Chronic nonmalignant pain: How to ‘turn down’ its physiologic triggers
Ease suffering by managing psychiatric and social factors that heighten pain awareness.
Mrs. A, age 50, reports recurrent headaches and neck pain from a motor vehicle accident in 1999. At the time, MRI revealed degenerative changes at the C5-C6 vertebrae without bony stenosis or spinal injury. Treatment consisted of conservative measures and physical therapy; she was not a candidate for surgical intervention.
Although Mrs. A can manage activities of daily living, pain prevents her from pastimes she previously enjoyed, including painting and pottery, and is causing problems in her marriage.
Mrs. A’s pain became much worse approximately 1 year ago. In the past year, its severity has lead to multiple clinical presentations and consultations. She uses transdermal fentanyl, 75 mcg/hr every 72 hours, and acetaminophen/ hydrocodone, 5 mg/500 mg every 4 hours up to 6 times a day for breakthrough pain. Even so, she still rates her pain as 7 on a 10-point scale.
Pain is a complex perception with psychological and sensory components. It is the most common reason patients seek treatment at ambulatory medical settings.1 Most pain remits spontaneously or responds to simple treatment, but up to 25% of symptoms remain chronic.1
Chronic pain—defined as pain at ≥1 anatomic sites for ≥6 months—can substantially impair adaptation and vocational and interpersonal functioning. Treatments that focus solely on analgesics are shortsighted and often of limited benefit. Patients with chronic pain need a rehabilitative approach that incorporates psychiatric and psychological intervention.
Complex chronic pain
Most individuals with chronic pain can maintain basic functioning, work, relationships, and interests. They work with healthcare providers and obtain relief from medications or other interventions.
Some, however, are preoccupied with—and entirely debilitated by—their pain. For them, life revolves around the pain and perceived disability. Many if not all aspects of this patient’s life are contingent on pain and fears it might worsen.2 Preoccupation with pain can profoundly affect social activities and prevent employment. The patient may become dependent on others, and being a patient can become a primary psychosocial state. A chronic pain patient also may become increasingly preoccupied with medication use and possibly abuse.
Limits of pain disorder criteria. Psychological factors can exacerbate and maintain chronic pain.3 Patients with a psychological component to their pain are likely to meet DSM-IV-TR criteria for pain disorder (Table 1), which include the possibility that psychological factors can precipitate, exacerbate, or maintain—but do not necessarily have to fully account for—pain. According to these criteria, pain can be associated with:
- a general medical condition
- psychological factors
Pain disorder associated with a general medical condition is recorded solely on Axis III (general medical conditions) when psychological factors have minimal or no involvement in the pain. When psychological factors are implicated, 1 of the other types of pain disorder would be encoded on Axis I. However, it is questionable whether these subtypes represent clinically useful subclassifications. Aigner et al4 determined that patients categorized into these subtypes could not be distinguished in terms of pain severity or disability.
Pain disorder criteria often are perceived as insufficiently operationalized—there is no checklist of symptoms that collectively define the syndrome.5,6 The clinician must infer whether—and to what extent—psychological factors are involved in the pain.5 There are no guidelines to help psychiatrists ascertain whether psychological factors “have an important role” in pain (criteria C) or if pain is “not better accounted for” by a mood disorder (criteria E).6 This distinction can be indecipherable because of frequent comorbidity of mood disturbances with pain.7,8 Some clinicians have suggested that pain disorder be removed from the somato-form disorder classification and instead confined to Axis III.9
DSM-IV-TR diagnostic criteria for pain disorder
A. Pain in ≥1 anatomical sites
B. Produces distress or impairs social, occupational, or other functioning
C. Psychological factors have an important role in pain onset, severity, exacerbation, or maintenance
D. Not intentionally produced or feigned (as in factitious disorder or malingering)
E. Not better accounted for by a mood, anxiety, or psychotic disorder and does not meet criteria for dyspareunia
Pain disorder associated with psychological factors, which are judged to have the major role in pain onset, severity, exacerbation, or maintenance
Pain disorder associated with both psychological factors and a general medical condition, which are judged to have important roles in pain onset, severity, exacerbation, or maintenance
Pain disorder associated with a general medical condition.* If psychological factors are present, they do not have a major role in pain onset, severity, exacerbation, or maintenance
* Not considered a mental disorder (encoded on Axis III) Source: Adapted from Diagnostic and statistical manual of mental disorders. 4th ed, text rev. Washington, DC: American Psychiatric Association; 2000
What are the risk factors?
Psychological and social covariates play a substantial role in the chronic pain experience (Table 2). How patients experience chronic pain also is influenced by personality and premorbid, semi-dormant characteristics that become activated by the stress of unremitting pain.7
Long-lasting pain has multiple effects, including changes in:
- thought patterns
- coping abilities
Psychological vulnerabilities may manifest as psychiatric disorders. The patient may become impatient with treatment measures and intolerant of adverse effects, and drop out of rehabilitation programs.
Patient factors that contribute to or perpetuate chronic pain
Poor modulation of emotions (anger, depression, anxiety)
Somatization (using pain to avoid confl icts, express anger, or punish others)
Problematic cognitive styles (catastrophizing, perceived loss of control)
Poor coping skills
Reinforcement for remaining sick and/or disabled:
Source: Adapted from reference 3
CASE CONTINUED: Underlying causes
Psychological and psychosocial factors appear to play an important role in Mrs. A’s pain. After her husband’s job was restructured, the couple moved away from Mrs. A’s mother, which she found distressing. Additionally, Mrs. A reports that her son has incurred substantial gambling debt.
Mrs. A admits she has “a hard time” accepting these events, but she cannot acknowledge anger or frustration. She avoids questions about such feelings and focuses on her pain. She reports, “The pain is always there and ruins my entire life. Absolutely nothing gives me relief.”
She does not endorse depressive or psychotic symptoms. She sometimes has passive thoughts of death when she feels hopeless about her persistent pain, but she vehemently denies suicidal ideas, intent, or plans. She has smoked 1 pack of cigarettes per day for 12 years but denies alcohol abuse or use of illicit substances.
She complains that her husband “is on the computer all day long.” She has difficulty telling him about her displeasure or asking him to share in activities. She feels that he disregards her feelings, and she is most apt to experience pain exacerbations when he does this. She denies ongoing litigation and is not receiving disability compensation.
Assessing a chronic pain patient includes evaluating somatic, psychological, and social factors (Table 3).3 A biopsychosocial approach recognizes that the patient’s experience of pain, presentation, and response to treatment are determined by the interaction of:
- biological factors
- the patient’s psychological makeup
- psychological comorbidities
- the extent of social support
- extenuating environmental circumstances.3,10
Single-dimension pain assessment instruments such as the Numeric Rating Scale or Visual Analog Scale can help quantify pain severity and intensity.11 Multidimensional assessments such as the Coping Strategies Questionnaire12 or Multidimensional Pain Inventory13 can enhance information gathered from a clinical interview by revealing emotional, cognitive, and subsyndromal psychological factors that contribute to pain.
A thorough psychiatric assessment may reveal psychiatric comorbidity and psychological conditions that mediate pain.8 Recognizing and treating coexisting psychiatric disorders often will enhance effective pain management.
Subsyndromal psychological factors—such as troubling affective states, problematic cognitive styles,14 and ineffective coping strategies and interpersonal skills—can accompany pain. If unattended, such factors can heighten the patient’s pain awareness and compromise rehabilitation.
For example, patients such as Mrs. A can aggravate pain by catastrophizing.15 Having a tendency to exaggerate pain and the significance of related life events interferes with their ability to attend to matters within their control and pursue productive activities.16 Catastrophizing is associated with increased pain and perceived disability, poor adjustment to pain, and marked emotional distress.17,18
How pain shapes beliefs. Pain can shape the manner with which patients make sense of events in their lives by altering the way they perceive themselves and the world. Problematic beliefs of the self (inadequacy and helplessness), of the world (dangerousness), and of the future (hopelessness) can produce significant distress. A patient with such beliefs may experience a loss of self-esteem, self-efficacy, and connections with others and may experience marked disappointment and disillusionment.
Such beliefs may lead to unhealthy behaviors, including:
- substance abuse
- nonadherence with treatment
- withdrawal from support systems
- incapacitating emotional states, such as marked dysphoria, anger, or anxiety.
Biopsychosocial assessment of chronic pain patients: 3 components
Determine pain onset/duration, location, quality, intensity, associated features, aggravating and alleviating factors
Single-dimension pain rating scales, such as Numeric Rating Scale or Visual Analog Scale
Review prescribed and over-the-counter analgesic use (adherence, excess use, impact on functional adaptation)
Mood and affect, cognitive content and processes, coping skills
Psychiatric comorbidities (substance abuse/dependence; anxiety, sleep, and somatoform disorders; delirium; depression; sexual dysfunction)
Suicide risk assessment
Multidimensional pain rating scales, such as Coping Strategies Questionnaire or Multidimensional Pain Inventory
Impact on relationships, including capacity for intimacy, mutuality, and sexuality
Impact on activities of daily living, vocational and recreational functioning
Determine functions patient can perform despite pain
Source: Adapted from reference 3
CASE CONTINUED: Multifaceted treatment
You prescribe amitriptyline, 20 mg at bed-time, for pain and refer Mrs. A for cognitive-behavioral therapy (CBT). The emphasis of therapy is to identify affective states and cognitive distortions that are temporally related to pain exacerbations, to develop coping skills to deal with stressors, and to effectively express her anger. Mrs. A learns relaxation techniques and self-hypnosis to reduce distress. These measures help reduce her pain severity ratings to 3 on a 10-point scale. She also participates in physical therapy and yoga classes, which increase her endurance.
Psychiatrists’ role in treatment
Many chronic nonmalignant pain syndromes—including arthritic conditions, back pain, and fibromyalgia—are tenacious and not easily cured. Treatment goals are to relieve pain and maximize the patient’s functioning and quality of life while minimizing risks of iatrogenic harm. As part of a biopsychosocial approach to care:
- diagnose and treat psychiatric comorbidities
- assess responses to treatment interventions
- refine treatment measures when patients do not achieve functional and adaptational goals
- initiate pharmacologic interventions for pain
- address subsyndromal emotional and cognitive impediments to functional restoration.
Psychotherapy. Meta-analyses of patients with chronic low back pain, rheumatoid arthritis, osteoarthritis, fibromyalgia, and unspecified somatic pain found that CBT is significantly more effective than wait-listing in reducing pain severity ratings and pain expression and in improving coping strategies.21-24 These analyses had limitations, however. Sample sizes were small because it is often difficult to retain patients in trials of complex, multicomponent treatment approaches.23 In addition, measures of healthcare utilization, analgesic use, and resuming work after treatment were sparse in several studies.