Transcript Chapter 2 Psychological Disorders and Chronic Pain

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
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
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 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
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)
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 disorder
 These 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
A conceptual model of the
transition from acute pain to
chronic pain.
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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
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
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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
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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.
A conceptual model of the
transition from acute pain to
chronic pain.
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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.
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.
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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
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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 Depression
 The research clearly establishes this relationship as to
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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
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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??
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 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
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Antecedent hypothesis
Consequence hypothesis
Scar hypothesis
Cognitive behavioral mediation model
Common pathogenic mechanism model
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
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Studies have shown high prevalence of SA in CPP
Current prevalence is 15-28%
Chronic Pain and Specific
Psychological Disorders.
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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
Chronic Pain and Specific
Psychological Disorders.
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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
Chronic Pain and Specific
Psychological Disorders.
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Studies have found up to 9% of patents provided incorrect
information
 Chronic Pain and Anxiety D/O
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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