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Psychological Pain as a symptom

Psychological Pain as a symptom. Somatic Symptom Disorder(somatization) Illness Anxiety Disorder( hypochondriass ) Functional Neurological Symptom Disorder(Conversion) Factitious Disorder Pain Disorder. Pain Disorder(DSM-5). Prevalence:5-12percent

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Psychological Pain as a symptom

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  1. Psychological Pain as a symptom • Somatic Symptom Disorder(somatization) • Illness Anxiety Disorder(hypochondriass) • Functional Neurological Symptom Disorder(Conversion) • Factitious Disorder • Pain Disorder

  2. Pain Disorder(DSM-5) • Prevalence:5-12percent • Is associated with affective and anxiety disorders • Chronic pain most frequently associated with depressive disorders • Acute pain most frequently associated with anxiety disorders

  3. Pain Disorder • Depressive disorders, alcohol dependence, and chronic pain are more common in relatives of individuals with chronic pain disorder • Increased risk for suicide: pain associated with severe depression Pain in terminal illness such as cancer

  4. Etiology • Psychodynamic factors • Behavioral Factors • Interpersonal Factors • Biological Factors

  5. Mind • Brain • Body

  6. Psychodynamic Factors: Intrapsychic Conflicts and body language Alexythymia Identification

  7. Behavioral and interpersonal factors: Punishment and Reward Secondary gain Manipulation of environment

  8. Depression and pain commonly occur. • Approximately half of patients with depression report pain.1 • Between 30-60% of individuals with pain report having comorbid depression.2,3,4 • 1) Katona et al. Clin Med. 2005;5:390-5; 2) Bair et al. Arch Intern Med 2003;163:2433-45 • 3) Hassett et al. Curr Pain Headache Rep. 2014;418:36; 4) Arnold et al. J Clin Psychiatry 2006;67:1219-25

  9. Chronic Pain equivalent of depression (Masked depression)

  10. Complexity: Multiple Symptoms Most common complaints: • Chronic widespread pain • Fatigue • Sleep disturbance • Poor mood • Cognitive difficulties • Muscle stiffness Frequently occurring complaints: • Gastrointestinal symptoms • Headache • Genitourinary • Numbness and tingling • Dizziness/loss of balance • Weakness • Skin changes Clauw DJ. JAMA 2014;311;1547-55 Mease et al. Arthritis Rheum 2008;59(7):952-60

  11. Complexity: High Rates of Co-Morbidity • Comorbidity with other chronic pain states 42-70% of patients with FM also meet criteria for CFS 32-80% of patients with FM meet criteria for IBS 42% of back pain patients meet criteria for FM Aaron & Buchwald. Ann Intern Med 2001;134:868–81 Brummett, Goesling, Tsodikov, Meraj, Wasserman, Clauw &Hassett. Arthritis Rheum 2013;65:3285-92. • Co-Morbidity with chronic systemic disease Rheumatoid arthritis, lupus, inflammatory bowel disease Lee et al. Ann Rheum Dis 2013;72:949-54. Bliddal et al. Best Prac Res ClinRheumatol 2007;21:391-402 Schlesinger, Hassett et al. Ann Rheum 2009 • Psychiatric co-morbidity – mostly anxiety and depression.

  12. Neurobiological perspective. Brain regions associated with physical pain overlap with psychological pain processing: • Sensory discriminative dimension • Somatosensory cortices (S1, S2) • Dorsal posterior insula • Affective emotional dimension • Anterior insula • Prefrontal cortex • Anterior cingulate cortex • Thalamus • Amygdala • Hippocampus Goesling, Clauw & Hassett. Curr Psychiatry Rep. 2013;15:421

  13. Neurobiological perspective. Neurotransmitters – pain • Serotonin • Norepinephrine • Glutamate • GABA Neurotransmitters - depression • Serotonin • Norepinephrine • Glutamate • GABA • Similar neurotransmitter anomalies exist. • Both respond to SNRIs, but SSRIs provide little pain relief. • SNRIs might be better thought of as “neuromodulators.” • Pain relief with SNRIs is often independent of changes in depression. Ablin, Buskila & Clauw. Curr Pain Headache Rep 2009;13:343-9

  14. Pain, Depression and Sleep Triad Pain Depression (anxiety/stress) Sleep

  15. Pain, Depression and Sleep Triad Pain Depression (anxiety/stress) Sleep

  16. Sleep Hygiene “Sleep and sleep hygiene” DHHS 64 million Americans have chronic insomnia (> 20%) Disrupting slow wave sleep over several nights in sedentary middle-aged females (without reducing total sleep efficiency) results in a decreased pain threshold, increased discomfort, and fatigue. Lentz et al., J Rheumatol 1999, 26(7), 1586-1592. In FM, >75% report sleep disturbances. Insomnia up to 65%, snoring and arousals up to 78%, RLS up to 41%, excessive daytime sleepiness up to 93%. FM with sleep studies = obstructive sleep apnea ~ 80% Abad et al., Sleep Med Rev 2008;12:211-28

  17. Non-Pharmacological Interventions

  18. Interventions that enhance positive emotions and resilience!

  19. Acknowledgments Dr Alireza Ahmadi

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