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Psychological and Social
Aspects of Chronic Pain
Steven Stanos, DO
Center for Pain Management
Rehabilitation Institute of Chicago
Dept. Physical Medicine & Rehabilitation
Northwestern University Feinberg School of
Medicine
Outline
Evolution of pain psychology
Diagnoses
• Pain disorder ,Depression
• Health Anxiety, Hypochondriasis
• Somatization disorder, PTSD
Losses and Gains
Chronic Pain Interrupts
• Behavior
• Function
• Identity
• Cognition
Harris S et al. Pain. 2003;105:363-370.
Gate Control Theory
Melzack R. In: Cousins MJ, Bridenbaugh PO, eds. Neural Blockade in Clinical
Anesthesia and Management of Pain. 3rd ed. Philadelphia, Penn: Lippincott
Williams & Wilkins; 1998.
Gate Control Theory
A. Sensory
B. Affective
C. Evaluative
Melzack et al. Pain. 1982;14:33-43.
Body Self Neuromatrix
INPUTS
Cognitive
Evaluative
SensoryDiscriminative
OUTPUTS
Pain Perception
C
S
Action Programs
A
MotivationalAffective
Time
Melzack R. J Dent Education 2001;65:1378-82.
Stress-Regulation
Programs
Time
The PAIN Patient
•
•
•
•
Demoralized from continued quest for relief
Cascade of ongoing stressors
In a state of “medical limbo”
Inactivity leads to preoccupation with “the body
in pain”
• Change from active to more passive coping with
the pain
“First off, you’re not a nut. You’re a legume.”
“Yellow Flags”
• Maladaptive beliefs
• Expectations and pain
behavior
• Reinforcement of pain
• Heightened emotional
activity
• Job dissatisfaction
• Poor social support
• Compensation
Cairns MC, Spine 2003; 28(9):953-59
Pain and Mood Disorders: Community
Sample
40
35
Percentage
30
Arthritis
No arthritis
Migraine
No Migraine
LBP
No LBP
25
20
15
10
5
0
MDD
Panic
McWilliams LA, et al. Pain 2004: 111(1-2).
GAD
Psychodynamic Theories
• Deep rooted personality
conflicts
• Pain & underlying
emotional conflicts
• Freud: “pain” emotional
response to an actual
loss or injury
• “pain” as “mourning”
Developmental Theory
George Engel, MD
•
•
•
•
“Psychogenic pain”
“Library” of pain experiences
Pain acquires “meaning”
Pain used unconsciously to resolve
developmental conflicts
1. Absolving one of guilty feelings
2. Focus on pain enables individual to
displace attention
3. Enables role of victimization
Engel GL. Am J Med. 1959;26:899-918.
“Conversion V”
Neurotic triad
Hypochondriasis (Hs)
Depression (D)
Hysteria (Hy)
Hs
Hy
D
Hanvik. J Consult Psychol 1951;15.
Richard Sternbach/
Learning Theory
• Trait theory
• Personality factors
predispose patients to CP
• Pain predispose one to
neuroticism and
hypochondriacal worries
• CP no purpose
Sternbach RA, 1974.
Cognitive Revolution: Dennis
Turk, PhD
• Attributions, efficacy,
expectations
• Personal control,
problem solving within
cognitive-behavioral
perspective
• BioPsychoSocial
approach
Turk DC, Flor H. Pain 1984;19:209-33.
Diathesis-Stress
STRESS
DIATHESIS
Turk DC, Flor H. Pain 1984;19:209-33.
COPING
Gatchel’s 3-Stage Model
Stage I: Normal emotional reaction
during acute phase
Stage II: Behavioral and psychological
reactions and problems
Stage III: Acceptance or habituation to
“sick role”
Gatchel RJ, 1991
Biological
PAIN
Psychological
Social
ACCEPTANCE
“Living with pain
without reaction,
disapproval, or
attempts to reduce
or avoid it . . .
A disengagement
from struggling
with pain.”
McCracken LM, Pain; 1998.
McCracken LM, J Back Musculoskel Rehab; 1999.
depression
• Costs (1990 vs. 2000)
• Treatment increased
50%
• Costs increase 7%
• 2000
– $26 billion (direct medical
costs)
– $5 billion (suicide)
– $51 billion (workplace
costs)
• Psychiatric
• Behavioral
• Physical
Greenberg PE, et al. J Clin Psychiatry 2003;64:1465-75.
Depression: Common Behavioral &
Physical Symptoms
Behavioral
• Interpersonal friction
• Anger
• Avoidance
• Reduced productivity
• Substance use/abuse
• Victimization
• Social withdrawal
Physical
• Fatigue
• Insomnia/hypersomni
a
• Appetite changes
• Pains and aches
• Muscle tension
• Gastrointestinal upset
Cassano eta l, J of Psychosom Research, 2002
Major Depressive Disorder
A. 5 or > of following symptoms,
present during same 2-week period
– Depressed mood most of the
day
– Diminished interest or pleasure
– Weight loss
– Insomnia/hypersomnia
– Psychomotor agitation or
retardation
– Fatigue or loss of energy
– Feelings of worthlessness guilt
– Diminished ability to think/
concentrate, or indecisiveness
– Recurrent thought of death
B. Symptoms cause
clinically significant distress
or impairment
C. Symptoms not caused
by effects of a substance or
general medical condition
D. Not better accounted for
by bereavement, marked
functional impairment,
morbid preoccupation with
worthlessness, SI, psychotic
symptoms or psychomotor
retardation
From DSM-IV, American Psychiatric
Association, 1994.
Depression: DSM-IV
Emotional
–
–
–
–
Guilt
Suicide
Lack of interest
Sadness
Associated
Symptoms
–
–
–
Physical
–
– Lack of energy
–
– Sleep disturbance
–
– Appetite change
– Change in psychomotor –
function
– Decreased concentration
Pain
Worry
Irritability
Obsessive rumination
Anxiety
Brooding
Tearfulness
Predictors of Depression in
Chronic Pain
•
•
•
•
Pain intensity
Frequency severe pain experienced
Number of painful areas
Psychosocial factors
– low self efficacy
– poor coping
– poor problem solving
• Functional disability
DSM / Pain Disorder History
DSM II ’68:
DSM III ‘80:
No diagnosis
“Psychogenic Pain Disorder”
Pain “grossly in excess”
Etiological Ψ Disorder:
1. temporal relationship
2. pain allows avoidance
3. promotes emotional support & attention
DSM III – R ’87:
“Somatoform Pain Disorder”
“Preoccupation with pain for at least 6
months”
DSM IV ’94:
“Pain Disorder”
Sullivan, Turk. Bonica’s Management of Pain.2001.
DSM-IV Pain Disorder
• Pain in 1 or > anatomical sites is predominant focus of
clinical presentation and of sufficient severity to warrant
clinical attention
• Pain causes significant distress or impairment in social,
occupational, or other areas of functioning
• Psychological factors judged to have important role in
onset, severity, exacerbation, or maintainment of pain
• Symptom or deficit is not intentionally produced or
feigned
• Not better accounted for by mood disorder, or psychotic
disorder
Pain
Catastrophizing
Pain-related
Anxiety and Fear
Helplessness
Self-efficacy
Pain Coping
Strategies
Readiness to Change
Acceptance
Keefe FJ, et al. Annu Rev Psych, 2005.
Increased:
Pain
Psychological Distress
Physical Disability
Decreased:
Pain
Psychological
Distress
Disability
ANGER
Fernandez, Turk.
Pain 1995;61.
Okifuji A.
J Psychsom Res
1999;47.
FEAR
ANXIETY
McCracken, Gross.
J Occ Rehab 1998;8.
Health Anxiety
Chronic pain patients
• Convinced disease present and
less able to accept medical
reassurance1
• Believe pain was caused by a
physical condition2
• 47% of patients unsure of
diagnosis and 20% disagreed
(linked to affective distress)3
• Chronic pain sample4:
51% severe disabling health
anxiety
37% hypochondriasis
1. Pilowsky,et al,1976; 2.Keefe,et al,1986;3.Geisser,et al.1998 4. Rode, et al, 2006.
Hyopochondriasis
• Preoccupation with fears of having, or the idea
that one has, a serious disease based on the
person’s misinterpretation of bodily symptoms.
– Prevalence between 5% and 9%
– Coexist with anxiety, depressive, or somatoform
disorders
– Hostility, antagonism, and dissatisfaction with medical
care.
Noyes R, et al. J Nerv & Mental Dis 1997.
Why doesn’t my patient want
to get better ?”
Secondary Gain
Internal
• Gratification preexisting unresolved
dependency & revengeful strivings
• Attempt to elicit care-giving
• Ability withdraw from unpleasant or
unsatisfactory life roles
• Adoption of “sick role”
• Convert socially unacceptable disability to a
socially acceptable one
Dersh, Polatin, Leeman. J Occ Rehab 2004;14.
Secondary Gain
External
• Financial awards
– Wage replacement
– Settlement
– Debt protection
• Protection from legal and other obligations
• Job manipulation
• Vocational retraining and skill upgrade
Secondary Losses
• Economic
• Meaningfully relating
to society via work
• Work social
relationships
• Meaningful and
enjoyable family roles
• Respect
• Community approval
Dersh, Polatin, Leeman. J Occ Rehab 2004;14.
• Negative sanctions
from family
• New role not
comfortable
• Social stigma of being
“disabled”
• Guilt over disability
Tertiary gains and losses
Gains
1. Gratification of
altruistic needs
2. Change in role
3. Decrease family
tension
4. Resolve marital
difficulties
Losses
1. Increased
responsibilities
2. Emotional effect
3. Disturbance within the
relationship
4. Guilt created by the ill
individual
5. Financial hardship
Panic Attack
A discrete period of intense fear or discomfort, in which four of the
following symptoms developed abruptly and reached a peak within 10
minutes
• Palpitations, accelerated
heart rate
• Sweating
• Trembling or shaking
• Sensations of shortness of
breath or smothering
• Feeling of choking
• Chest pain or discomfort
• Nausea or abdominal pain
• Feeling dizzy, lightheaded,
faint
• Depersonalization
• 10. Fear of losing control or
going crazy
• 11. Fear of dying
• 12. Paresthesias
• 13. Chills or hot flushes
• 14. Persistent concern about
having additional attacks
• 15. Worry about implications
• 16. Significant change in
behavior related to attacks
From DSM-IV, American Psychiatric Association, 1994.
Somatoform disorders
•
•
•
•
•
Somatization disorder
Pain disorder
Hypochondriasis
Conversion
Undifferentiated somatoform
Somatization
“a tendency to experience and communicate
somatic distress and symptoms
unaccounted by pathological findings, to
attibute them to physical illness, and to
seek medical help for them”
- Lipowski
Somatization Disorder
• History of many ongoing physical
complaints beginning before age 30 yrs
causing significant impairment in social,
occupational, or other areas of function
• Each of following symptoms:
1. (4) pain
3. (1) sexual
2. (2) G.I.
4. (1) pseudoneurologic
• Prevalence: 0.13% and 0.4% (smith, 1991)
• Strong association with childhood physical &
sexual abuse
Conversion Disorder
• One or more symptoms or deficits affecting voluntary
motor or sensory function that suggest a neurologic or
other general medical condition
• Psychological factors associated with symptoms,
initiation or exacerbation preceded by conflicts of other
stressors
• Symptoms not intentionally produced or feigned
• Not explained by general medical condition or substance
• Causes significant distress or impairment
• Specify type of symptom: motor, sensory, seizure, or
mixed
From DSM-IV, American Psychiatric Association, 1994.
Posttraumatic Stress Disorder
A. Exposed to traumatic event in which both of following
were present:
1. Event involved actual or threatened death or serious
injury
2. Person’s response involved intense fear,
helplessness, or horror
B. Traumatic event persistently re-experienced in 1 or >
following ways
1. Recurrent & intrusive distressing recollections
2. Recurrent distressing dreams
3. Acting or feeling as if the traumatic event were
recurring
4. Intense psychological distress at exposure to cues
5. Physiological reactivity on exposure to cues
PTSD Cont.
C. Persistent avoidance of stimuli
associated with the trauma and numbing
of general response of 3 or more:
1. Efforts to avoid thoughts, feelings, or
conversations
2. Efforts to avoid activities, places, or people that
arouse recollections
3. Inability to recall important aspects of trauma
4. Diminished interest or participation in activities
5. Detachment, estrangement
6. Restricted range of affect
7. Sense of forshortened future
From DSM-IV, American Psychiatric Association, 1994.
PTSD Cont.
D. Persistent symptoms of increased
arousal, as indicated
by 2 or more:
1. Difficulty falling/ staying asleep
2. Irritability or outbursts of anger
3. Difficulty concentrating
4. Hypervigilance
5. Exaggerated startle response
From DSM-IV, American Psychiatric Association, 1994.
Personality Disorder
Long-standing pattern of disordered
behavior and emotions with symptoms
severe enough to interfere with the
individual’s ability to:
(DSM-IV)
function
interact with others
maintain reality testing
Epidemiology of PD
• PD in general population: 0.5%~3%1
• PD in persons presenting to psychiatry
2%~16%2
• PD in chronic pain: 31%~59%
dramatic (B) cluster & anxious (C) cluster3,4
1. Amer Psych Ass.: Diagnostic and Statistical
Manual of Mental Disorders, 1994.
2 Kaplan H, Sadock B. 1991.
3. Reich J. Thompson D.1987.
4. Reich J, Tupin JP, Abramowitz SI. 1983.
Personality Disorders
Axis I: Clinical syndromes
Axis III: General Med
Condition
Axis II: Personality disorders
Cluster A (odd / eccentric)
Cluster B (dramatic / emotional)
Cluster C (anxious / fearful)
Axis IV: Psychosocial &
environmental
problems
Axis V: Global
assessment of
functioning (GAF) scale
(0-100)
Personality or Personality
Disorder?
• Personality traits: Enduring patterns of perceiving,
relating to, and thinking about the environment and
oneself, are exhibited in a wide range of important
social and personal contexts
• Personality disorder: Enduring pattern of inner
experience & behavior that deviates markedly from
the expectations of the individual culture, is pervasive
and inflexible, has an onset in adolescence or early
childhood, is stable over time, and leads to distress
or impairment.
Personality Disorder in DSM-IV
• Cluster A (odd/eccentric cluster):
Paranoid, Schizoid, and Schizotypal
• Cluster B (dramatic/emotional cluster):
Antisocial, Borderline, Histrionic, and
Narcissistic
• Cluster C (fearful/anxious cluster):
Avoidant, Dependent, and Obsessivecompulsive
Parking and PD
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