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9 Articles in Volume 17, Issue #3
Anxiety and Pain
Central Pain in Rheumatoid Arthritis
Imagine Dragons’ Dan Reynolds Educates People About Ankylosing Spondylitis
Letters to the Editor: Ehlers-Danlos Syndrome, Arachnoiditis
Managing Cancer-Related Pain: A Look at Alternative Approaches
Pain Management in the Elderly: Focus on Safe Prescribing
Painful Genetic Diseases
Responding to Women's Pain Early and Effectively
The 5 Most Misunderstood Terms in Pain Medicine

Anxiety and Pain

The association between anxiety disorders and pain may be stronger than the association between depression and pain. Learn more about the most common anxiety disorders seen in pain patients, as well as new DSM-5 diagnostic criteria.

Relative to depression, anxiety disorders have received less attention in the chronic pain literature. Interestingly, the aggregated association of anxiety disorders with chronic pain may be stronger than the association with depression. In the updated Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the American Psychiatric Association (APA) moved post-traumatic stress disorder (PTSD) out of the chapter on anxiety disorders and put it into a new chapter.1 This reflects the recognition that PTSD is its own disorder, while still maintaining a close relationship with anxiety disorders, obsessive-compulsive and related disorders (OCD), and dissociative disorders.1 Most prior pain research has evaluated the effects of anxiety disorders overall, including PTSD, on chronic pain and vice versa.2-4 Therefore, in this review, we present the research as such but include specific sections dedicated to the trauma and stress-related disorders.

Managing anxiety with chronic pain requires management distinct from PTSD and OCD.

Diagnosis of Anxiety Disorder

Anxiety disorders cause distress in more than 30 million Americans in their lifetimes.5 The direct and indirect costs of anxiety disorders are estimated to be about $42 billion per year in the United States.6 Anxiety disorders impair work, and social and physical functioning.7 There also appears to be an elevated prevalence of anxiety disorders among individuals with a variety of medical conditions, including arthritis.8

The 12-month prevalence of anxiety disorders among all US adults is listed in Table 1.9-12 Earlier pain research listed the overall prevalence of comorbid anxiety disorders and pain as ranging between 16.5% and 28.8%.13 Newer studies suggest that anxiety disorders may be present in up to 60% of patients with chronic pain.3 Of course, these estimates are dependent on the methods used to assess for anxiety, the DSM criteria employed, and the spectrum of anxiety disorders included in the studies. In the US National Comorbidity Survey Part II, anxiety disorders were present in 35% of adults in the community with chronic arthritic pain versus 17% of the general population.14 In the Midlife Development in the US Survey (MIDUS), these findings were replicated and extended to persons with migraines and chronic back pain.15

Little consistency exists in the chronic pain literature about specific anxiety disorder diagnoses, but it appears that panic disorder16-18 and generalized anxiety disorder (GAD)18-20 are diagnosed most commonly. Panic disorder and pain share several psychological vulnerabilities, such as hyperarousal, somatic cues, and attentional biases, which may underlie both the anxiety and pain conditions.15 It also is possible that individuals use worry as a strategy for reducing somatic arousal associated with pain, making them more prone to developing GAD.15 In addition, studies have suggested that people with chronic pain may have a pre-existing anxiety disorder21,22 and/or report the onset of anxiety after experiencing pain.22 There is a growing understanding of the impact of anxiety and fear upon chronic pain and vice versa, and their overlap is common.23 More severe chronic pain has been associated with more severe anxiety symptoms.24 The presence of anxiety also has been shown to lead to more frequent reports of pain.25

How Is the Diagnosis of Anxiety Disorder Different in the New DSM-5?

DSM-5 has several changes related to anxiety disorders. In addition to the creation of new sections for PTSD and OCD, the diagnoses of agoraphobia, specific phobia, and social anxiety have been updated.1 In addition, panic attacks now can be categorized as either expected or unexpected, rather than by type as outlined in the DSM-IV-TR. Furthermore, panic disorder and agoraphobia are no longer linked together, and are now recognized as 2 separate disorders. Childhood and adolescent anxiety disorders, such as separation anxiety and selective mutism, have been moved to the chapter on anxiety disorders.26

Assessments for Anxiety Disorders

The use of structured diagnostic interviews by trained mental health professionals is recommended to assess anxiety disorders among adults.22 Perhaps the most commonly recognized self-report measure used to assess for anxiety is the Beck Anxiety Inventory27 and the anxiety scales of the Brief Symptom Inventory.28 Some measures, such as the State-Trait Anxiety Inventory, are characterized more accurately as measures of general distress.29 Other instruments measure a specific diagnosis, such as the Mobility Inventory for agoraphobia,30 and some measure major symptoms particular to a diagnosis, such as the Penn State Worry Questionnaire, which measures worry in GAD.31

Treatment of Anxiety Disorders

A variety of cognitive and behavioral treatment approaches have been studied for chronic pain and anxiety, including breathing control, muscle relaxation, exposure therapy, attention-diversion, desensitization, and hypnosis.23,32 According to the American Psychological Association’s (Division 12) Society of Clinical Psychology, the treatment of anxiety consists primarily of cognitive and behavioral therapies (CBTs), regardless of the particular type of anxiety disorder.33

CBTs have the strongest research support for the treatment of anxiety. Acceptance and commitment therapy (ACT) has been found to have modest research support for mixed anxiety conditions. For panic, CBT remains the treatment with the strongest research support. However, applied relaxation and psychoanalytic treatments have been found to have modest research support, although they are somewhat controversial. For specific phobias, exposure therapies—directly facing a feared object, situation, or activity—have been found to have the strongest research support.

Four major classes of medications—selective serotonin reuptake inhibitors (SSRI), serotonin-norepinephrine reuptake inhibitors (SNRI), tricyclic antidepressants (TCAs), and benzodiazepines—also may be helpful in the treatment of anxiety disorders. However, when treating anxiety in people who suffer from chronic pain, prescribing a benzodiazepine and an opioid concurrently generally is discouraged.34

In August 2016, the FDA added a new black box warning for all opioid and benzodiazepine products that discusses “serious risks associated with using these medications at the same time, including the risk of extreme sleepiness, respiratory depression, coma, and death.”35 The treatment of anxiety also can include interventions that are more invasive, such as electrical stimulation therapies (cranial electrotherapy stimulation).36 A referral to a mental health professional is recommended for an accurate diagnosis and discussion of various treatment options. Providers also can consider other complementary and alternative interventions, such as acupuncture and exercise, to increase reconditioning of chronic pain symptoms and ameliorate anxiety outcomes.37,38

What About Trauma and Stress Disorders?

Trauma- and stress-related disorders include disorders in which exposure to a traumatic or stressful event is listed explicitly as a diagnostic criterion. The trauma- and stress-related disorders include reactive attachment and disinhibited social engagement, PTSD, acute stress, adjustment, and other trauma- and stress-related disorders (Table 2).10,39-42

Common sequelae that follow a traumatic event include chronic pain and PTSD. Earlier studies reported a prevalence of PTSD among chronic pain patients as 1.7%.43 However, about 10% of veterans referred to a pain clinic44 and 10% of patients attending a multidisciplinary chronic pain center45 have been shown to meet criteria for PTSD. Approximately 35% of injured workers referred to a rehabilitation program46 and about 30% to 50% of patients whose pain is secondary to a motor vehicle accident47 report symptoms of PTSD. Studies also suggest that hospitalized burn patients have been found to have high rates of PTSD (45%) 12 months post-injury.48    

Studies examining the prevalence of chronic pain in individuals with a primary diagnosis of PTSD have reported even higher co-prevalence rates. Pain is the most common physical complaint among patients who suffer from PTSD.49 Research has shown that anywhere from 60% to 80% of veterans with PTSD report that they have a chronic pain condition.50,51 Research indicates that patients with chronic pain related to trauma or PTSD experience more intense pain and affective distress,52 higher levels of life interference,53 and greater disability54 than their counterparts without trauma or PTSD.

PTSD Diagnosis

DSM-5 criteria for PTSD differ significantly from those in DSM-IV. Criterion A was broadened to include traumatic events that were experienced directly, indirectly, or witnessed by the individual, and the subjective reaction criterion was eliminated (feelings of fear, helplessness, or horror).1 There now are 4 symptom clusters in DSM-5: reexperiencing, arousal, avoidance, and persistent negative alterations in cognitions and mood. Furthermore, DSM-5 adds separate criteria for PTSD in children 6 years old or younger.1 The other Trauma- & Stressor-Related Disorders diagnoses are used when full criteria for PTSD is not met.

DSM-5 criteria for acute stress disorder also differ significantly from those in DSM-IV; as with PTSD, criterion A for acute stress disorder is now more explicit. Since acute post-traumatic reactions are heterogeneous, an individual may meet diagnostic criteria if they exhibit any 9 of 14 symptoms related to intrusion, negative mood, dissociation, avoidance, and arousal.1 Adjustment disorders were reserved in DSM-IV as a residual category for individuals who exhibited clinically significant distress without meeting the criteria for a more discrete disorder. However, in DSM-5, adjustment disorders have been re-conceptualized as a heterogeneous array of stress-response syndromes that occur after exposure to a distressing event.

Assessing PTSD  

PTSD can be diagnosed accurately by a trained mental health professional. The gold standard assessment is the Clinician Administered PTSD Scale for the DSM-5 (CAPS-5), which employs an interview with the patient about trauma and PTSD symptoms. Throughout the course of therapy, the PTSD Checklist for DSM-5 (PCL-5) can be used to monitor PTSD symptoms and as a screening tool. The National Center for PTSD website provides helpful information for both the public and professionals. There also is a Primary Care-PTSD screen assessment available.

Treatment for PTSD and Pain

A multidisciplinary treatment approach to pain has been found to be the most effective method for patients with comorbid chronic pain and PTSD.45 As noted by Sharp, several of the more common causes of chronic pain include traumatic events; thus, it is not unusual for patients presenting with chronic pain to also describe significant levels of distress including PTSD.55 The multidisciplinary treatment model should emphasize helping patients see how the traumatic event may be linked to both their chronic pain and PTSD.

Psychotherapy is the most effective therapy for patients with both pain and PTSD. Patients may benefit from CBTs (exposure therapy, pacing, and activity scheduling) to alleviate both conditions.55,56 According to the APA, prolonged exposure (PE) and cognitive processing therapy (CPT) are among the therapies that have the strongest research evidence for the psychological treatment of PTSD.33 PE is based on the notion that repeated exposure to trauma-related thoughts, feelings, and situations can help reduce distress. PE consists of imaginal exposures (recounting the traumatic memory and processing the revisiting experience) and in vivo exposures (repeatedly confronting trauma-related stimuli that were previously avoided). CPT is based on the notion that by changing the content of cognitions about a trauma, one can impact emotional and behavioral responses to the trauma. CPT focuses initially on the question of why the trauma occurred and then the effects of the trauma on the patients’ beliefs about themselves, others, and the world. Shipherd et al found that CPT may improve pain-related function56 and pain scores57 among veterans suffering from PTSD and chronic pain.

Another controversial therapy with growing research evidence is Eye Movement Desensitization Reprocessing (EMDR). EMDR is based on the notion that PTSD symptoms result from insufficient processing/integration of sensory, cognitive, and affective elements of the traumatic memory. Bilateral eye movements (proposed to facilitate information processing/integration) are paired with cognitive processing of the traumatic memories. Studies that have compared EMDR to exposure therapy without eye movements have found no difference in outcomes.58,59 Thus, it appears that while EMDR is effective, the mechanism of change may be exposure, and the eye movements may be an unnecessary addition.

Although not as effective as psychotherapy, medications may help manage PTSD symptoms.60 These medications, which act on neurotransmitters involved in the fear and anxiety circuitry of the brain, include SSRIs, mood stabilizers, atypical antipsychotics, and benzodiazepines, among other agents. Again, use of a benzodiazepine with an opioid is discouraged.34,35 Most of the time, medications do not entirely eliminate symptoms but provide symptom reduction; they have been shown to be more effective when used in conjunction with psychotherapy.61

In cases of comorbid PTSD and substance use disorder, Seeking Safety has been shown to have strong research support. Seeking Safety is a present-focused therapy to help people attain a feeling of safety from trauma/PTSD and substance abuse. Other psychological treatments also may be effective in treating PTSD, but they have not been evaluated with the same scientific rigor as the aforementioned treatments. Of course, a referral to a mental health professional is recommended for an accurate diagnosis and discussion of various treatment options.

In the next installment of A to Z Mental Health, the author will discuss somatic symptom disorders in patients with chronic pain.

Last updated on: April 12, 2019
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Painful Genetic Diseases

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