderPain disorder

• HypochondriasisHypochondriasis

• ConversionConversion

• Undifferentiated somatoformUndifferentiated somatoform

Somatization

“a tendency to experience and communicate somatic distress and symptoms

unaccounted by pathological findings, to attibute them to physical illness, and to

seek medical help for them”

- Lipowski

Somatization Disorder

• History of many ongoing physical complaints beginning before age 30 yrs causing significant impairment in social, occupational, or other areas of function

• Each of following symptoms:1. (4) pain 3. (1) sexual2. (2) G.I. 4. (1) pseudoneurologic

• Prevalence: 0.13% and 0.4% (smith, 1991)

• Strong association with childhood physical & sexual abuse

Conversion Disorder• One or more symptoms or deficits affecting voluntary

motor or sensory function that suggest a neurologic or other general medical condition

• Psychological factors associated with symptoms, initiation or exacerbation preceded by conflicts of other stressors

• Symptoms not intentionally produced or feigned• Not explained by general medical condition or substance• Causes significant distress or impairment• Specify type of symptom: motor, sensory, seizure, or

mixed

From DSM-IV, American Psychiatric Association, 1994.

Posttraumatic Stress DisorderA. Exposed to traumatic event in which both of following were

present:

1.Event involved actual or threatened death or serious injury

2.Person’s response involved intense fear, helplessness, or horror

B. Traumatic event persistently re-experienced in 1 or > following ways

1.Recurrent & intrusive distressing recollections

2.Recurrent distressing dreams

3.Acting or feeling as if the traumatic event were recurring

4. Intense psychological distress at exposure to cues

5.Physiological reactivity on exposure to cues

PTSD Cont.C. Persistent avoidance of stimuli

associated with the trauma and numbing of general response of 3 or more:

1.Efforts to avoid thoughts, feelings, or conversations

2.Efforts to avoid activities, places, or people that arouse recollections

3. Inability to recall important aspects of trauma4.Diminished interest or participation in activities5.Detachment, estrangement6.Restricted range of affect7.Sense of forshortened future

From DSM-IV, American Psychiatric Association, 1994.

PTSD Cont.

D. Persistent symptoms of increased arousal, as indicated by 2 or more:1. Difficulty falling/ staying asleep

2. Irritability or outbursts of anger

3. Difficulty concentrating

4. Hypervigilance

5. Exaggerated startle response

From DSM-IV, American Psychiatric Association, 1994.

Personality Disorder

Long-standing pattern of disordered behavior and emotions with symptoms severe enough to interfere with the individual’s ability to:

function

interact with others

maintain reality testing(DSM-IV)

Epidemiology of PD

• PD in general population: 0.5%~3%1

• PD in persons presenting to psychiatry 2%~16%2

• PD in chronic pain: 31%~59%

dramatic (B) cluster & anxious (C) cluster3,41. Amer Psych Ass.: Diagnostic and Statistical

Manual of Mental Disorders, 1994.2 Kaplan H, Sadock B. 1991.

3. Reich J. Thompson D.1987.4. Reich J, Tupin JP, Abramowitz SI. 1983.

Personality Disorders

Axis I: Clinical syndromes

Axis II: Personality disorders

Cluster A (odd / eccentric)

Cluster B (dramatic / emotional)

Cluster C (anxious / fearful)

Axis III: General Med Condition

Axis IV: Psychosocial & environmental problems

Axis V: Global assessment of functioning (GAF) scale (0-100)

Personality or Personality Disorder?

• Personality traits: Enduring patterns of perceiving, relating to, and thinking about the environment and oneself, are exhibited in a wide range of important social and personal contexts

• Personality disorder: Enduring pattern of inner experience & behavior that deviates markedly from the expectations of the individual culture, is pervasive and inflexible, has an onset in adolescence or early childhood, is stable over time, and leads to distress or impairment.

Personality Disorder in DSM-IV

• Cluster A (odd/eccentric cluster): Paranoid, Schizoid, and Schizotypal

• Cluster B (dramatic/emotional cluster): Antisocial, Borderline, Histrionic, and

Narcissistic

• Cluster C (fearful/anxious cluster): Avoidant, Dependent, and Obsessive-

compulsive

Parking and PD

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