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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
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Outline
Evolution of pain psychology
Diagnoses
• Pain disorder ,Depression
• Health Anxiety, Hypochondriasis
• Somatization disorder, PTSD
Losses and Gains
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Chronic Pain Interrupts
• Behavior
• Function
• Identity
• Cognition
Harris S et al. Pain. 2003;105:363-370.
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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.
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Gate Control Theory
A. Sensory
B. Affective
C. Evaluative
Melzack et al. Pain. 1982;14:33-43.
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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.
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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
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“First off, you’re not a nut. You’re a legume.”
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“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
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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).
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Psychodynamic Theories
• Deep rooted personality conflicts
• Pain & underlying emotional conflicts
• Freud: “pain” emotional response to an actual loss or injury
• “pain” as “mourning”
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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.
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“Conversion V”
Neurotic triad
Hypochondriasis (Hs)
Depression (D)
Hysteria (Hy)
Hs
D
Hy
Hanvik. J Consult Psychol 1951;15.
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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.
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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.
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Diathesis-Stress
DIATHESIS COPING
STRESS
Turk DC, Flor H. Pain 1984;19:209-33.
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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
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PAIN
Biological
Psychological Social
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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.
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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.
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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
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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
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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
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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
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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”
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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
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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.
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ANGERANGER
Fernandez, Turk.
Pain 1995;61.
Okifuji A.
J Psychsom Res
1999;47.
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ANXIETYANXIETY
McCracken, Gross. McCracken, Gross.
J Occ RehabJ Occ Rehab 1998;8. 1998;8.
FEARFEAR
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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.
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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.
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Why doesn’t my patient want to get better ?”
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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
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Secondary Gain
External• Financial awards
– Wage replacement– Settlement– Debt protection
• Protection from legal and other obligations• Job manipulation• Vocational retraining and skill upgrade
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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
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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
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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.
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Somatoform disorders
• Somatization disorderSomatization disorder
• Pain disorderPain disorder
• HypochondriasisHypochondriasis
• ConversionConversion
• Undifferentiated somatoformUndifferentiated somatoform
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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
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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
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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.
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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
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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.
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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.
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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)
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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.
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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)
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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.
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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
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Parking and PD