psychological disorders and chronic pain there's been significant work attempting to...

Chapter 2 Psychological Disorders and Chronic Pain

Psychological Disorders and Chronic PainThere's been significant work attempting to

differentiate " functional" pain patients from" organic" pain patients.

Sternbach (1974) challenged the utility and the validity of attempting to make a functional – organic the economy when dealing with chronic pain

Psychological Disorders and Chronic PainHence, the biopsychosocial model of pain attempts to

avoid overly simplistic biomedical disease models.As pain becomes more chronic, the psychosocial

variables play an increasingly dominant role in the maintenance of pain behaviors and suffering

Psychological concomitants of pain There is evidence to suggest the chronic pain patients

develop specific psychological problems because of the failure to alleviate their pain

Sternbach, et al (1973) compare the MMPI profiles of the group below back pain patients with less than six months and a group of chronic low back pain patients with more than six months

Psychological concomitants of pain

Chronic pain patients had more elevated scales 1,2 &3(hypochondriasis, depression, and hysteria) which are typically known as the neurotic triad

It is hypothesized that chronic pain wears down psychological resources

A conceptual model of the transition from acute pain to chronic pain.Gatchel (1991, 1996) propose a broad conceptual

model that hypothesizes three stages that may be involved in the transition of acute low back pain and chronic low back pain disabilityStage one is associated with emotional reactions such as

fear, anxiety, worry and so forth as a consequence of the perception of pain during the acute phase

A conceptual model of the transition from acute pain to chronic pain.Stage II is associated with a wide array of behavioral

psychological reactions and problems such as learned helplessness depression distress anger in somatizationEven though there's relationship between depression

and pain the nature of the relationship is inconclusive. (Chicken or egg)

A conceptual model of the transition from acute pain to chronic pain.Studies focusing on psychiatric disorders associated with

pain showed even when some what controversial category diagnosis such as somatoform pain disorder was excluded, 77% of the patient's met Lifetime diagnostic criteria and 59% demonstrated current symptoms for at least one psychiatric diagnosis

Most common diagnoses were major depressive disorders, substance use disorders and anxiety disorders

51% met criteria of these met criteria for at least one personality disorderThese are all base rates that are higher than the general

population

A conceptual model of the transition from acute pain to chronic pain.

There were strikingly high rates of psychopathology in this chronic pain population

Very important, was the finding that of those patients with a positive lifetime history for psychiatric syndromes 54% of those with major depression, 94% of those with substance use disorders and 95% of those with anxiety disorders and experienced the syndrome before the onset of their back pain


These were the first results to suggest that certain psychiatric symptoms appear to precede chronic low back pain (substance use disorders and anxiety disorders), whereas as others (specifically, major depression) develop either before or after the onset of their low back pain (Gatchel & Dersh, 2002)

Returning to Gatchel's model it is assumed the patient's bring with them certain predisposing personalities and psychological characteristics which may be exacerbated by the stress of pain


As this problem persisted leads into the progression of stage III which can be viewed as the acceptance or adoption of the sick role

Superimposed on this model is the reality of physical deconditioning syndrome (Mayor and Gatchel 1988)This refers to significant decrease in physical capacity (strength,

flexibility and endurance) due to disuse and resultant atrophy of the injured area

There is a two-way pathway between the physical deconditioning the foregoing stages research has clearly demonstrated the physical deconditioning can

feedback and have a negative effect on emotional well-being. Conversely, negative emotional states like depression can feedback negative effects on physical functioning.

A conceptual model of the transition from acute pain to chronic pain. Data supporting the conceptual model

Rates of major depressive disorder range from 34-57% in studies with patients with chronic low back pain versus 5% to 26% in the general population

Recent studies also lend support to Gatchell model showing that elevated rates of psychopathology significantly decrease following intensive rehab

Studies also support that psychosocial variables are better predictors of pain and disability chronicity more so than physical factors

Again, such studies support a greater understanding regarding psychopathologies present in chronic pain patients but the manner in which they emerge depends of the premorbid characteristics of the particular patient

Polatin et all (19993) study reviewed high rates of psycholopathology among chronic pain compared to general population Chronic low back pain pts displayed increased prevalence of depressive disorders, anxiety

do, substance use and "somatization" Not only does this pathology lead to the chronic pain but also contribute to its chronicicty.


This psychopathology showed pathology decrease following an intensive rehabilitation.

Vittengl et al (1999( decreased prevalence of Axis II personality disorders 6 months after completion of the treatment program

CLASS ASSIGNMENT TO EVALUATE THIS STUDYNote Gatchel et al model support that psychosocial

factors contribute more to the chronicity of pain that physical factors.


Certain studies explored Axis I & II Dx as predictors of poor reintegration into the work force. However, somewhat mixed results. Gatchel, Polatin, Mayer and Garcy (1994) shows no significant results

regarding the number of Axis I and Axis II dx and type was found to be predictive of a patient’s ability to return to work.

However, Burton, Polatin and Gatchel (1997) found that the number of Axis I disorders,, a past dx of substance abuse and a past or current dx of anxiety disorder, dx of borderline personality, and a variety of other psychosocial variables were predictive of patients not returning to work after completion of a rehab program.

The Psychosocial Disability Factor Investigators have said that only a small amount of the total disability

phenomenon on in some ones complaining of CLBP can be due to physical impairment.

Most cases of lower back pain are considered soft tissue injury that can not be verified on physical examination.

Chronic Pain and Specific Psychological Disorders.Though there is a unique relationship between

psychopathology and chronic pain, a model consistent with Gatchel model is merging as the overarching theoretical perspective : diathesis-stress model

Chronic Pain and DepressionThe research clearly establishes this relationship as to whether

it is causal or subsequent relationshipThe Prevalence among the general population – 5%-17%Among the chronic pain low back 45%-65%Among the upper extremity chronic pain is 80%Issues is the definition of depression

Is it simply Mood , a symptom, a syndrome or full dx

Chronic Pain and Specific Psychological Disorders.

Therefore assessment has varied from self report to observation to charting etc

In assessment there is “criterion contamination” symptoms with pain and depression overlap Name a few??

In light of research suggesting that depression can be an antecedent, consequence or concomitant , Fishbain et al (1997) proposed 5 hypotheses to account for these relationships Antecedent hypothesis Consequence hypothesis Scar hypothesis Cognitive behavioral mediation model Common pathogenic mechanism model


In the above, c,d,e support the diathesis stress model b the way of the psychological being the diathesis and pain the stress

Chronic Pain and Substance Abuse Studies have shown high prevalence of SA in CPP Current prevalence is 15-28%


Lifetime prevalence is 23-41% Polatin et all (1993) –study- 94% of CPP with lifetime sSA had

the onset before the pain CPP are at increased risk for a new SA d/o during the 5 years

following the onset of CPP than any other time in life Current opiod analgesic addiction is 3-16% SA leads to increase risk of other d/o


Most common substance is Alcohol (current & lifetime) and opiod (current)

Controversy is how to classify certain pts that are kept on analgesics and do not display behavioral or psychological addiction ASAM developed separate criteria for defining addiction in

chronic pain with opiods CLASS TASK PLEASE FIND AND DISCUSS THIS CRITERIA

NEXT CLASS Identifying is also an issue as their is denial and or fear of

having meds removed


Studies have found up to 9% of patents provided incorrect information

Chronic Pain and Anxiety D/O High rates of anxiety d/o’s in pain pts Most commonly diagnoses is panic and generalized anxiety

disorders, obviously also adjustment d/o with anxiety

psychological disorders and chronic pain there's been significant work attempting to...

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