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Psychological and Social Aspects of Chronic Pain

Psychological and Social Aspects of Chronic Pain. Steven Stanos, DO Center for Pain Management Rehabilitation Institute of Chicago Dept. Physical Medicine & Rehabilitation Northwestern University Feinberg School of Medicine. Outline. Evolution of pain psychology Diagnoses

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Psychological and Social Aspects of Chronic Pain

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  1. Psychological and Social Aspects of Chronic Pain Steven Stanos, DO Center for Pain Management Rehabilitation Institute of Chicago Dept. Physical Medicine & Rehabilitation Northwestern University Feinberg School of Medicine

  2. Outline Evolution of pain psychology Diagnoses • Pain disorder ,Depression • Health Anxiety, Hypochondriasis • Somatization disorder, PTSD Losses and Gains

  3. Chronic Pain Interrupts • Behavior • Function • Identity • Cognition Harris S et al. Pain. 2003;105:363-370.

  4. 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.

  5. Gate Control Theory A. Sensory B. Affective C. Evaluative Melzack et al. Pain. 1982;14:33-43.

  6. INPUTS Cognitive Evaluative Sensory- Discriminative Motivational- Affective OUTPUTS Pain Perception Action Programs Stress-Regulation Programs Body Self Neuromatrix C S A Time Time Melzack R. J Dent Education 2001;65:1378-82.

  7. 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

  8. “First off, you’re not a nut. You’re a legume.”

  9. “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

  10. Pain and Mood Disorders: Community Sample Percentage McWilliams LA, et al. Pain 2004: 111(1-2).

  11. Psychodynamic Theories • Deep rooted personality conflicts • Pain & underlying emotional conflicts • Freud: “pain” emotional response to an actual loss or injury • “pain” as “mourning”

  12. 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.

  13. “Conversion V” Neurotic triad Hypochondriasis (Hs) Depression (D) Hysteria (Hy) Hs Hy D Hanvik. J Consult Psychol 1951;15.

  14. 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.

  15. 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.

  16. Diathesis-Stress STRESS DIATHESIS COPING Turk DC, Flor H. Pain 1984;19:209-33.

  17. 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

  18. Biological PAIN Psychological Social

  19. ACCEPTANCE “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.

  20. 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 depression Greenberg PE, et al. J Clin Psychiatry 2003;64:1465-75.

  21. 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 Depression: Common Behavioral & Physical Symptoms Cassano eta l, J of Psychosom Research, 2002

  22. A. 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 Major Depressive Disorder From DSM-IV, American Psychiatric Association, 1994.

  23. 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 Depression: DSM-IV

  24. 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

  25. 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” Sullivan, Turk. Bonica’s Management of Pain.2001.

  26. 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

  27. Increased: Pain Psychological Distress Physical Disability Pain Catastrophizing Pain-related Anxiety and Fear Helplessness Self-efficacy Pain Coping Strategies Readiness to Change Acceptance Decreased: Pain Psychological Distress Disability Keefe FJ, et al. Annu Rev Psych, 2005.

  28. ANGER Fernandez, Turk. Pain 1995;61. Okifuji A. J Psychsom Res 1999;47.

  29. FEAR ANXIETY McCracken, Gross. J Occ Rehab 1998;8.

  30. Health Anxiety Chronic pain patients • Convinced disease present and less ableto 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 anxiety 37% hypochondriasis 1. Pilowsky,et al,1976; 2.Keefe,et al,1986;3.Geisser,et al.1998 4. Rode, et al, 2006.

  31. 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.

  32. Why doesn’t my patient want to get better ?”

  33. 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 Secondary Gain Dersh, Polatin, Leeman. J Occ Rehab 2004;14.

  34. Secondary Gain External • Financial awards • Wage replacement • Settlement • Debt protection • Protection from legal and other obligations • Job manipulation • Vocational retraining and skill upgrade

  35. 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 Secondary Losses Dersh, Polatin, Leeman. J Occ Rehab 2004;14.

  36. Gains 1. Gratification of altruistic needs 2. Change in role 3. Decrease family tension 4. Resolve marital difficulties Losses Increased responsibilities Emotional effect Disturbance within the relationship Guilt created by the ill individual Financial hardship Tertiary gains and losses

  37. 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 Panic Attack A discrete period of intense fear or discomfort, in which four of the following symptoms developed abruptly and reached a peak within 10 minutes From DSM-IV, American Psychiatric Association, 1994.

  38. Somatoform disorders • Somatization disorder • Pain disorder • Hypochondriasis • Conversion • Undifferentiated somatoform

  39. 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

  40. 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) sexual 2. (2) G.I. 4. (1) pseudoneurologic • Prevalence: 0.13% and 0.4% (smith, 1991) • Strong association with childhood physical & sexual abuse

  41. 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.

  42. Posttraumatic Stress Disorder A. 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

  43. 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 trauma 4. Diminished interest or participation in activities 5. Detachment, estrangement 6. Restricted range of affect 7. Sense of forshortened future From DSM-IV, American Psychiatric Association, 1994.

  44. 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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