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Co-Existing Psychological Factors

The patient’s personality and emotional state may adversely affect the use of medication such as opioids and treatment outcomes.
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During the recent decade, a growing number of physicians in the field of pain management have shown increasing interest in integrating alternative approaches such as a psychological modality in the assessment and treatment of their chronic pain patients. This trend developed out of a growing frustration over poor treatment outcomes from increasing numbers of patients. More and more physicians have begun to realize that in spite of state of the art bio-medical interventions, prolonged pain, excessive use of analgesics, and lingering depression and anxiety halt the patient’s progress, suggesting a psychological factor that elicits, maintains, and exacerbates their ailments.

Many pain treating physicians find it hard to view chronic pain as having multifactoral characteristics. There appear to be numerous reasons for this reluctance and further studies may shed light on understanding this behavior. It is possible that negative stereotypes still exist in the medical community about psychological services. Lack of knowledge and awareness of the functions of the pain-treating psychologist — who views the chronic pain patient as a whole rather than as a part — may be a possibility. Other reasons may relate to a physician’s professional image in seeking to “cure” or “improve” the patient’s disease condition via a strictly bio-medical model rather than “giving in” to alternative medicine approaches. Other possibilities may include growing involvement of the insurance bureaucracy in a patient’s care which may limit the physician’s treatment options and potentially discourage referrals to psychologists.

The purpose of this paper is to bring attention to psychological factors in the chronic patient’s psychological profile and, in particular, mood disorders and substance abuse that can interfere with the medical approach and affect treatment outcomes.

Chronic Pain and Mood Disorders

When pain prevents people from doing the things that give them fulfillment and purpose in life, depression is inevitable and yet is often overlooked or inadequately treated in pain management. When chronic pain and depression co-exist, physical and psychological illnesses become enmeshed and blur the boundaries between the two.1 Studies support a mutually reinforcing relationship between depression and pain. The prevalence of major depression is higher for medically ill patients, particularly those in chronic pain. While the prevalence of major depression in the general population is approximately 4%, it is approximately 30% among chronic pain patients.2 Further, the lifetime prevalence of depression in studies of chronic back pain, pelvic pain and chest has been found to be 65%.3

A recent review of chronic pain patients’ psychological profiles at the Pain and Stress Management Center (PSMC) in Ridgewood, New Jersey revealed that at least 75% of these patients suffered from depression and anxiety disorder related to their chronic medical conditions. Depressed chronic pain patients reported greater pain intensity, less life control, and more use of passivity/avoidance as coping strategies. They also described greater interference from pain and manifested more pain-centric behavior than chronic patients without depression.4 Anxiety disorder was found to have a significantly higher rate in patients with chronic pain than in individuals found in the general population.5 Anxiety patients complained of major symptoms that characterized depression and anxiety, among them being: frequent fatigue, sadness, disturbance in sleep and appetite, helplessness, hopelessness, disinterest in pleasurable activities, restlessness, agitation, decline in concentration and memory, worthlessness, and guilt. Table 1 presents a patient questionnaire intended to provide an initial assessment of mood disorders of chronic pain patients.

Table 1. Initial patient mood assessment questionnaire.

Patient Denial

Physicians are not alone in overlooking the emotional component in chronic pain. Often patients will not acknowledge their own depressed moods due to denial or response bias caused by the fear of being perceived weak, being labeled with a psychogenic diagnosis, or consequences such as the loss of insurance coverage or benefits. Although the association of chronic pain and depressive disorder has been established in the literature, its mechanisms are not yet clearly defined. The complexity of the interplay between depression and chronic pain creates a challenge for the conscientious physician. For example, patients in pain often suffer insomnia and fatigue which are common vegetative symptoms of depression. Patients usually attribute these symptoms to pain rather than depression. Although it can be difficult to distinguish cause and affect in the pain/depression cycle, once it is recognized and defined it will require active interactions by the educated physician to prevent errors that would affect a positive treatment outcome.

Table 2 illustrates certain noticeable behavior patterns of pain patients having co-existing psychological factors.

Noticeable behavioral patterns of pain patients with co-existing psychological factors
  1. Prolonged pain in spite of appropriate medical treatment.
  2. Excessive use of analgesics.
  3. Mood disorders associated with the injury/illness prior or post surgery, i.e., the patient is overly anxious or shows labile behavior (depression)
  4. Lingering, indecisiveness, self doubt and inadequacy.
  5. Non-compliance or inconsistency with the physician’s therapeutic regiments including medical, home instructions and follow-up appointments.
  6. Occasional loss of prescriptions
  7. Excessive visits as well as overuse of the health care system that includes frequent visits at various medical groups and/or hospitals and treatment by increasing number of physicians.
  8. Repeated injuries and/or reoccurring pain condition. Repeated surgeries.
  9. Lack of family and/or social support.
  10. History of medical problems, mental problems and addiction in the patient’s family system.
  11. History of disturbance of interpersonal relationships.
  12. Symptoms of Borderline and or Sociopathic behavioral patterns, when the patient becomes emotionally invested in his/her illness for monetary or psychological gains, i.e., attention seeking, control, manipulation, involved with litigations and/or disability or workmen’s compensation programs.
  13. Ongoing discontentment with treatment & display of inappropriate anger.
  14. Runs out of medication prematurely.
  15. Overly friendly or very withdrawn.

Table 2. Noticeable behavioral patterns of pain patients with co-existing psychological factors.

Last updated on: January 28, 2012
First published on: September 1, 2004