Assessing pain in depression: what do ratings on unidimensional pain scales really mean?

Pain sensitivity is modulated by affective temperament: Results from the population-based CHRIS Affective Disorder (CHRIS-AD) study

BACKGROUND

Nociceptive pain modulation is related to psychological and psychiatric conditions. Evidence from clinical studies backs innate temperaments as potential precursors of mood symptoms and disorders, and pain sensitivity. Our study examines the modulation effect of affective temperaments on pain sensitivity in a general population adult sample, accounting for possible intervening mood symptoms, lifetime anxiety and depression, and pain treatments.

METHODS

The sample is part of the CHRIS-AD study, Italy. Primary outcomes were the pain sensitivity questionnaire PSQ-total intensity score and the experimental pressure pain threshold (PPT). Affective temperaments were evaluated with the TEMPS-M. Lifetime depression, anxiety, current mood disorders, and treatments were self-reported via rating-scales. Directed acyclic graphs theory guided linear and mixed linear regression model analyses.

RESULTS

Among 3804 participants (aged 18-65; response rate 78.4 %, females 53.3 %, mean age 38.4 years) for any given temperament, both the PSQ-total and the PPT were associated with temperament. The TEMPS-M four cyclothymic-related temperaments aligned on the pain-sensitive pole and the hyperthymic on the pain-resilient pole. The inclusion of current or lifetime mood symptoms, or pain drug use, as possible intervening pathways only partly diluted these associations, with stronger evidence for an effect of trait anxiety.

LIMITATIONS

The main limitations were the lack of experimental measures of suprathreshold pain intensity perception, and detailed information on affective disorders in the study population.

CONCLUSIONS

These findings support the hypothesis of a biological dichotomous diathesis of affective temperaments towards pain sensitivity; hyperthymic suggesting protection, whereas cyclothymic suggesting predisposition.

Mood Spectrum Disorders and Perception of Pain

Evaluation of pain perception in chronic pain patients with a concomitant mood-spectrum disorder.

DESIGN

The observational retrospective study is based on patient data collected in psychosomatic consultations held at the Gift Institute for Integrative Medicine in Pisa, Italy, from 2002 to 2014. Evoked pain stimulus threshold and tolerance were evaluated using the cold pressor test. Clinical pain intensity and Sensorial, Affective, and Evaluative dimensions were assessed using the Italian Pain Questionnaire, and Anxiety and Depressive symptoms using the Hospital Anxiety Depression Scale. Mood-spectrum disorders were diagnosed via the Mini-International Neuropsychiatric Interview, and affective temperament in accordance with Akiskal and Pinto's criteria (1999). Of a total of 627 chronic pain clinic patients, 381 were diagnosed with a concomitant mood-spectrum (MS) disorder, unipolar (US) in 61.41%. Pain threshold (t = 2.28; p < 0.05) was lower, and all clinical pain dimensions (t = 2.28; p < 0.05) increased, in MS patients compared to those without psychiatric disorders. Pain intensity (F = 3.5, p < 0.05) and cognitive pain component scores (F = 7.84; p < 0.0001) were higher in US and, to a lesser extent Bipolar Spectrum, than in subjects with other (n.112) or no psychiatric disorders (n. 134). Suicide ideation was highest in US (F = 37.20; p < 0.0001), although in BS major depressive episodes had more melancholic features (F = 46.73; P < 0.0001), and a longer history of psychiatric disorders before the pain onset than US (F = 20.31; p < 0.0001). Pain management should take into account pre-existing psychiatric disorders.

Psychological distress and cancer pain: Results from a controlled cross-sectional survey in China

We evaluated the pain associated with cancer and its impact on pain management, anxiety, and depression in Chinese patients using a controlled cross-sectional study. One hundred and twenty-six cancer outpatients were evaluated from January 2012 to June 2014; 64 reported pain and 62 did not. Patients with cancer eligible for this study were older than 18 years and able to effectively communicate with medical personnel. Patients were administered a questionnaire regarding their medical status. The information collected was used along with patient charts to complete a socio-demographic and clinical characteristic summary for each patient. Results showed that patients who reported pain had mean State-Trait Anxiety Inventory (STAI) scores of 46.38 for state anxiety and 44.64 for trait anxiety, as well as a mean BDI (Beck Depression Inventory) score of 19.17. The pain-free patient group had mean STAI scores of 40.73 for state anxiety and 42.87 for trait anxiety, and a mean BDI score of 15.35. In conclusion, patients who reported pain were more prone to anxiety and depression, with pain severity being a strong predictor of anxiety. Adequate pain assessment and adjustment proved necessary for pain management.

Experimental pain sensitivity in subjects with major depression: Many pain complaints without hypersensitivity

OBJECTIVE

Patients with major depression frequently complain of pain, but conflicting data exist concerning their changes in pain sensitivity. This study aimed at comparing the sensitivity to moderate controlled pain between subjects presenting a major depressive episode (isolated and recurrent depressive episodes or a bipolar disorder), controls, and subjects with schizophrenia from a previous study.

METHOD

Pain sensitivity was assessed obtaining the visual analog scale (VAS) rating for the application of a 160 kPa pre-fixed pressure (fpVAS), the pressure corresponding to a VAS score of 3, and the time required to achieve a VAS score of 3 during ischemia induction. The effects of depression intensity, alexithymia, current and past general pain, and of six weeks of antidepressant treatment on fpVAS were investigated.

RESULTS

The results did not differ significantly between the depressed groups and the controls, without any effect of depression intensity. Presence of long-lasting pain and current pain felt on the day of testing correlated with fpVAS. The subjects of the depressed group were less sensitive than subjects with schizophrenia. FpVAS was significantly lower before and after antidepressant treatment in the subjects presenting clinical improvement.

CONCLUSIONS

No difference in experimental pain sensitivity and expression between major depressive episode subjects and controls, in opposite to pain complaints, is to be detected. The changes in the sensation of pain routinely attributed to subjects presenting depression may result from changes in a differential processing of pain signals, not in relation with the depression intensity, or the kind of depressive disorder.

Quality of life in major depressive disorder: the role of pain and pain catastrophizing cognition

OBJECTIVE

Pain symptoms are frequent complaints in patients with major depressive disorder (MDD). Although it is known that pain intensity and pain-related cognition predict quality of life (QOL) in patients with chronic pain, limited studies have examined their roles in MDD. The study aimed to determine whether pain and pain catastrophizing were independent predictors of QOL in MDD after accounting for the impact of anxiety and depression.

METHODS

This is a prospective, naturalistic follow-up study. Ninety-one Chinese patients were enrolled during an acute episode of MDD, 82 of them were reassessed 3 months later using the same assessment on pain, anxiety, depression, and QOL. Pain intensity was evaluated using a verbal rating scale and a visual analog scale. Quality of life was assessed using the 36-item Short Form Health Survey. Pain-related cognition was assessed at baseline with the Pain Catastrophizing Scale.

RESULTS

There was significant improvement in pain, anxiety, depression, and QOL from baseline to 3-month follow-up. Hierarchical regression analyses showed that pain intensity was significantly associated with QOL at baseline and 3 months. Pain complaint was more important than anxiety and depressive symptoms in predicting changes in both physical and psychosocial domains of QOL. After controlling for the severity of pain, anxiety, and depression, Pain Catastrophizing Scale score was independently associated with QOL in MDD.

CONCLUSION

The study supports the specific role of pain and pain-related cognition in predicting QOL in depressed patients. Further studies targeting pain-related cognition for improving the outcome of MDD are necessary.