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11 Articles in Volume 18, Issue #8
Challenges & Opportunities for Pain Management In Veterans
Chronic Pain and Psychopathology in the Veteran and Disadvantaged Populations
ESIs: Worth the Benefits?
Letters to the Editor: Recovery Centers Reject MAT, Cannabis for Chronic Headaches, Central Pain
Medication Management in the Aging
Pain Management in the Elderly
Pharmacists as Essential Team Members in Pain Management
Photobiomodulation for the Treatment of Fibromyalgia
Plantar Fasciitis: Diagnosis and Management
Slipping Rib Syndrome: A Case Report
What types of risk screening tests are available to clinicians prescribing opioid therapy?

Chronic Pain and Psychopathology in the Veteran and Disadvantaged Populations

A DSM-5 review highlights unique clinical comorbidities in Veterans and disadvantaged patient populations with chronic pain.

The opioid epidemic reflects a serious unmet need for better recognition and treatment of common mental health problems in patients with chronic pain.1 Frontline practitioners may at times be faced with chronic pain patients suffering from undiagnosed mental health disorders when tapering opioid therapy. In most cultures, the majority of mental health cases go unrecognized in primary care settings.2 About 60% of previously undetected cases could have been recognized if the patients had been evaluated for mental health disorders.3

Complicating these assessments is the fact that patients attending pain specialty clinics often have more difficult-to-treat pain conditions and comorbid psychiatric disorders, use more outpatient services, and receive a greater number of opioid prescriptions.These data support the inclusion of mental healthcare in the specialized treatment of chronic pain.

Numerous studies have documented a strong association between chronic pain and psychopathology.5 Research has shown that chronic pain is most often associated with depression, anxiety, somatoform, personality, and substance use disorders, but less is known about pain’s relationship with other mental health conditions, such as schizophrenia spectrum/psychotic, sleep-wake, bipolar, neurocognitive, obsessive-compulsive, and dissociative disorders.

Mental Health in the Elderly(Source: 123RF)

One pivotal study in 1986 delineated the distribution of assigned diagnoses using the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III) published by the American Psychiatric Association for 283 male and female chronic pain patients.Each participant completed an extensive 3-day evaluation period as part of the admission to the Comprehensive Pain Center of the University of Miami School of Medicine. Subjects completed two hours of detailed, semi-structured psychiatric interviews based on DSM-III.

The results of the study found that anxiety and depressive disorders were the most frequently assigned diagnoses. Males were significantly over-represented with intermittent explosive disorders, adjustment disorders, and alcohol abuse and other drug dependence. Females were significantly over-represented with depressive and somatization disorders.6 See Table I for total prevalence.

Population Subgroups

It is well documented that chronic pain is more common in Veterans than the non-veteran US population, most often in the context of severity and comorbidities. Veterans are also at high-risk for harms from opioid medication. In fact, pain is one of the most common reasons Veterans consult with their primary care providers and one of the most prevalent symptoms reported by returning military personnel.7 Almost half of patients within Veterans Affairs (VA) healthcare settings experience pain on a regular basis.8 Previous research has found that past military service may contribute to “hypersensitivity” to pain symptoms.9-11 Pain severity and co-concurrence with mental health comorbidities result in high impact pain. Pain, medical, and/or mental comorbidities are often related to military service and/or require Veteran-specific expertise. Therefore, integrated care, or systematic coordination of medical, psychological, and social aspects of healthcare, is required for high quality pain care.

Chronic pain also disproportionately affects economically-disadvantaged persons, including minority groups, women, and older adults.12,13 Minority groups tend to have higher rates of chronic pain, and greater risk for pain-related disability.14 This demographic also has higher rates of major chronic physical and psychological comorbid conditions.15-17

The following section reviews a pilot study conducted by the author and his research team at the Jesse Brown VA Medical Center in Chicago, IL, between November 2013 and October 2014 that compared the APA’s 5th Edition of the DSM (DSM-5) disorders using emerging measures among Veterans who suffered from mixed, idiopathic chronic pain. These measures may potentially be useful tools to enhance clinical decision-making in a highly disadvantaged population of minorities and women. In addition, the study serves as a replication of previous studies using the most recent version of the DSM-5.18

Methods & Materials

Sample Characteristics

A sample of 272 Veterans ranging from 18- to 89-years-old with mixed, idiopathic conditions (ie, back, neck, extremity, head, and fibromyalgia) were recruited from the Pain Education School program at Jesse Brown VA Medical Center. Veterans voluntarily participated in the program and were free to withdraw at any time. Approximately 29 (11%) dropped before completing the pre-assessment. No exclusion criteria were used. As part of the introduction to the pain education program, all participants completed a pre-education assessment which included the World Health Organization Disability Assessment Schedule (WHODAS 2.0)19 and the DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure-Adult (CCSM-A).20

The WHODAS 2.0 is a 36-item, self-administered measure that assesses disability in adults across six domains (cognition, mobility, self-care, getting along, life activities, and social participation). Each item asks the individual to rate how much difficulty they had in the specific areas of functioning during the past 30 days. The CCSM-A is a 23-item, self-administered measure that assesses 12 psychiatric domains: depression, anger, mania, anxiety, somatic symptoms, psychosis, sleep problems, memory, repetitive behaviors, dissociation, personality, and substance use. Each item inquires about how much (or how often) the individual has been bothered by the specific symptom during the prior two weeks. Analysis of variance was used to evaluate sex differences among the aforementioned psychiatric domains using the GNU PSPP Statistical Analysis Software.21 The “N-1” chi-squared tests were computed as recommended by past studies to compare percentages using the MedCalc software.22-24

  • 243 (89%) participants identified as male; 28 (10%) identified as female; and one person identified as transgender and/or gender nonbinary.
  • 154 (57%) participants were African American; 92 (34%) were Caucasian; 23 (8%) were Latino; and three were of other races.
  • Participants aged 55- to 64-years-old were the most represented age group (37%).
  • Only 10% were between 18- to 24-years-old, and only 6% were 75-years-old or older.
  • Males and females did not differ significantly with regard to age or race.


The WHODAS 2.0 assessed disability in participating adults over the prior 30 days. DSM-5 recommends calculation and use of the average scores for each domain and for general disability.19 In terms of reported disability using the WHODAS 2.0, the average participant reported:

  • mild disability with understanding and communicating (M(13.74)/6 = 2.29);
  • moderate disability with getting around (M(15.25)/5 = 3.05);
  • mild disability with self-care (M(8.42)/4 = 2.11);
  • mild disability with getting along with people (M(11.83)/5 = 2.37);
  • mild to moderate disability with life activities for household (M(10.99)/4 = 2.75) and school work (M(10.26)/4 = 2.57);
  • and mild to moderate disability with participation in society (M(21.22)/8 = 2.65).

The general disability score indicated a mild to moderate overall disability (M(91.18)/36 = 2.53). There was a significant difference among race (F(3,268) = 4.19, P < 0.01) with Latinos reporting more disability (M = 105.78) than Caucasians (M = 97.62), African Americans (M = 86.24), and individuals of other races (M = 35.33).

Program Outcomes

Sleep problems (77%), somatic symptoms (74%), and anger (74%) were the most frequently endorsed domains. Depression (67%), anxiety (60%), and memory problems (54%) were the second most reported with more than half of the sample endorsing the domains (see Table I). The percentage of endorsers of all the domains was significantly different from the original 1986 study aforementioned with the exception of the anxiety and substance use domains.

Males were significantly overrepresented in the substance use domain compared to women (males, n = 20; females, n = 11, F(1,268) = 3.78, P = 0.05). Males were also significantly overrepresented in the mania domain (males, n = 54; females, n = 36, F(1,269) = 3.96, P = 0.05). Females were significantly overrepresented in the anxiety domain compared to men (females, n = 71; males, n = 58, F(1,269) = 3.94, P = 0.05). See also Table II. There were no other significant differences between the sexes on any of the other domains.



The 2016 release of the CDC guidelines on opioid prescribing for chronic pain highlighted the need for frontline providers to assess for risk of overdose or the development of a substance use disorder.25 Recommendations call for the need to implement comprehensive pain assessments, including a diagnosis with appropriate differential and an appraisal of pain level and function. In addition, an assessment should include a psychological evaluation and an evaluation of addiction risk. Frontline providers may benefit from useful tools to enhance clinical decision-making in this regard. Past research has shown that psychological diagnoses are comorbid with chronic pain.6 However, with the release of the DSM-5, the way in which the healthcare community defines these diagnoses has been reformed and, in turn, may change how these domains are represented in the chronic pain population.


The results of the pilot study presented herein indicated that participants reported mild to moderate difficulty in specific areas of functioning and overall general disability. However, Latinos reported significantly higher disability than the other racial groups. Clinical studies in general report ethnic differences in pain perception and response. Minorities (especially Latinos) remain at risk for inadequate pain control. Several other factors may affect how an individual identifies with their ethnic or cultural group, including their gender, age, generation, acculturation, social economic status, ties to their mother country, primary language, degree of isolation, and residence in ethnic neighborhoods. These factors may mediate the relationship between ethnic background and pain.

The percentage of endorsers of all the psychiatric domains was found to be significantly different from the 1986 study aforementioned with the exception of anxiety and substance use disorders. We also witnessed more mania, memory, and repetitive thoughts and behaviors being endorsed in this sample. This may be due to the dimensional versus categorical measurement of DSM-5.18 One must keep in mind that the differential diagnosis of bipolar disorder includes other conditions that may have manic-like symptoms, including organic mood disorders such as endocrine or metabolic conditions, drug intoxications, and tumors. Clinicians may also consider whether the patient truly has memory loss or another cognitive problem. Some degree of memory loss is expected with aging, medications, and depression. Furthermore, it is important to note that the differential diagnosis of obsessive-compulsive disorder (OCD) includes depression, phobic disorders, anorexia nervosa, cluster C personality, and schizophrenia. The significant difference may also be because of a high rate of false positive answers on the measure when used as a screening tool.26 Future studies and/or endeavors in clinical practice should use the lowest threshold.


A number of benefits to these cross-cutting measures should be recognized. The measures are easy to administer, score, and interpret. The measures are self-administered, which facilitates patient engagement in their own assessment and care. Many of the measure items were derived from existing psychometrically sound and valid measures.27 There were also some limitations to using these emerging measures. For example, the CCSM-A fails to measure post-traumatic stress (PTSD), which is prevalent in the Veteran population. However, the differential diagnosis of PTSD does include anxiety disorders, phobias, and OCD, which were represented in this sample. The CCSM-A also fails to measure polarizing or “taboo” disorders, such as neurodevelopmental, feeding/eating, elimination, sexual dysfunction, gender dysphoria, paraphilic, and “process” addictive disorders.


The purpose of the pilot study presented was to compare different types of DSM-5 disorders identified using emerging measures (WHODAS 2.0 and the CCSM-A) among Veterans who suffer from mixed, idiopathic chronic pain. These findings suggest that the CCSM-A may serve as a useful measure to screen chronic pain patients for mental health concerns not just in Veterans but among other vulnerable groups. The items on the CCSM-A represent symptoms commonly seen in clinical practices, regardless of a patient’s subsequent diagnosis. These measures may help providers document all of these symptoms, aid in developing more precise treatment plans, monitor treatment progress, and note improvements even if the symptoms do not disappear completely.

In conclusion, while it is foreseeable that some providers may use these emerging measures as screening tools, these measures may serve better in helping to identify the negative prediction of symptoms. The author hopes to encourage frontline providers to incorporate the use of these emerging measures in the future medical care of Veterans, as well as other vulnerable groups with chronic pain.

Last updated on: November 7, 2018
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