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8 Articles in Volume 16, Issue #8
Genetic Testing in Pain Medicine—The Future Is Coming
Genetic Factors in Fibromyalgia and Chronic Widespread Pain
IV Treatment of Centralized Pain and Headache
Low Back Pain and Osteopathic Manipulative Medicine: A Trend in Pain Management
Clinician as Patient: What I Learned About the Role of Physical Therapy in Pain Management
Mental Health & Vocational Rehabilitation: Information for Pain Management
Neuroinflammation and Peripheral Inflammation—A Big Difference
Letters to the Editor: Genetic Testing

Mental Health & Vocational Rehabilitation: Information for Pain Management

Numerous studies have found a strong relationship between chronic pain and mental health disorders.1 Previous research has shown that chronic pain is most often associated with depression, anxiety, post-traumatic stress disorder (PTSD), personality disorders, and substance use disorders.2 Furthermore, past research has found that the presence of the comorbidity between mental health disorders and chronic pain is associated with an increase in suicidal behaviors and mortality.3

The diathesis-stress model purports that pre-existing characteristics of the patient (genetics) are activated by the onset of chronic pain (environment) and then exacerbated by stress of this chronic condition, eventually resulting in a mental health disorder.1 The stress may result from the physical sensation of pain as well as the secondary losses (financial, physical ability, self-esteem, etc) associated with pain.4

This cycle, known as chronic pain syndrome, is best treated with an interdisciplinary approach.5 Interdisciplinary pain rehabilitation programs are based on a functional restoration approach, involving the use of multiple disciplines, including vocational rehabilitation. Vocational rehabilitation is a process that enables persons with functional, psychological, developmental, cognitive, and emotional impairments to overcome barriers to accessing, maintaining, or returning to employment.6 The following is a review of mental health disorders that are commonly found in patients who suffer with chronic pain—depression, anxiety, and PTSD—and the role of vocational rehabilitation in treatment (see Table 1).

download this Table as a pdf

What Is Depression?

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) contains several depressive disorders, including major depressive disorder (including bereavement), persistent depressive disorder, disruptive mood dysregulation disorder, and premenstrual dysphoric disorder.7

Depression is a state of low mood and aversion to activity that can affect a patient’s thoughts, behaviors, feelings, and physical well-being for a duration of at least 2 weeks. A patient can experience changes in thinking, including problems with concentration, decision-making, and even forgetfulness. Negative thinking leads to pessimism, poor self-esteem, excessive guilt, and self-criticism, which are characteristic of depression.

Some patients who suffer from chronic pain may have suicidal thoughts during a more serious depression. In fact, a review of past studies concluded that suicide ideation, suicide attempts, and suicide completions are commonly found in chronic pain patient populations.8

There are several warning signs that a patient may be suicidal (see Table 2). The role of the provider in these cases is simple—plan for the patient’s safety! A suicide prevention safety plan may include calling the mental health professional with whom the patient is working, referring the patient to the local hospital or emergency room, calling 911 and reporting that the patient is having suicidal thoughts and needs assistance (with the patient’s permission), completing a working and portable safety plan document, and/or giving the patient the telephone number for the national suicide hotline, 1-800-273-TALK (8255).

Changes in behavior may also occur, including excessive crying, temper outbursts, decreases in sexual libido, social discomfort and isolation, neglect of personal hygiene, loss in productivity, and dysania, or difficulty getting out of bed.

Changes in behavior during depression are reflective of the feelings being experienced, such as sadness, irritability, anhedonia (loss of pleasure in activities), lack of motivation, fatigue, helplessness, and hopelessness. Patients who suffer from depression may also experience changes in physical well-being, such as variations in sleep, fluctuations in appetite, deceleration/acceleration in activities, escalation in aches, and increased pain.

Research has shown that depression in patients who suffer from pain is associated with more pain complaints and greater impairment. According to Bair et al, “depression and pain share biological pathways and neurotransmitters, which has implications for the treatment of both concurrently.”9 In addition, when elevated, many of the same neurotransmitters (serotonin, norepinephrine, and dopamine) are associated with both pain and psychosocial disorders.10-14 Numerous clinical trials have revealed a correlation between decreased serotonin functioning and lowered pain thresholds.15-17

What Is Anxiety?

The new DSM-5 contains several anxiety disorders, including panic disorder, agoraphobia, specific phobia, social anxiety disorder, separation anxiety disorder, and selective mutism.7 Anxiety is an emotion characterized by feeling apprehensive and worried (possibly without knowing why), and is accompanied by several physical symptoms, which may include tense muscles, trembling, churning stomach, nausea, diarrhea, headache, backache, heart palpitations, numbness, and/or sweating/flushing. It is easy to mistake symptoms of anxiety for physical illness and become concerned about suffering a heart attack or stroke, which in turn increases anxiety.

Negative thinking is the cornerstone of an anxiety disorder. Pain catastrophizing is a type of irrational thought. Pain catastrophizing is the tendency to describe a pain experience in more exaggerated terms than the average person, to ruminate on it more (eg, “My pain is terrible’”), or to feel more hopeless about the experience (“My pain is never going to get better”). Research on pain catastrophizing has found that catastrophic thinking is associated with a more intense experience of pain, which in turn leads to increased use of health care and longer hospital stays. Simple screening tools are available to identify patients with pain catastrophizing, and treatments that improve outcomes are available.

The DSM-5 chapter on anxiety disorder no longer includes obsessive-compulsive disorder (OCD) or PTSD. However, the sequential order of these chapters in DSM-5 reflects the close relationships among them. The relationship of the neuroendocrine system, especially the hypothalamic–pituitary–adrenal (HPA) axis, to both psychosocial and pain disorders has been well established. The HPA axis is the body’s primary stress pathway, and it is activated by corticotropin-releasing factors from the hypothalamus, which stimulate the release of cortisol from the adrenal glands. Cortisol modulates the metabolism of serotonin, norepinephrine, and dopamine.18

One investigation—which found strong associations between chronic pain and anxiety disorders, such as panic disorder—raised the possibility that improved efforts in detecting and treating anxiety disorders may be required in pain treatment.19

What Is PTSD?

The DSM-5 criteria for PTSD have changed significantly from past classifications.7 The new criteria identify the trigger to PTSD as exposure to actual or threatened death, serious injury, or sexual violation. There are also 4 symptom clusters in PTSD, including re-experiencing, arousal, avoidance, and negative emotional states.7

Re-experiencing symptoms involves reliving the traumatic event in the form of nightmares, memories, or flashbacks. Arousal symptoms can be similar to those experienced in anxiety and can cause difficulty sleeping, outbursts of anger or irritability, and difficulty concentrating. Patients often report being on guard and can become easily startled. Patients who suffer from PTSD also report avoidance symptoms, or efforts made by the patient to avoid reminders of the trauma, such as sights, sounds, smells, or people. Negative emotional states may be another way to avoid the traumatic event. Patients who suffer from PTSD may find it difficult to get in touch with their feelings, report feeling emotionally numb, or feel detached from their loved ones.

Most of the available evidence in the literature has come from studies of PTSD and chronic pain.20 The literature has described common characteristics for patients who suffer from chronic pain. Patients who suffer from chronic pain can often be characterized as possessing a prevailing sense of harm avoidance and lessening of self-directedness, or the ability to regulate and adapt behavior to the demands of a situation. Because of an increase in the diagnosis of PTSD following the wars in Iraq and Afghanistan, many physicians are more familiar with the dual diagnosis of PTSD and chronic pain. This profile has also been shown to predict the presence of a personality disorder.21

What Is a Personality Disorder?

Personality disorders have long been noted in the chronic pain population. The prevalence of personality disorders has been found to be significantly greater in the pain population than in the general, medical, or psychiatric populations.4 Personality disorders are characterized by enduring maladaptive patterns of behavior, cognition, and inner experience and inflexible patterns of long duration that lead to significant distress or impairment.7

DSM-5 lists 10 personality disorders, grouped into 3 clusters: “A” for odd disorders; “B” for dramatic, emotional, and erratic disorders; and “C” for anxious or fearful disorders. Research has found that cluster “C” personality disorders tend to be over-represented in chronic pain populations, which again underlies the role of an anxiety spectrum in chronic pain.22 The management and treatment of personality disorders can be challenging and controversial. By definition, the difficulties experienced by patients diagnosed with a personality disorder have been enduring and affect multiple areas of functioning, which may lead to poor outcomes.

There are several options for treatment of the aforementioned mental health disorders (depression, anxiety, PTSD, and personality disorders) available in the community, including individual psychotherapy, family/couples therapy, group therapy, psychological education, self-help modalities, eye movement desensitization and reprocessing, and psychiatric medications. The goal of treatment is to teach patients healthier coping mechanisms, including taking a walk, talking to friends, trying relaxation exercises, using distraction, writing or reading, and spending time with loved ones—basically whatever works for the patient! Patients seeking mental health treatment can also seek help for relationship problems, stress related to their medical problems, emotional problems (such as anger management), troublesome thoughts or ideas, confused thinking, aggressive or self-harming behaviors, memory problems, substance abuse, homelessness, and vocational issues.

How Are Work And Pain Related?

Pain is the number one cause of adult disability in the US. Approximately 13% of the total workforce reported experiencing a loss in productive time during a 2-week period of employment due to a common pain condition.23 Workers who were missing from productive time due to a pain condition lost a mean of 4.6 hours/week. The majority of the lost productive time (77%) was explained by reduced performance while at work and not work absence.23

A 2010 report by the Institute of Medicine indicated that the annual value of lost productivity ranged between $297 billion and $335 billion.24 The value of lost productivity was based on 3 estimates, including days of work missed, hours of work lost, and lower wages. Furthermore, for many people, employment is an essential part of one’s identity. Work helps patients gain a sense of pride and self-satisfaction, earn money to cover bills and pay for activities during leisure time, expand social networks, develop new skills, and improve general mood and health.Research has shown that work is beneficial while unemployment is associated with poorer physical health, mental health, and well-being.25 Work can be therapeutic and can reverse the adverse health effects of unemployment among many disabled people, patients with common health problems, and social security beneficiaries. Thus, more and more attention is being paid to preventing disability and promoting return to work in pain management.

What Is Vocational Rehabilitation?

Vocational rehabilitation programs have been developed for patients with chronic diseases and consist of a systematic assessment of the problems at work and the development of individual solutions. The aims of vocational rehabilitation are to improve psychosocial skills and implement work accommodations by using several different methods, including education, assessment, counseling, training, and role playing.

The most important outcome measures of vocational rehabilitation are employment status, actions to arrange work accommodations, and psychosocial measures, such as self-efficacy and social competence. Research has found that demographic (age), job-related (activity level), and psychological factors should be emphasized, rather than only physical capacity, in the evaluation of vocational potential and the assessment of disability in patients with pain.26 Jobs should be safe and accommodating for sickness and disability, keeping in mind that the beneficial effects of work outweigh the risks of work, the harmful effects of long-term unemployment, or prolonged sickness absence.25

Vocational rehabilitation interventions emphasize job retention. Those programs that emphasize training in requesting work accommodations and feelings of self-confidence or self-
efficacy in dealing with work-related problems have been found to be effective.27 Psychosociodemographic variables (such as sex and beliefs in vocational return) have also been found to be powerful overall predictors of failures, better predictors of vocational rehabilitation outcomes, and superior to the signs and symptoms recorded by physicians.28 There is strong scientific evidence for vocational rehabilitation for musculoskeletal conditions.29 Not all healthcare providers or systems have vocational rehabilitation programs available (see Table at end of article for a list of State Programs).

The evidence suggests that effective vocational rehabilitation depends on work-focused health care and accommodating workplaces. These are interdependent and must be coordinated with the patient. The concept of early intervention is central to vocational rehabilitation: the longer one is off work, the greater the obstacles to return.

In the first 6 weeks or so, most people with common health problems can be helped to return to work by following a few basic steps, including identifying people after approximately 6 weeks’ sickness absence, directing them to appropriate help, and ensuring the content and standards of the interventions provided. Only 20% of people receiving incapacity benefits for more than 6 months will return to work in the following 5 years.30 For people who are out of work more than approximately 6 months and on benefits, vocational rehabilitation needs to be underpinned by education about the value of work for health and recovery and integrated with management skills. For claimants with mental health problems and for long-term benefit recipients, these efforts may include a work-focused interview to help identify links between functional abilities and task demands in the workplace.

Research studies have identified musculoskeletal disorders31 and contributions from psychiatric conditions32 as the most common causes for long-term unemployment. There are several other reasons a patient may have been out of work for an extended period of time, including a lack of incentive to return to work, previous claims for benefits have been denied, becoming accustomed to being off work, negative impact on work ability due to demands on the body, ineffective management of pain at work, history of being punished at work due to pain, and the perception that exposure to the employer, colleagues, or other aspects of work will lead to relapse.33

Potential responses to this information may include addressing job-related fears and dissatisfaction, fears of reinjury, psychosocial barriers to return to work, adversarial relationships between employer and employee, and workplace accommodations that may be barriers. There is strong evidence which suggests that work disability duration is significantly reduced by work accommodation offers.34

There are a multitude of accommodations to consider, including:

  • allowing use of paid or unpaid leave for medical treatment
  • providing self-paced workload or the ability to modify one’s schedule
  • providing support for maintaining concentration
  • allowing for frequent breaks
  • dividing large assignments into smaller tasks and steps
  • scheduling regular meetings with the supervisor to determine goals and address concerns
  • using organizers, calendars, and daily reminders
  • setting clear expectations of the patient’s responsibilities and consequences for not meeting them
  • establishing long- and short-term goals
  • providing praise and positive reinforcement.

Past research has suggested adopting the traditional disability paradigm in the design of work rehabilitation programs for workers with mental health problems.35

There are special accommodations that can be considered for patients with mental health and addiction concerns, including referring them to counseling or employee assistance programs; providing structure; allowing a flexible schedule for counseling or attendance to Alcoholics Anonymous (AA)/Narcotics Anonymous (NA) meetings;  not mandating job-related social functions with exposure to triggers (eg, alcohol); providing a healthy and sober working environment; avoiding references to drugs and alcohol; and encouraging employees to use company-sponsored health programs.

Vocational rehabilitation efforts for claimants with mental health problems and for long-term benefit recipients may also include support services, such as developing a resume and interviewing skills. Innovative programming that includes obtaining and supervising work trials to help claimants with mental health problems and long-term benefit recipients to acclimate to the routine of work may also be offered along with return-to-work credit or financial support.29

Case Studies

A 55-year-old male veteran reporting lower back pain with radiation to the legs and diagnosed with depression and opioid use disorder was referred to the Compensated Work Therapy (CWT) program by his psychiatrist using the computerized patient record system within a local VA facility. The CWT Transitional Work Experience Program is offered to patients who suffer from both physical and mental health disorders and helps them transition into a regular job in the community. Upon entering the vocational rehabilitation program, the patient was asked about the type of job he would like to have after completing the CWT program. In this case, the patient was interested in working in either carpentry or the driving industry. In addition, the patient and the counselor developed several goals the patient wanted to achieve while in the program, including developing skills in trade work, networking skills with employers, internet job-searching skills, and interviewing skills using a performance-based interviewing style. As a result of participating in the CWT program, the patient is now working as a shuttle driver.

A 30-year-old male veteran reporting fibromyalgia symptoms and anxiety self-referred to the vocational rehabilitation and employment office at the VA regional office by registering online for the VetSuccess program (www.vabenefits.vba.va.gov/vonapp/main.asp). To qualify, he had to have been discharged other than dishonorably, had to have a service connection disability rating of at least 10%, and be within 12 years from receiving the service connection disability. VetSuccess offers several vocational rehabilitation options, including programs catered toward reemployment, rapid access to employment, self-employment, employment through long-term services, and independent living resources. The young man had already received training in counseling. Thus, he was given rapid access to employment working as a counselor in the employment office.

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Last updated on: June 17, 2020

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