Co-Morbid Psychological Disorders in Interventional Pain Management
Pharmacological and technological advances offer new and continuously improving means for the management of chronic noncancer pain.1 Despite increasing accuracy of interventional strategiesincluding epidural injections, radiofrequency lesioning, intrathecal drug delivery systems (IDDS), spinal cord stimulators (SCS), and peripheral nerve stimulationthere remains a significant number of patients that continue to fail these interventions.2,3 Although the reasons for failure are varied, there is some suggestion that they may be population-dependant variables,4 patient lack of acceptance of persisting pain,5 and patient non-compliance.6 A common thread however in treatment failure appears to be undiagnosed psych-ological overlay accompanying chronic pain.7 The purpose of this article is to review the role certain psychological factors play in interventional pain management and how the pain practitioner can better recognize these factors prior to costly interventions.
Understanding and Recognizing the Role of Affect in Pain Management
Certain patient specific risk factors con-tribute not only to an intrinsic vulnerability to aberrant behaviors, but also have the potential to impact the outcome of interventional procedures.8 In an attempt to predict factors leading to poor treatment outcomes, Barnes et al9 identified patients with certain personality characteristics which they found were unlikely to take full advantage of treatment. These individuals were likely to either terminate treatment early because they were unsatisfied or be non-compliant during the treatment process. These pre-treatment personality characteristics included indiv-iduals reporting high levels of depression, high levels of pain intensity (anxiety), increased perception of pain, fear of re-injury, higher compensation payments, and those individuals that were stubborn and distrustful of treatment staff (personality concerns).
It has been well documented that a significant number of patients suffering from chronic low back pain meet clinical criteria for surgical intervention, however they continue to report little or no decrease in pain following surgery.10 Sim-ilarly, not all patients who undergo less invasive procedures for pain management report satisfactory results. Geurts et al11 found that patients given a placebo treatment versus those given radiofrequency lesioning of dorsal root ganglia for chronic lumbosacral radicular pain reported similar outcomes. Of course one explanation for the lack of treatment difference could be operator error. If it were possible to remove operator error, however, the variables to account for these differences would have to reside within the patients themselves. It is for this reason that much research has been performed to identify those patient-specific variables that account for intervention outcome differences.10,12-17 The intuitive belief is that identification and mediation of those patient variables will lead to greater numbers of successful interventions and decreasing utilization of health care resources.
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