Screening for psychiatric morbidity. The pattern of psychological illness and premorbid characteristics in four chronic pain populations

Pain characteristics of older persons with medically unexplained symptoms, older persons with medically explained symptoms and older persons with depression

OBJECTIVES

The main objective of the current study is to compare chronic pain characteristics of older patients with Medically Unexplained Symptoms (MUS), to those of patients with Medically Explained Symptoms (MES), and to those of patients with Major Depressive Disorder (MDD).

METHOD

By combining data from the OPUS and NESDO study, we compared pain characteristics of 102 older (>60 years) MUS-patients to 145 older MES-patients and 275 older MDD-patients in a case-control study design. Group differences were analyzed using ANCOVA, adjusted for demographic and physical characteristics. Linear regression was applied to examine the association between pain characteristics and somatization (BSI-53 somatization scale) and health anxiety (Whitely Index).

RESULTS

Older MUS-patients have approximately  two times more chance of having chronic pain when compared to older MES-patients (OR = 2.01; p = .013) but equal chances as opposed to MDD-patients. After adjustments, MUS-patients report higher pain intensity and disability scores and more pain locations when compared to MES-patients, but equal values as MDD-patients. Health anxiety and somatization levels were positively associated with the number of pain sites in MUS-patients, but not with pain severity or disability.

CONCLUSION

Older MUS-patients did not differ from MDD-patients with respect to any of the chronic pain characteristics, but had more intense and disabling pain, and more pain locations when compared to older MES-patients.

Perioperative Pain Correlates and Prolonged Postoperative Pain Predictors: Demographic and Psychometric Questionnaires

Introduction

Perioperatively, patients are near-guaranteed to experience acute pain by virtue of the surgical tissue insult. The transition of acute pain to pathological chronic pain is a complex and poorly understood process. To study this, the prevalence of pain was examined preoperatively, and at 6 weeks and 3 months postoperatively.

Methods

Fifty-four patients undergoing moderate-major gynaecological surgery at Christchurch Women’s Hospital (Christchurch, New Zealand) were recruited over a period of 11 weeks. Follow-up by telephone was conducted at 6 weeks and 3 months following surgery. Demographic information including age, gender, ethnicity, work, and education status were collected, as well as aspects of medical history. Participants were subjected to psychometric questionnaires at each time-point.

Results

Of the participants, 15.7% experienced significant pain at 6 weeks postoperatively; 8.2% of participants experienced significant pain at 3 months postoperatively. The psychometric questionnaires used found differences between those experiencing pain and those not experiencing pain at given observation points. Only the Brief Illness Perception Questionnaire (BIPQ) appeared predictive of developing prolonged postoperative pain. The mean difference (7.4 on a 0–50) scale should assist in clinical decision-making regarding analgesia.

Conclusion

Only the BIPQ was predictive of developing prolonged postoperative pain. While none of the demographic factors observed significantly predicted the development of ‘prolonged pain’, the not significant data followed expected trends. Several relationships were detected in this study that should further efforts in developing preoperative predictors to promote the secondary prevention of postoperative pain states.

Electronic supplementary material

The online version of this article (doi:10.1007/s40122-015-0037-7) contains supplementary material, which is available to authorized users.

Expert panel consensus recommendations for the pharmacological treatment of acute pain in the Middle East region

The findings of an expert panel convened to review critically how best to apply evidence-based guidelines for the treatment of acute pain in the Middle East region are presented. The panel recommended a three-step treatment protocol. Patients with mild-to-moderate levels of acute pain should be treated with paracetamol (step 1). If analgesia is insufficient after 1-2 days, a selective cyclo-oxygenase-2 inhibitor or, if gastrointestinal safety and bleeding risk are not an issue, a non-specific nonsteroidal anti-inflammatory drug, should be used (step 2). If analgesia remains inadequate, treatment with tramadol, or paracetamol plus codeine/tramadol is recommended (step 3). Patients reporting severe pain should be referred to a pain clinic or specialist for opioid analgesic treatment. Measures of pain and functioning that have been validated in Arabic, with culturally appropriate and easy to understand descriptors, should be used. Early and aggressive acute pain management is important to reduce the risk of pain becoming chronic, especially in the presence of neuropathic features.

Prevalence of and factors associated with psychiatric morbidity in chronic pain patients

OBJECTIVE

The reported prevalence of psychiatric morbidity in chronic pain patients (CCPs) was high, although it varied tremendously since structured diagnostic instruments were seldom used for diagnosis in previous studies. Study in this area after the launching of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) was scarce. This study serves to estimate the prevalence of psychiatric morbidity in patients attending a chronic pain clinic by using the Structured Clinical Interview for DSM-IV (SCID) Axis I disorders and to identify factors highly associated with psychiatric disorders, particularly depression, which is treatable.

METHOD

Consecutive patients attending a chronic pain clinic were recruited during a 6-month period. Psychiatric diagnoses were made by using the SCID. Logistic regression was used to identify factors predicting overall psychiatric morbidity and depression.

RESULTS

Prevalence of psychiatric disorders in this 89-patient sample was 62.9%. Current major depressive disorder was present in 31.5% and somatoform disorders in 33.7%. Anxiety disorders and current substance use disorders each constituted 18. "Younger age of onset of pain" (odds ratio [OR]=0.956, P<.05) and "higher pain intensity" (OR=1.544, P<.001) were independently associated with presence of psychiatric disorders. "Higher pain intensity" (OR=13.7, P<.05), "negative pain cognition" (OR=0.967, P<.05) and "problems with social and leisure activities" (OR=38.5, P<.05) were associated with depression.

CONCLUSION

Prevalence of psychiatric disorders in this Chinese chronic pain clinic sample with reference to the DSM-IV was similar to that reported in previous studies. Specific factors were identified to alert pain physicians to underlying psychiatric disorders.

Is one question enough to screen for depression?

AIMS

The aim of this study was to determine if chronic pain patients with symptoms of depression could be identified by one single question.

METHODS

Data from 595 patients, 55% women, and 45% men, from three different patient populations; low back pain patients (n = 387), whiplash patients (n = 119), and disability pensioners (n = 89), were analysed. We evaluated the test characteristics of one question on depression from the Subjective Health Complaints (SHC) Inventory. The respondents report if, and to what extent, they have been affected by sadness/depression in the last 30 days. The Hopkins Symptom Checklist-25 (HSCL-25) was used as the criterion standard. HSCL-25 is a self-report symptom rating scale with two dimensions: depression and anxiety. ''Depressed'' was defined as having a score above 1.75 on the depression subscale.

RESULTS

Thirty-three per cent of the patients were depressed according to HSCL-25. The sensitivity of the single SHC depression-question was 79%, and the specificity was 81%. Positive predictive value was 67% while negative predictive value was 89%. Kappa value for all groups combined was 0.58 (p < 0.001). The receiver operating characteristic (ROC) curve showed an area under the curve of 0.83.

CONCLUSIONS

The depression-question from SHC identified most of the depressed patients measured by HSCL-25 in low back pain patients, whiplash patients, and disability pensioners, and can therefore be considered an indicator of depression. Satisfactory sensitivity and specificity were detected, as well as similar responsiveness as determined by the ROC analyses. The results indicate that one simple question could replace a whole questionnaire (HSCL-25) in identifying depressive patients.

[The psychic structure of chronic pain patients]

OBJECTIVES

The study investigates the psychic structure and psychiatric comorbidity of chronic pain patients according to Kernberg's concept of personality organization.

METHODS

We assessed 48 chronic pain patients attending the Behavioural Medicine Pain Clinic in the Department of Psychiatry. Patients were diagnosed using the SCID (DSM-IV). Psychic structure was assessed using the Structured Interview of Personality Organization (STIPO).

RESULTS

At least one psychiatric diagnosis was found in 94 % of the patients, and 63 % of the patients met the criteria of at least one diagnosis of a personality disorder. In 58 % of the patients, we diagnosed a borderline personality organization, with high deficits in the dimensions of coping, defence mechanisms and identity.

CONCLUSIONS

The high prevalence of borderline personality organization confirms the importance of a diagnostic investigation of the psychic structure and the necessity for psychotherapeutic treatment in chronic pain patients.

Long-term sick leavers with difficulty in resuming work: comparisons between psychiatric-somatic comorbidity and monodiagnosis

The number of patients with difficulty in resuming work after long-term sick leave has increased in several European countries including Sweden. The general aim of this study was a comprehensive description--based on multidisciplinary diagnostics and assessments--of patients with the common feature of marked difficulty in resuming working life after a long absence. A particular aim was to elucidate the possible effect of comorbidity on pain descriptors, disability, quality of life, assessed working ability and rehabilitation needs. Six hundred and thirty-five long-term sick leavers were referred from National Insurance Offices and consecutively accepted for investigation. Several self-report questionnaires were used. All patients were examined by three board-certified specialist physicians in psychiatry, orthopaedic surgery and rehabilitation medicine, respectively. Fifty-five percent of the patients had psychiatric-somatic comorbidity. The three most frequent combinations of diagnoses in the comorbidity group were fibromyalgia/myalgia and depressive episode, fibromyalgia/myalgia and recurrent depression, spinal pain and depressive episode, whereas the three most frequent in those with psychiatric diagnosis only were depressive episode, recurrent depression, phobias/anxiety. Differences in pain descriptors and in difficulties with activities were found among the three groups. All had lower health-related quality of life than references. Only one-sixth had no assessed working capacity and only 3% were assessed as able to resume work without rehabilitation; 80% were multidisciplinarily assessed as needing rehabilitation. Patients with psychiatric diagnoses, with or without concomitant somatic diagnoses, need medical rehabilitation or medical/vocational rehabilitation in combination to a greater extent than patients with somatic diagnoses only. This implies that medical rehabilitation programmes ought to adapt increasingly to the needs of patients with psychiatric-somatic comorbidity.

Medically unexplained symptoms and somatoform disorders: diagnostic challenges to psychiatrists

BACKGROUND

Clinical limitations of the criteria of somatoform disorders (SDs) have been criticized. However, little objective evidence supports this notion. We aimed to examine the prevalence of SDs in a population with medically unexplained symptoms (MUS), which was expected to have higher probabilities meriting such diagnoses, and to evaluate factors that may influence the clinical judgment of psychiatrists.

METHODS

Data of subjects with MUS (n = 101, 9.5%) as their chief consulting problems, of 1,068 consecutive ethnic Chinese adult medical inpatients referred for consultation-liaison psychiatry services, were reviewed. Psychiatric diagnoses including SDs and clinical variables were collected. Those with SDs were followed-up 1 year later, and structured interviews were applied.

RESULTS

Patients with MUS had a high level of psychiatric comorbidity, especially depression (35.6%) and anxiety disorder (29.7%), rather than SDs (9.9%). Most diagnosed with SDs suffered from persistent MUS at the 1-year follow-up. Pain was the most common presentation of MUS. Most of the subjects diagnosed with SDs were female and younger, with multiple painful sites at presentation, no past psychiatric diagnosis and no comorbid organic diagnoses. The diagnosis of SDs was seldom given in those with simultaneous MUS and mood symptoms.

CONCLUSION

A significant proportion (9.5%) of patients in psychiatric consultation suffered from MUS, and most were comorbid with depression and anxiety. The identification of SDs was made in only 9.9%. Because MUS are associated with a high rate of mental comorbidities, psychiatric consultations while facing such clinical conditions are encouraged.

The impact of pain and depression on assessment of rehabilitation need: a cross-sectional study in long-term sick-listed patients

The aim of this study was to examine the relationship between pain extent, severity of depressive symptoms and recommended rehabilitation measures in long-term sick-listed patients. In this cross-sectional study, the medical records of 228 long-term sick-listed patients consecutively referred to a multidisciplinary setting were examined retrospectively. Three specialists in psychiatry, orthopaedic surgery and rehabilitation medicine had made joint rehabilitation recommendations into the four different groups: (i) back to work without rehabilitation; (ii) vocational rehabilitation or adjusted work; (iii) medical rehabilitation and (iv) sick pension. Each patient filled in a pain drawing as a measure of pain extent and the self-administered Montgomery-Asberg-Depression-Rating Scale for evaluating the severity of depressive symptoms. Ninety-five percent of the patients had ongoing pain and 53% had depression. No statistically significant difference was seen between the outcome groups regarding the pain extent. A statistically significant difference was seen between the back to work without any rehabilitation and vocational rehabilitation or adjusted work groups in Montgomery-Asberg-Depression-Rating Scale score versus the medical-rehabilitation and sick-pension groups [P<0.001 between groups (chi(2) test); P<0.05 within groups (Tukey-Kramer Honestly Significant Difference test)]. In conclusion, two-thirds of the patients were assessed to need medical rehabilitation. These patient groups could be separated from the ones who were assessed to be able to go back to work without medical rehabilitation by the severity of the ongoing depression, but not by the pain extent alone. It was found that the combination of severity of depression and pain extent provided more information than the severity of depression alone.

Cognitive Dysfunction and Depression May Decrease Activities in Daily Life More Strongly Than Pain in Community-Dwelling Elderly Adults Living With Persistent Pain

BACKGROUND AND OBJECTIVES

Chronic pain, dementia, and depression may reduce activities of daily life in elderly people. We evaluated the correlation between pain intensity and daily activities, cognitive state, and depression, as well as their interrelationships in home-dwelling elderly people with chronic pain.

METHODS

Forty-one elderly home-dwelling people who suffered from long-lasting pain, and who participated in a rehabilitation program, were enrolled. Severity of pain at rest and after pain-provoked motion was assessed on a visual analog scale (VAS, 0 to 100) and a 5-point verbal rating scale (VRS). Cognitive status was assessed with the mini-mental state examination (MMSE, 0 to 30), depression on the geriatric depression scale (GDS, 0 to 15), and functional ability in daily life was assessed with the Barthel Index (0 to 100).

RESULTS

VAS and VRS scores correlated positively with each other. Rating pain at rest on the VRS (mean 1.0, median 1) correlated with severity of depression (GDS mean 5.4) (r = 0.3997, P < 0.01), while scores on the VAS did not. Pain ratings at rest did not correlate with the Barthel Index (mean 87.7), but the latter correlated positively with motion-evoked VRS pain scores (mean 2.8, median 3) (r = 0.42829, P < 0.01). The MMSE (mean 25.3) did not correlate with any pain parameter, but it correlated positively with the Barthel Index (r = 0.3660, P < 0.05). The Barthel Index correlated negatively with the GDS (r = -0.39969, P < 0.01).

CONCLUSION

In home-dwelling elderly people, chronic pain states do not seem to reduce daily activities as much as cognitive dysfunction and depression. The seemingly controversial finding of a positive correlation between daily activities and pain in motion, and lack of correlation with pain at rest, may be explained by a relatively low intensity of pain in our study people.

Pain Management: A Fundamental Human Right

This article surveys worldwide medical, ethical, and legal trends and initiatives related to the concept of pain management as a human right. This concept recently gained momentum with the 2004 European Federation of International Association for the Study of Pain (IASP) Chapters-, International Association for the Study of Pain- and World Health Organization-sponsored "Global Day Against Pain," where it was adopted as a central theme. We survey the scope of the problem of unrelieved pain in three areas, acute pain, chronic noncancer pain, and cancer pain, and outline the adverse physical and psychological effects and social and economic costs of untreated pain. Reasons for deficiencies in pain management include cultural, societal, religious, and political attitudes, including acceptance of torture. The biomedical model of disease, focused on pathophysiology rather than quality of life, reinforces entrenched attitudes that marginalize pain management as a priority. Strategies currently applied for improvement include framing pain management as an ethical issue; promoting pain management as a legal right, providing constitutional guarantees and statutory regulations that span negligence law, criminal law, and elder abuse; defining pain management as a fundamental human right, categorizing failure to provide pain management as professional misconduct, and issuing guidelines and standards of practice by professional bodies. The role of the World Health Organization is discussed, particularly with respect to opioid availability for pain management. We conclude that, because pain management is the subject of many initiatives within the disciplines of medicine, ethics and law, we are at an "inflection point" in which unreasonable failure to treat pain is viewed worldwide as poor medicine, unethical practice, and an abrogation of a fundamental human right.

[Relationship of depression and anxiety with social desirability in chronic pain patients]

OBJECTIVE

This study examines the extent of self-reported pain and psychological distress in chronic pain patients and the influence of social desirability on the data collected.

METHODS

In a cross-sectional multi-center study with 494 chronic pain patients, a pain questionnaire was used similar to the German Federal Health Survey of 1998. Depression and anxiety were measured with the German version of the Hospital Anxiety and Depression Scale (HADS-D) and social desirability with the German Marlowe-Crowne short scale for the measurement of social desirability (KS-SE).

RESULTS

Chronic pain patients reported stronger and more frequent pain, as well as higher psychological distress than the general population of Germany. Of the patients, 36.4% showed depression (HADS-D/D >or =9) and 31.4% anxiety (HADS-D/A > or =11). Depressed/anxious patients stated pain intensities higher than non-depressed/non-anxious patients. In all, 48.4% of the patients achieved social desirability levels in the marked or moderate range. There were positive correlations for social desirability with self-reported pain and the use of therapy, as well as age. A negative correlation was found between anxiety and social desirability, while for depression this interaction appeared only after partial correlation analysis with control of pain and therapy variables.

CONCLUSIONS

Both psychological distress and social desirability are common in chronic pain patients. Patients with high scores for social desirability reveal less depression and anxiety. The psychological distress caused by pain seems to be expressed by somatic complaints and therapy seeking. Since pain research is strongly dependent on the patient's self-report, social desirability should be considered as a factor which may impact measurements and decisions.

Dimensions of psychological dysfunction in patients with fibromyalgia: development of an Italian questionnaire

Our objective was to observe whether dysfunctional psychological dimensions of pain could be detected in fibromyalgia patients through the development of a new questionnaire. An original questionnaire composed of 51 items was given to 250 patients (185 females and 65 males, mean age 55+/-12.8 years) suffering from chronic fibromyalgia according to the criteria of the Multicenter Criteria Committee of the American College of Rheumatology. A Varimax computerized program of factorial analysis with orthogonal and oblique rotation of the axes was used to analyze the data. Five strong independent factors were identified: 1) catastrophizing and 2) external control beliefs (cognitive); 3) alexithymia (emotional); 4) restless behavior (behavioral); and 5) need for support (relational). Our questionnaire is a preliminary development of an Italian language psychological characterization of FM patients which may be a relevant and useful tool for the evaluation of the outcome of clinical/psychological treatment of FM.

A preliminary communication on whether general dental practitioners have a role in identifying dental patients with mental health problems

OBJECTIVE

To examine whether general dental practitioners regard themselves as having a role in identifying dental patients with mental health problems.

METHOD

Telephone interviews were conducted with, and postal questionnaires were sent to, a random sample (n = 94) of general dental practitioners on Health Authority lists within the Mersey Region. A total of 84 general dental practitioners responded, resulting in an 89% response rate.

RESULTS

The majority of general dental practitioners had encountered patients with mental health problems (78% of interviewees, 56% of questionnaire responders). However, nearly half of the interviewees (46%) do not refer patients with mental health problems. When referrals to dental specialists were made, they tended to be regarding a physical manifestation rather than a psychological one. The majority of interviewees and questionnaire responders (55% and 82% respectively) expressed a 'positive' response to the development of a referral role. Nevertheless, there were some reservations concerning the practicalities of its development and implementation.

CONCLUSION

The majority of general dental practitioners consider a role in identifying patients with possible mental health problems. This role might include, being able to identify patients with undiagnosed mental health problems, and being aware of dental conditions which may be caused by mental health problems. To achieve this, inter-professional co-operation between general dental practitioners and other health professionals requires development.

Psychological factors and the development of chronic pain

OBJECTIVE

What is the role of psychological factors in chronic pain and chronic pain disability?

METHODOLOGY

The literature search identified 20 observational studies to provide evidence about this question.

RESULTS

Most studies evaluated psychological variables as predictors of return to work. Most studies were prospective cohort studies, including those providing the most data about etiology. In some studies, weak methods and analyses limited the conclusions. In addition, the methodologic criteria of the literature search excluded some well-known reports about this subject.

CONCLUSIONS

Because of the small number of studies, there was inadequate evidence that chronic pain results from a prior psychiatric disorder (level 4a). The studies provided limited evidence (level 3) that chronic depression plays a role in the development of new pain locations (although not for low back pain); that prior nervousness and past negative life events predict work disability; and that depression, anxiety, and a sense that control rests outside of one's own self may predict slower recovery from pain and disability. These findings do not prove that psychological factors have a role in the development of chronic pain. Psychological impairment may precede the onset of pain. Based on current knowledge, it may also arise as a complication of chronic pain.

Alternative diagnostic criteria for major depressive disorder in patients with chronic pain

Chronic pain is associated with high rates of major depressive disorder (MDD), but somatic symptoms caused by pain may complicate the diagnosis of MDD. Different methods to address this issue include the adoption of an inclusive approach to diagnosis (i.e. including all symptoms when assessing MDD, regardless of their presumed cause), an etiologic approach (i.e. disregarding symptoms that are caused by medical problems), and a substitutive approach (i.e. replacing somatic symptoms with non-somatic alternatives). In this study, 129 patients with chronic pain (56 men and 73 women) underwent semi-structured interviews addressing 23 individual symptoms of MDD. Detailed probing was undertaken into patients' perceptions of the causes of those symptoms that could potentially be brought on by pain. We found that the prevalence of MDD was highest with the inclusive diagnostic method (35.7%), lowest with an etiologic approach that discounted symptoms based on patient attributions (19.4%), and intermediate with the substitutive method (30.3%). Although some symptoms, such as insomnia, fatigue, and difficulty concentrating, were reported by 34--53% of the patients who did not meet criteria for MDD, they were still more common among those who did (85--94%, P<0.001). Patients who met criteria for MDD with the inclusive method, but who did not meet criteria using the etiologic method, had Beck Depression Inventory scores (M=24.5) that were comparable to those of patients who were consistently classified with MDD across methods (M=25.6). These scores were much higher than those of patients who were consistently classified without MDD (M=13.8, P<0.001). In conclusion, excluding criterion symptoms that patients attribute to pain can reduce the observed prevalence of MDD by about 45%. However, this method introduces a problem of false-negative diagnoses that appears to be more significant than the problem of false positives associated with the inappropriate inclusion of somatic symptoms.

Psychiatry has much to offer for chronic pain

OBJECTIVE

The objective of this study was to make an argument in favour of the inclusion of psychiatrists on chronic pain clinic teams.

METHOD

The argument takes the form of answers to four central questions: (i) does pain involve an emotional experience; (ii) do psychiatric disorders accompany chronic pain; (iii) can psychiatric disorders present as chronic pain; and (iv) which patients present to pain units, and what do we know of their personalities?

RESULTS

The affirmative case was substantiated in respect of the first three questions. In examining the last question, evidence indicates that patients who present to chronic pain units frequently have personality features that make assessment and therapy difficult.

CONCLUSIONS

Psychiatry is the field of medicine where practitioners have the most experience with emotional states and personality, and is the only field where they have specialized skills in the diagnosis and treatment of psychiatric disorders. Psychiatry has much to offer in chronic pain management and chronic pain management teams should include a psychiatrist. This conclusion has resourcing and training implications.

Chronic spinal disorders and psychopathology. research findings and theoretical considerations

BACKGROUND CONTEXT

Numerous studies have documented a strong association between chronic spinal disorders and psychopathology. However, there have been methodological shortcomings associated with much of this.

PURPOSE

This article reviews the relevant research literature, including methodological refinements that have resulted in improved measurement of psychopathology, in order to provide the most updated conclusions concerning the links between spinal disorders and psychopathology.

STUDY DESIGN

A systematic review of all Medline referenced articles on this subject during the past three decades.

METHODS

Previous research has shown that chronic spinal disorders are most often associated with depressive disorders, somatoform disorders, anxiety disorders, substance use disorders, and personality disorders. In addition to reviewing this research, the relationship between chronic spinal disorders and depressive disorders is examined in more detail.

RESULTS

Although the relationship between spinal disorders and psychopathology is complex, a diathesis-stress model is emerging as the dominant overarching theoretical model. In this model, diatheses are conceptualized as pre-existing semidormant characteristics of the individual before the onset of chronic spinal disorders, which are then activated by the stress of this chronic condition, eventually resulting in a diagnosable depressive disorder.

CONCLUSIONS

In the present review, a diathesis-stress model was applied specifically to the relationship between chronic spinal disorders and depressive disorders. Such a model may also be applicable to the relationship between chronic spinal disorders and other types of psychopathology, such as anxiety and substance use disorders. However, conclusive empirical support will require a prospective research design, given that these diatheses could be validly assessed only before the onset of the chronic pain condition.

Diagnostic change and personality stability following functional restoration treatment in chronic low back pain patients

This study examined personality pathology in a group of patients with chronic low back pain (CLBP) using both diagnostic interviews and dimensional self-report instruments. A group of CLBP patients (N = 125) was assessed before functional restoration treatment and compared with a matched normal comparison group (N = 75). The CLBP group evidenced broad personality pathology in all assessment modes pretreatment relative to the normal comparison sample. In addition, two subsamples of CLBP patients (n = 49 and n = 56) were assessed after treatment. Reductions in personality pathology between pre- and posttreatment assessments were more pronounced for diagnostic interview than dimensional self-report assessments. These results are discussed in the context of personality assessment and CLBP.

Changes in psychopathology following functional restoration of chronic low back pain patients: A prospective study

Past research has consistently demonstrated high rates of psychopathology in patients disabled with chronic low back pain. The purpose of the present study was to evaluate whether functional restoration treatment of these patients would lead to significant changes in psychopathology. Fifty-six patients were evaluated for current psychiatric disorders, using a structured clinical interview for DSM-III-R disorders, upon admission to a comprehensive 3 week functional restoration program, and again at 6 months following their rehabilitation. Results clearly documented significant decreases in prevalence rates of psychiatric disorders, particularly somatoform pain disorder and major depression. Such findings demonstrate that effective rehabilitation can significantly decrease the high rates of psychopathology commonly found in chronic low back pain patients.

Psychological medicine, pain, and musculoskeletal disorders

There is a two-way relationship between pain and psychological illness. Pain may be produced by psychological states and may cause psychological disturbances. For these reasons, pain and psychiatric problems are often associated. Selection is also highly important in influencing the population of all hospital clinics dealing with chronic nonfatal illness. Patients from this group show increased emotional difficulty, which in the past has been misunderstood as evidence of a psychological etiology.

The role of psychological factors in chronic pain. II. A critical appraisal

This paper, the second of two, concerning the study of psychological factors in chronic pain, presents a critical appraisal of the literature. Questionable assumptions, flawed methodology, and conceptual problems in earlier work are discussed, as are gradual improvements in methodological rigour and conceptual clarity. Methodological weaknesses in studies, including lack of control groups, selection biases, overinterpretation of correlational data, and use of inappropriate testing instruments are examined. Questions are raised about persisting tendencies to split mind from body by attributing pain to either organic or psychological causes. Despite advances in research and thinking in recent years, several issues remain unresolved in both the research enterprise and the clinical setting. These are discussed in relation to the respective needs of the researcher, the clinician, and the patient. Limitations on research conducted in clinical settings are considered and targets for improved methodology in studies are identified.

Pain perception in psychiatric disorders: a review of the literature

Aberrations of pain experience occur frequently in psychiatric disorders and hence pathological alterations in the basic mechanisms underlying pain experience can be expected. Nevertheless, pain perception, as one of the most important basic mechanisms of pain experience, has rarely been assessed experimentally in psychiatric disorders. The authors review the relevant experimental studies on pain perception in patients with anxiety disorders, schizophrenia, depression, eating disorders and personality disorders and suggest lines for future research. Finally, they point out that the experimental study of pain perception is useful not only in understanding aberrant pain experiences in psychiatric disorders but also in elucidating pathophysiological mechanisms because pain perception is controlled by neurochemical and neurohormonal functions known to be affected by psychiatric disease processes.

Is disease progression the major factor in morphine 'tolerance' in cancer pain treatment?

To assess the contribution of pharmacological tolerance to increasing doses of morphine, 29 cancer patients requiring oral morphine to treat pain were studied by two teams working independently. The first team assessed physical impairment, pain intensity and pain treatment. The second team assessed depressive disorders (DSM III criteria), emotional and behavioural depressive patterns (Retardation Depressive Scale, Polydimensional Mood Scale). All patients were seen at the initiation of morphine therapy and followed to the first morphine dose modification. Evaluations were carried out in out-patient clinics except staging investigations which were undertaken at the beginning and at the end of the study. Our results showed that (1) in 24 of the 25 patients for whom morphine doses were increased, progressive disease was recorded; (2) in 4 patients, morphine doses were not increased and in these patients their disease was stable or in remission; and (3) changes in depressed mood were not correlated with pain intensity. These data strongly suggest that, instead of pharmacological tolerance, the main factor resulting in increasing oral morphine requirement in cancer pain management is pain increase due to disease progression.

Anxiety and depression in patients with abdominal bloating

Eighteen patients with a syndrome of abdominal bloating and discomfort were examined to explore the relationship between their symptoms and their emotional problems. They were compared with 33 patients with Crohn's disease and 38 normal, healthy volunteers. Using the Hospital Anxiety and Depression Scale, patients with bloating were found to resemble patients with Crohn's disease. Both groups showed increased anxiety and depression. After controlling for age, sex, education, occupation, personality variables and childhood experience, there was a trend towards more anxiety in the bloating group compared with normal subjects and a significant difference for depression. These characteristics appear to be related to the effects of the illness or to selection, but not to personality or childhood experience. Although psychiatric problems are common among patients with abdominal bloating and pain who stay in touch with a clinic, they are not the primary cause of the disorder.

Parental representations of patients with panic disorder and generalised anxiety disorder

Previous studies using the Parental Bonding Instrument have shown a general trend for neurotic subjects to score their parents as less caring and more protective. Such a finding was broadly replicated in a study of 80 clinically anxious subjects and age- and sex-matched controls. Although direct comparisons of PBI scores failed to reveal clear-cut differences between generalised anxiety (GA) and panic disorder (PD) subgroups, logistic regression analyses revealed higher odds ratios for parental assignment to aberrant categories in the GA group, with PD patients reporting a more limited pattern of overprotective parenting only. Our findings suggest that adverse parental behaviour may be relevant to the pathogenesis of GA, while parental 'affectionate constraint' may be a parental response to early manifestations of PD.

The validity of the General Health Questionnaire for first-stage screening for mental illness in pain clinic patients

The validity of the 28-item version of the General Health Questionnaire (GHQ-28) was determined by comparison with the Clinical Interview Schedule (CIS) in 56 pain clinic patients. Despite some limitations, the GHQ can be used effectively and cheaply as the first stage of an assessment to identify potential "cases" of mental disorder which must then be verified using a second-stage clinical interview such as the CIS. This process can result in a considerable reduction in the proportion of patients requiring a psychiatric interview and, therefore, in reduced service costs. Factors associated with lower validity coefficients include female sex, age above 60 years and pain with a duration of less than 2 years.

Toward an integrated understanding of fibromyalgia syndrome. II. Psychological and phenomenological aspects

The present paper is the second of a 2-part series in which extant empirical literature concerning fibromyalgia syndrome (FS) is reviewed in order to provide a preliminary approach to forming an integrated understanding of the syndrome. Research on psychological disturbance in FS is reviewed with particular emphasis on affective dysfunction among FS patients. The phenomenology of FS is then described. We attempt to suggest that FS represents a quantitatively and qualitatively experience distinct from similar chronic pain syndromes. Substantive findings in FS research are summarized in the final section and potential ways in which these findings might be integrated to provide a more cohesive model for future research are suggested.

Prevalence, onset, and risk of psychiatric disorders in men with chronic low back pain: a controlled study

This study used structured diagnostic interviews and DSM-III criteria to assess lifetime prevalence and pre-morbid risk of psychiatric disorder in a sample of men with long-standing chronic back pain (CLPB) attending a primary care clinic. A control group of age and demographically matched men without history of back pain was also studied. Compared to controls, men with CLBP had significantly higher lifetime rates of major depression (32% vs. 16%), alcohol use disorder (64.9% vs. 38.8%), and a major anxiety disorder (30.9% vs. 14.3%). Almost all CLBP men ever experiencing a mood disorder reported recurrent, not single, episodes. The 6 month point prevalence of major depression, but not other disorders, was also significantly elevated for men with CLBP. In CLBP, the first episode of major depression generally (58.1%) followed pain onset. While the initial major depressive episode usually commenced within the first 2 years of established pain, late onset mood disorder was also common. By comparison in most cases (81%) onset of alcohol use disorders considerably preceded pain. When an age-matching procedure was used to gauge relative vulnerability to psychiatric illness in patients and controls, CLBP patients had significantly higher pre-pain rates of alcohol use disorder but not depression. After age of pain onset, CLBP subjects had over 9 times the risk of developing major depression, but had similar rates of developing alcoholism. We conclude that (1) alcohol use disorders rather than depression may increase risk of developing CLBP, and (2) risk of new onset and recurrent major depression remains high for men throughout their pain career. This suggests that psychological adaptation to long-standing pain may be less successful than previously thought, especially with regard to recurrent mood disorder.

Psychological events are both risk factors in, and consequences of, chronic pain

This study questioned 2 assumptions often inherent in psychogenic explanations of pain: (1) that a relationship exists between pain and life events predating pain onset, and (2) that pain patients are a psychologically homogeneous group. Chronic pain sufferers in multiple settings and control subjects participated in this study in which the relationships between pain and 20 psychological variables were examined. Pain was defined and assessed in 3 different ways: (1) membership in a pain group, (2) number of specialists consulted for pain, and (3) pain intensity. Of the 20 psychological variables examined, only less emotional repression and greater "ergomania" (excessive work) were consistently associated with pain on all 3 pain criteria. In addition, pain patients were more likely to have had a relative with pain. Comparisons of pain patients in different settings showed that pain clinic patients reported having been more active throughout their lives, but were currently more depressed and experienced less life satisfaction than patients who were not in a specialized pain centre. These results are interpreted in the light of current multicausal views of pain and conclusions are drawn about the role of psychological variables both as risk factors in, and as consequences of pain.

Neglected factors in chronic pain treatment outcome studies--referral patterns, failure to enter treatment, and attrition

An increasing number of chronic pain treatment outcome studies have appeared in the literature. In general, these studies support the efficacy of multidisciplinary pain programs, as well as specific treatment modalities such as biofeedback and relaxation. Reviews of this literature have tended to be cautiously optimistic. Some concerns, however, have been raised about the methodological adequacy of these studies, particularly in terms of the lack of control groups, the brief duration of follow-up periods, and the vague criteria used for establishing the success of the therapeutic interventions. Other factors that mitigate conclusions regarding the generalizability of the favorable results reported need to be considered. In this paper 3 rarely discussed topics that are implicit within most treatment outcome studies and that need to be given greater attention are examined. These topics include: (1) referral patterns to pain clinics (who are referred to pain clinics, when, and how representative is the referred sample?); (2) failure to enter treatment (e.g., exclusion criteria, lack of available financial support to cover the cost of treatment, patient's refusal to accept recommendations), and consequently, the representativeness of the treated sample; and (3) patient's attrition. In this paper we discuss each of these factors as they underscore important qualifications that have to be made in evaluating treatment outcome studies.

A systematic inquiry into recollections of childhood experience and their relationship to adult defence mechanisms

The relationships between childhood experience, measured by the PBI, and adult defence mechanisms, evaluated through the DMI, were examined in 114 subjects. There were modest but significant correlations between the primitive defences of 'turning against others' and 'projection' on the one hand, and a lack of parental care, as experienced by the subjects, on the other. 'Principalisation' (e.g. intellectualisation, isolation and rationalisation) and 'reversal' (e.g. negation, reaction formation, denial and repression) were positively associated with parental care. These findings account for only a small portion of the variance but show that, as with certain personality traits, actual or perceived childhood experience contributes in a recognisable fashion to the patterns of adult defences and behaviour.

Psychosocial correlates of temporomandibular joint pain and dysfunction

This study examines psychological differences between temporomandibular joint pain and dysfunction (TMJPD) patients, pain controls, and healthy controls. Two hundred and two patients were classified, according to the diagnostic criteria of Eversole and Machado, as either myogenic facial pain (n = 42), internal derangement type I (n = 69), internal derangement type II (n = 85), or internal derangement type III (n = 6). Patients completed the Basic Personality Inventory, the Illness Behavior Questionnaire, the Multidimensional Health Locus of Control, the Perceived Stress Scale, and the Ways of Coping Checklist. Subjects also answered question pertaining to TMJPD symptomatology, including chronicity and severity. After conservative treatment with simple jaw exercise and ultrasound, patients were contacted again at 5 months to complete follow-up questionnaires similar to those previously completed. Comparison groups were comprised of 79 patients attending outpatient physiotherapy clinics for pain-related injuries not involving the temporomandibular joint and 71 pain-free, healthy students. Data were analyzed using multivariate statistics. The results indicate a significant relationship between pain intensity (and to some extent chronicity) and diverse measures of personality among the pain controls but not among the TMJPD patients. This calls into question the validity of assuming individual pain disorders are subsets of a larger, homogenous pain disorder population. TMJPD patients and pain controls score higher on hypochondriasis and anxiety than the pain-free controls but these elevations are not clinically significant. The elevations decrease to normal levels in response to a positive treatment outcome. There were no differences between the TMJPD patients and the pain controls on any of the measures. These results suggests that TMJPD patients do not appear to be significantly different from other pain patients or healthy controls in personality type, response to illness, attitudes towards health care, or ways of coping with stress.

Psychological defence mechanisms in patients with pain

There is a long standing position that pain, and especially chronic pain, may arise from psychological mechanisms of defence. We have compared a group of chronic pain patients with a sample of psychiatric patients attending for reasons other than pain. The pain group had less evidence of poor care in childhood (measured by the Parental Bonding Instrument) and tended to use more mature psychological defence mechanisms (assessed with the Defense Mechanisms Inventory), compared with the other group. The pain group also had fewer current psychiatric diagnoses but more evidence of anxiety and depression on the Hospital Anxiety and Depression Scale. We conclude that in general the patients with chronic pain had more normal childhoods and more mature defences than the psychiatric control group. They showed an increase in the diagnosis of depression, attributable to reactive factors. In the sample of patients with pain the majority of the psychological change cannot be attributed to the operation of primitive psychological defences.

The validity of the General Health Questionnaire in a sample of accidentally injured adults

The 20-item version of the General Health Questionnaire (GHQ) was given to 110 accidentally injured adults during the hospital stay. The patients were asked to rate their mental state prior to the accident. They also filled in the GHQ twice during a follow-up period of 28 months. All patients were twice examined by a psychiatrist who was blind to the patients' GHQ response. The overall values for sensitivity and specificity were good during the follow-up period and only slightly better using Chronic scoring procedure (80%-80%). The optimal cutting point for case screening varied across the different time-periods (2/3 pre-accident, 3/4 follow-up). Patients with permanently higher case-scores at follow-up than at pre-accident were among those severely affected by the injuries from a psychosocial point of view. The nine subjects who scored as a case at each of the three points of time all qualified for a DSM-III diagnosis. Sixty-three percent of the patients with a case score on two occasions qualified for a DSM-III diagnosis. The study indicates that GHQ-20 would be a useful measure of the psychosocial state of trauma patients seen in the course of rehabilitation.

Psychiatry and chronic pain

Pain and chronic pain have been defined by the International Association for the Study of Pain. Psychological mechanisms are recognized in the production of pain, but their importance has probably been overstated. Selection factors have not been attended to sufficiently, and traditional methods which have been relied upon for the diagnosis of hysterical pain have been misleading. Much emotional change seen with pain is a consequence of the physical disorder. Types of illness, seen by psychiatrists working with patients in pain, are described, and brief comments offered on their management.

Screening for psychiatric illness in patients with oral dysesthesia by means of the General Health Questionnaire--twenty-eight item version (GHQ-28) and the Irritability, Depression and Anxiety Scale (IDA)

Thirty-one consecutive subjects suffering from oral dysesthesia and without detectable organic disease were seen in a university outpatient dental clinic. They were assessed with a screening test for psychiatric illness, the General Health Questionnaire, 28-item version (GHQ-28). Twelve subjects also completed the Irritability, Depression and Anxiety Scale (IDA). At the 4/5 cutoff on the GHQ, 51.9% of the patients showed evidence of psychiatric illness. The IDA appeared to be more sensitive than the GHQ-28 in terms of detecting psychiatric illness, especially depression, and 75% of the 12 subjects who completed both scales were found to be depressed on the IDA. These results were compared to results obtained by another cross-sectional study of different types of pain clinics in which the same scales were used to screen for psychiatric illness. The subjects with oral dysesthesia as measured by the IDA appeared to have psychiatric illness more often than the other subjects with chronic pain, except those attending a psychiatric clinic. The GHQ-28 results on the other hand showed less psychiatric illness in the latter group. Our findings indicate that psychiatric illness, especially depression, may play an important role in this disorder and that the IDA may be more sensitive than the GHQ for detecting depression.

The relationship between pain drawings and the psychological state

Pain patients may be requested to complete pain charts as part of their evaluation at pain clinics. Inferences are made about the 'psychological content' of the patient's pain on the basis of the extent and distribution of the pain as illustrated in these drawings. In this study, the records of 328 patients from 4 distinct types of chronic pain service, were scored for how many body parts were included in the pain drawings and the percentage of body surface area involved. Four psychological instruments were used to quantify the psychological status of the patients. These included 2 measures of current psychological status (the General Health Questionnaire-28, and the Irritability/Depression and Anxiety Questionnaire), 1 measure of childhood quality (the Parental Bonding Index), and 1 measure of premorbid personality (the Hysteroid/Obsessoid Questionnaire). No significant correlation was found between the percentage of body surface area affected by pain, and the measures of childhood quality. Only very limited correlations were found between the percentage of the body surface area with pain and the measures of current psychological state and premorbid personality. Hence, strong emphasis should not be placed on the involvement of multiple areas as a sign of psychological illness.