Chapter 2 Psychological Disorders and Chronic Pain

1. Chapter 2 Psychological Disorders and Chronic Pain

2. Psychological Disorders and Chronic Pain • There'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

3. Psychological Disorders and Chronic Pain • Hence, 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

4. 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

5. 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

6. 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 disability • Stage 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

7. 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 somatization • Even though there's relationship between depression and pain the nature of the relationship is inconclusive. (Chicken or egg)

8. 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 onepersonality disorder • These are all base rates that are higher than the general population

9. 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

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

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

12. 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.

13. A conceptual model of the transition from acute pain to chronic pain. • 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 STUDY • Note Gatchel et al model support that psychosocial factors contribute more to the chronicity of pain that physical factors.

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

15. 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 Depression • The research clearly establishes this relationship as to whether it is causal or subsequent relationship • The 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

16. 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

17. Chronic Pain and Specific Psychological Disorders. • 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%

18. Chronic Pain and Specific Psychological Disorders. • 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

19. Chronic Pain and Specific Psychological Disorders. • 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

20. Chronic Pain and Specific Psychological Disorders. • 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