Pain location and psychological characteristics of patients with chronic pain

Protective and Risk Factors at the Intersection of Chronic Pain, Depression, Anxiety, and Somatic Amplification: A Latent Profile Approach

Objective

Research indicates a complex nexus between chronic pain, depression, anxiety, and somatic amplification (PDAS) symptoms, marked by high rates of co-morbidity and mutually maintaining mechanisms. Although recent frameworks have attempted to explain co-occurrence rates of pain and other comorbid disorders, the interrelations between PDAS and their impacts on pain outcomes have not been adequately examined with a person-centered approach. Using nationally representative data, this study assessed the heterogeneity in PDAS symptomatology and examined links among risk and protective factors in different profiles.

Methods

Data were derived from 1027 participants in the National Survey of Midlife Development in the United States (MIDUS) who completed telephone interviews or self-report measures that assessed PDAS, various sources of social supports (family, friends, spouses/partners, religion, coworkers, and supervisors), and the number of healthcare visits.

Results

We found heterogeneity in symptom severity rather than symptom type across classes over time. Regardless of comorbidity severity, people reported similar levels of somatic symptoms, which may help clinicians more effectively diagnose comorbidity issues among chronic pain patients. As PDAS symptomatology increased by group, the perceived levels of social support decreased. Membership in a higher symptom severity class was associated with being female, younger age, and an increase in medical, but not mental health visits.

Limitations

Limitations included the use of a cross-sectional design, reliance on self-report measures, and a sample largely comprised of Whites.

Conclusion

PDAS co-occurs across classes, which may relate to shared risk and protective factors. This study lays the foundation to investigate similar questions for overlapping symptoms that occur during the same period, which would shed light on whether—among middle to older age adults—these disorders are attributable to a common mechanism and if they may inform transdiagnostic treatments.

Investigating Attachment Insecurity and Somatosensory Amplification, and the Mediating Role of Interpersonal Problems

Abstract. Background: Somatosensory amplification involves perceptual sensitivity to and cognitive-affective interpretation of bodily sensations and external stimuli, contributing to heightened experiences of somatic symptoms. However, little is known about somatosensory amplification in relation to vulnerabilities such as attachment insecurity. Aims: The present study investigated the link between attachment insecurity and somatosensory amplification, including the mediating role of dysfunctional interpersonal behaviors. Method: A sample of 245 adult community members completed the Somatosensory Amplification Scale, Generalized Anxiety Disorder Scale, and abbreviated versions of the Experiences in Close Relationships scale and Inventory of Interpersonal Problems. Correlational and regression analyses were used to examine relations among study variables, including a hypothesized parallel mediation model. Results: Somatosensory amplification was significantly associated with attachment anxiety, but not attachment avoidance. Regression analyses, controlling for general anxiety symptoms and gender, found that interpersonal sensitivity (but not aggression or ambivalence) mediated the link between attachment anxiety and somatosensory amplification. Limitations: Study limitations include the use of cross-sectional data and a non-clinical sample. Conclusion: The findings indicate that somatosensory amplification may be related to individuals’ attachment anxiety, through the mediating effect of interpersonal sensitivity problems.

Alexithymia in individuals with chronic pain and its relation to pain intensity, physical interference, depression, and anxiety: a systematic review and meta-analysis

Numerous studies have examined how alexithymia (difficulty identifying and describing one's emotions and a preference for externally oriented thinking) relates to chronic pain and associated disability. We conducted a systematic review and meta-analysis to summarize individual studies that either assessed alexithymia in individuals with chronic pain vs controls or related alexithymia to pain intensity, physical interference, depression, and anxiety. We searched MEDLINE, Embase, and PsycINFO from inception through June 2017; 77 studies met the criteria (valid assessment of alexithymia in adults or children with any chronic pain condition) and were included in analyses (n = 8019 individuals with chronic pain). Primary analyses indicated that chronic pain samples had significantly higher mean alexithymia scores compared with nonclinical (d = 0.81) and clinical nonpain (d = 0.55) controls. In chronic pain samples, alexithymia was significantly positively associated with pain intensity (d = 0.20), physical interference (d = 0.17), depression (d = 0.46), and anxiety (d = 0.43). Secondary meta-analyses of 14 studies that conducted partial correlations that controlled for negative affect-related measures revealed that alexithymia was no longer significantly related to pain intensity or interference. Meta-analysis findings demonstrated that alexithymia is elevated in individuals with chronic pain and related to greater pain intensity and physical interference, although the latter relationships may be accounted for by negative affect. Critical future work is needed that examines alexithymia assessed using non-self-report measures, develops a person-centered perspective on this construct, and identifies how alexithymia is relevant to the assessment and treatment of individuals with chronic pain.

Chronic low back pain and the transdiagnostic process: How do cognitive and emotional dysregulations contribute to the intensity of risk factors and pain?

Background and aims

Based on a transdiagnostic approach, this study assesses the impact of cognitive and emotional processes (difficulties in emotional regulation, impulsiveness, rumination and somatosensory amplification) on the psychological risk factors of chronic low-back pain.

Methods

The study was carried out with 256 patients with chronic low-back pain. All the variables were assessed through a booklet of 10 validated questionnaires. Multiple regression analysis and moderation analysis were performed.

Results

Predictors included in multiple regression models explain 3%-42% (adjusted R 2) of the variance in psychological risk factors. Moreover, analyses reveal a significant moderator effect of somatosensory amplification on the link between fear-avoidance beliefs linked to work and pain intensity (F (3;250) = 12.33; p = .00), of somatosensory amplification and brooding on the link between depression and functional repercussions (FR) on everyday life (F (3;252) = 13.36; p = .000; F (1;252) = 12.42; p = .00), of the reflection dimension of rumination on the link between the helplessness dimension of catastrophizing and FRs on sociability (F (3;252) = 37.02; p = .00). There is also a moderation analysis with a significant trend concerning the lack of emotional awareness and the difficulties in controlling impulsive behaviours.

Conclusions

Our results indicate an important role of some dimensions of difficulties in emotional regulation, somatosensory amplification and rumination in the increase in negative affects and dysfunctional beliefs, and in the links between those psychological risk factors and pain/disability.

Implications

This study identifies some cognitive and emotional dysregulations substantially involved in work-related chronic pain. This contribute to put in place psychotherapeutic protocols to tackle these deficits and dysregulations in a relevant way.

Somatosensory amplification - An old construct from a new perspective

The paper reviews and summarizes the history and the development of somatosensory amplification, a construct that plays a substantial role in symptom reports. Although the association with negative affect has been supported by empirical findings, another key elements of the original concept (i.e. body hypervigilance and the tendency of focusing on mild body sensations) have never been appropriately addressed. Recent findings indicate that somatosensory amplification is connected with phenomena that do not necessarily include symptoms (e.g. modern health worries, or expectations of symptoms and medication side effects), and also with the perception of external threats. In conclusion, somatosensory amplification appears to refer to the intensification of perceived external and internal threats to the integrity of the body ("somatic threat amplification") rather than amplification of perceived or actual bodily events only. Practical implications of this new approach are also discussed.

"Lacking warmth": Alexithymia trait is related to warm-specific thermal somatosensory processing

Alexithymia is a personality trait involving deficits in emotional processing. The personality construct has been extensively validated, but the underlying neural and physiological systems remain controversial. One theory suggests that low-level somatosensory mechanisms act as somatic markers of emotion, underpinning cognitive and affective impairments in alexithymia. In two separate samples (total N=100), we used an established Quantitative Sensory Testing (QST) battery to probe multiple neurophysiological submodalities of somatosensation, and investigated their associations with the widely-used Toronto Alexithymia Scale (TAS-20). Experiment one found reduced sensitivity to warmth in people with higher alexithymia scores, compared to individuals with lower scores, without deficits in other somatosensory submodalities. Experiment two replicated this result in a new group of participants using a full-sample correlation between threshold for warm detection and TAS-20 scores. We discuss the relations between low-level thermoceptive function and cognitive processing of emotion.

Analyzing the Aesthetic Impressions of Alexithymic Japanese Students

We investigated the association between alexithymic tendencies as measured by the 20-item Toronto Alexithymia Scale and the characteristics of aesthetic impressions for words and drawings. Impressions were measured using the semantic differential technique in three groups of Japanese students (High scores n = 31, Moderate scores n = 40, and a Control group n = 182) who were presented only words (Word condition), only drawings (Drawing condition), or pairs comprising one word plus one drawing that represented the same emotional categories (Drawing/Word condition). In a factor analysis on the data from participants, three factors (Evaluation, Activity, and Potency) were extracted. Based on the factor scores, the distances among the three conditions were calculated for each of the groups. For Potency, significant group differences were found between the Drawing/Word and other conditions. In the High-scoring alexithymia group, in particular, the Potency impressions based on tactile sensation, e.g., soft–hard, blunt–sharp, were amplified regardless of stimulus condition. These results are discussed in the context of somatosensory amplification associated with alexithymia and the difficulty of distinguishing between emotion and somatic sensations.

Alexithymia and chronic pain: the role of negative affectivity

OBJECTIVES

Alexithymia has been shown to be associated with key pain-related variables in persons with chronic pain from western countries, but the generalizability of these findings across cultures has not been examined adequately. Also, there remain questions regarding the importance of alexithymia to patient functioning over and above the effects of the general negative affectivity.

METHODS

Alexithymia, pain intensity, pain interference, depression, anxiety, and pain catastrophizing were measured in 128 Japanese patients with chronic pain. Because of the low internal consistency coefficients for 2 of the alexithymia scales (measuring difficulty describing feelings and externally oriented feelings) in our sample, we limited our analyses to a scale assessing difficulty identifying feelings and the total alexithymia scale score.

RESULTS

Although the 20-item Toronto Alexithymia Scale total and the Difficulty Identifying Feelings scale scores were not significantly associated with pain intensity, these scales were associated with pain interference, catastrophizing, and negative affectivity in our sample. However, these associations became nonsignificant when measures of negative affectivity were controlled.

DISCUSSION

The findings support the cross-cultural generalizability of significant associations between alexithymia and both pain interference and catastrophizing. However, whether (1) alexithymia influences patient functioning indirectly by its effects on negative affect or (2) the univariate associations found between alexithymia and measures of patient functioning are a byproduct of both being influenced by negative affect needs to be tested using longitudinal and experimental research.

Psychiatric disorders in children and adolescents presenting with unexplained chronic pain: what is the prevalence and clinical relevancy?

The prevalence of psychiatric disorders among children with unexplained chronic pain (UCP) is high in unselected populations and pain clinics, yet the clinical relevance of these disorders in children referred for unexplained pain is not known. This study assessed the prevalence of clinically relevant psychiatric disorders and their predictors in children referred to a children's hospital for UCP. Psychiatry morbidity was assessed in 134 children, aged 8-17 years, using the Diagnostic Interview Schedule for Children-parent version (DISC-P) and the Semi-structured Clinical Interview for Children and Adolescents (SCICA). Clinical relevance was determined using a maladjustment criterion of 61 or lower on the Children's Global Assessment Scale (CGAS). Pain parameters were measured with standardized questionnaires. Results were analysed by logistic regression. According to the DISC-P, 21% of the children had clinically relevant psychiatric disorders, predominantly anxiety disorders (18%). According to the SCICA, 28% of the children had clinically relevant psychiatric disorders, consisting of anxiety, affective, and disruptive disorders (12, 19, and 9%, respectively). Headache (compared to musculoskeletal pain) was an independent clinical predictor of psychiatric morbidity (OR = 3.10; 95% CI 1.07-8.92, p = 0.04/adjusted OR 2.99; 95% CI 1.02-8.74, p = 0.04). In conclusion, clinically relevant psychiatric disorders are common among children and adolescents referred for UCP. Adding a child psychiatrist assessment, treatable affective and disruptive disorders become identifiable. Children with an additional risk are those presenting with headache.

Lower-order pain-related constructs are more predictive of cold pressor pain ratings than higher-order personality traits

Pain is a debilitating condition affecting millions each year, yet what predisposes certain individuals to be more sensitive to pain remains relatively unknown. Several psychological factors have been associated with pain perception, but the structural relations between multiple higher- and lower-order constructs and pain are not well understood. Thus, we aimed to examine the associations between pain perception using the cold pressor task (CPT), higher-order personality traits (neuroticism, negative affectivity, trait anxiety, extraversion, positive affectivity, psychoticism), and lower-order pain-related psychological constructs (pain catastrophizing [pre- and post-], fear of pain, anxiety sensitivity, somatosensory amplification, hypochondriasis) in 66 pain-free adults. Factor analysis revealed 3 latent psychological variables: pain- or body-sensitivity, negative affect/neuroticism, and positive affect/extraversion. Similarly, pain responses factored into 3 domains: intensity, quality, and tolerance. Regression and correlation analyses demonstrated that: 1) all the lower-order pain constructs (fear, catastrophizing, and hypochondriasis) are related through a single underlying latent factor that is partially related to the higher-order negative-valence personality traits; 2) pain- or body-sensitivity was more strongly predictive of pain quality than higher-order traits; and 3) the form of pain assessment is important-only qualitative pain ratings were significantly predicted by the psychological factors.

PERSPECTIVE

Consistent with the biopsychosocial model, these results suggest multiple pain-related psychological measures likely assess a common underlying factor, which is more predictive of qualitative than intensity pain ratings. This information may be useful for the development and advancement of pain assessments and treatments while considering the multidimensional nature of pain.

Clinical application of somatosensory amplification in psychosomatic medicine

Many patients with somatoform disorders are frequently encountered in psychosomatic clinics as well as in primary care clinics. To assess such patients objectively, the concept of somatosensory amplification may be useful. Somatosensory amplification refers to the tendency to experience a somatic sensation as intense, noxious, and disturbing. It may have a role in a variety of medical conditions characterized by somatic symptoms that are disproportionate to demonstrable organ pathology. It may also explain some of the variability in somatic symptomatology found among different patients with the same serious medical disorder. It has been assessed with a self-report questionnaire, the Somatosensory Amplification Scale. This instrument was developed in a clinical setting in the U.S., and the reliability and validity of the Japanese and Turkish versions have been confirmed as well.

Many studies have attempted to clarify the specific role of somatosensory amplification as a pathogenic mechanism in somatization. It has been reported that somatosensory amplification does not correlate with heightened sensitivity to bodily sensations and that emotional reactivity exerts its influence on somatization via a negatively biased reporting style. According to our recent electroencephalographic study, somatosensory amplification appears to reflect some aspects of long-latency cognitive processing rather than short-latency interoceptive sensitivity.

The concept of somatosensory amplification can be useful as an indicator of somatization in the therapy of a broad range of disorders, from impaired self-awareness to various psychiatric disorders. It also provides useful information for choosing appropriate pharmacological or psychological therapy. While somatosensory amplification has a role in the presentation of somatic symptoms, it is closely associated with other factors, namely, anxiety, depression, and alexithymia that may also influence the same. The specific role of somatosensory amplification with regard to both neurological and psychological function should be clarified in future studies. In this paper, we will explain the concept of amplification and describe its role in psychosomatic illness.

Impact of pain severity and location on health-related quality of life

Despite evidence that persistent pain affects well-being, little is known about the relationship of the location of pain to psychological and functional well-being. To determine whether patients with musculoskeletal disorders (MSD) are more likely to be depressed and functionally disabled compared to patients with pain at other sites, we conducted a secondary data analysis of the Medical Outcome Study--an observational study of adult outpatients with chronic medical conditions. Of the 3,360 patients who completed the baseline assessment, 1,237 (36.8%) had MSD and 2,123 (63.2%) had no MSD. Among patients in the MSD group, 84.5% reported > or = mild pain as compared to 70% in the no MSD. In multivariate analyses, MSD patients were more likely than non-MSD patients to be depressed (beta coefficient=-1.9, p=0.008) and functionally disabled (beta coefficient=-4.4, p<0.0001). However, the impact of MSD was eliminated after controlling for pain severity. Regardless of the location of pain, pain severity appears to be an important correlate of functional status, both mental and physical.

Personality traits related to chronic pain location

BACKGROUND

Previous research has yielded inconsistent findings on the relationship between personality characteristics and chronic pain. The present study examines measures of alexithymia, somatosensory amplification, attachment, counterdependency, and emotional distress in 140 consecutive general medical outpatients seen in psychiatric consultation.

METHODS

Forty-five subjects having no chronic pain (NP) were compared to 49 subjects with chronic pain restricted to their back and/or extremities (BE) and with 46 subjects having pain involving other regions of the body (OP).

RESULTS

Findings demonstrated marked counterdependency traits in the BE group relative to the other two groups. By contrast, traits of alexithymia and somatosensory amplification, insecure attachment, and a high level of emotional distress characterized the OP group. A multiple logistic regression model combining counterdependency and secure attachment was 86% accurate in predicting BE (c = 0.86).

CONCLUSIONS

The study's findings suggest that personality traits vary according to chronic pain location, although the nature of the relationship still needs to be determined.

Psychometric properties of the Pain Attitudes Questionnaire (revised) in adult patients with chronic pain

Previous evidence supports the utility of the newly developed pain attitudes questionnaire (PAQ) for assessing pain-related stoicism and cautiousness in community-dwelling pain-free adults (Yong et al., 2001). A revised questionnaire (PAQ-R) was examined in the present study to determine the generalizability of psychometric properties when used with chronic pain patients. Results from both exploratory and confirmatory factor analyses suggest that the factor-structure of the revised questionnaire was best represented by a five- rather than a four-factor solution, thus, suggesting that chronic pain patients do not conceptualize the questionnaire items, in particular, with respect to the stoicism attitudes, in the same manner as the community-dwelling adults. A satisfactory internal consistency reliability of the PAQ-R was replicated in chronic pain patients. There was also evidence to suggest that chronic pain patients from different age cohorts do apply a similar frame of reference and calibration scale when responding to the items on the questionnaire. However, the cohorts of patients across the age spectrum show some differences in pain attitudes and possible reasons were discussed.

Relationship between somatosensory amplification and alexithymia in a Japanese psychosomatic clinic

To examine the relationship between somatosensory amplification and three factors of alexithymia (difficulty identifying feelings, difficulty describing feelings, and externally oriented thinking), 48 outpatients attending a Japanese psychosomatic clinic and 33 comparative outpatients completed the Somatosensory Amplification Scale (SSAS), 20-item Toronto Alexithymia Scale (TAS-20), Profile of Mood States (POMS), and other self-rating questionnaires. The scores on the SSAS and the first and second TAS-20 factors were higher (all P<0.001) in the psychosomatic group than in the comparison group. The SSAS was positively associated (both P<0.01) with these two TAS-20 factors, controlling for the effects of age, sex, group, and POMS tension-anxiety and depression. Somatosensory amplification appears to be associated with difficulties identifying and describing feelings, not externally oriented thinking, in Japanese patients.