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13 Articles in Volume 18, Issue #6
Authorities’ Use of Big Data May Harm—or Help—Your Chances of Investigation
Gaps in the Pharmacist’s Pain Management Role
How can cyproheptadine manage complicated chronic pain cases?
Letters to the Editor: Trackable Pills; Buprenorphine; CRPS Diagnosis
Managing a New High-Dose Opioid Patient
Managing Opioid Use Disorder
Medication Selection for Comorbid Pain Management (Part 2)
Mobile Trackers and Digital Therapeutics
New Insights in Understanding Chronic, Central Pain
Nocebo Effects: How to Prevent them in Patients
Polarizing Topics in Chronic Pain
The Fight to End Peripheral Neuropathy
Urine Drug Monitoring

Polarizing Topics in Chronic Pain

A review of the less reported DSM-5 categories.

Despite numerous studies documenting a strong association between chronic pain and psychopathology,1 there is still scant research into certain related mental health categories, such as neurodevelopmental, feeding and eating, elimination, sexual dysfunction, gender dysphoric, paraphilic, and “process” or behavioral addictive disorders. Some of these mental conditions are less polarizing, or “taboo,” than they were in the past while others are considered more opposing than ever. Even though these disorders seem very different, they all may bring discomfort to patients when discussed. The following summary describes these conditions according to the most recent edition of the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM-5),2 and provides insights into their relationship with pain as well as available treatments for each. Table I provides the prevalence rates of these disorders.

Neurodevelopmental Disorders

Neurodevelopmental disorders categorized in DSM-5 include intellectual disability, communication, autism spectrum, attention deficit/hyperactive, motor disorders, and specific learning disorders.2-4 Diagnostic criteria for intellectual disability (previously termed mental retardation) include deficits in cognitive capacity beginning in the developmental period. Communication disorders include language, speech sound, childhood-onset fluency (stuttering), and social (pragmatic) communication disorders. Autism spectrum disorder encompasses autism, Asperger’s, childhood disintegrative, and pervasive developmental disorders, and is characterized by deficits in social communication and social interaction, and restricted repetitive behaviors, interests, and activities. Attention-deficit/hyperactivity disorder (ADHD) diagnostics have remained unchanged since DSM-IV, but the condition was moved into the neurodevelopmental disorders chapter of DSM-5 to reflect brain developmental correlates. Motor disorders include developmental coordination, stereotypic movement, Tourette’s, persistent (chronic) motor or vocal tic, provisional tic, and other tic disorders. Specific learning disorders combine reading (dyslexia), mathematics (dyscalculia), written expression, and so forth.2

Chronic pain has been shown to be a significant problem for individuals with intellectual disabilities.5 Caregivers in one study of chronic pain in adults with an intellectual disability reported that 15.4% of their sample experienced chronic pain for an average of 6.3 years. Significantly more females than males reported pain, although age, communication ability, and level of intellectual disability were not found to be associated with pain.

The presence of pain was also associated with other disabilities/healthcare problems, including physical disability, cerebral palsy, or problems with mobility. In addition, the study investigated the impact of pain on emotional well-being. Caregivers reported that the chronic pain led to anxiety, self-injury, depression, and challenging behaviors.5

Feeding and Eating Disorders

Disorders categorized underfeeding and eating include pica, rumination, avoidant/restrictive food intake, anorexia nervosa, bulimia nervosa, and binge-eating disorders.2,6-10 Pica and rumination disorder have been revised in DSM-5 for clarity and to indicate that the diagnoses may be made for individuals of any age. Avoidant/restrictive food intake disorder is a broad category intended to capture those who substantially restrict their food intake and experience significant associated physiological or psychosocial problems but do not meet criteria for other eating disorders. Anorexia nervosa has remained conceptually unchanged from DSM-IV, including that the individual must be at a significantly low body weight for their developmental stage. Bulimia nervosa also remains unchanged with the patient engaging in binge eating and inappropriate compensatory behavior once a week. Binge-eating disorder requires the person to engage in a minimum average frequency of binge eating at least once weekly over the prior 3 months. Of note, lifetime bulimia nervosa and binge eating disorders have significant associations with numerous physical conditions.2 The odds of bulimia nervosa and binge eating disorder predicting musculoskeletal pain (1.6 to 2.8) and other pain conditions (1.9 to 2.8) are generally comparable.11 There is no research currently available linking the other feeding and eating disorders to chronic pain.

Elimination Disorders

Elimination disorders listed in DSM-5 include enuresis and encopresis; primarily affecting children, their descriptions essentially remain unchanged from previous DSM versions.2 Along with these conditions, gastrointestinal symptoms, like constipation, may also be experienced by some patients. Functional urological and gastrointestinal disorders are interrelated and characterized by a chronic course and considerable treatment resistance. A study led by Walker et al. investigated whether functional abdominal pain among adolescents predicted functional gastrointestinal disorders with chronic pain in adults.12 The study found that two-thirds of adolescents with a high pain dysfunctional profile would later develop a pain-related gastrointestinal disorder.12 These adolescents were characterized by low perceived pain coping efficacy and high levels of negative affect, pain catastrophizing, and functional disability.12 The most frequent problem in adults in urologic practice is recurrent or chronic genital pain with no physical cause.13 Despite the frequency of the problem, very little has been written about genital pain and various approaches to treatment have been generally ineffective.13

Sexual Dysfunctions

Disorders tied to sexual dysfunction include delayed ejaculation, erectile, female orgasmic, female sexual interest/arousal, genito-pelvic pain/penetration, male hypoactive sexual desire, premature (early) ejaculation, and substance/medication-induced disorders.2,14-17 Sexual dysfunctions may be referred to as sexual pain or as a disturbance in one or more phases of the sexual response cycle. According to DSM-5, these disorders now require a minimum duration of approximately six months and more precise severity criteria. Genito-pelvic pain/penetration disorder is new in DSM-5 and represents a merging of vaginismus and dyspareunia, which are highly comorbid and have been difficult to distinguish.2

In one trial investigating sexual difficulties in 237 patients with chronic pain in inpatient and outpatient pain programs, 73% of respondents reported pain-related difficulty with sexual activity; there were few differences between men and women.18 Most of the respondents had several difficulties and in various combinations, including arousal, positioning, performance, and relationship issues; positioning was the only issue not associated with less frequent sexual activity.18 Another study by Kwan et al, found that sexual dysfunction may be predicted by psychological factors and pain duration, but other issues, such as sleep and activities of daily living, have more of a significant impact on quality of life.19

Gender Dysphoria

Gender identity disorder, or gender dysphoria, is considered to be a multicategory concept rather than a dichotomy.2 A post-transition specifier has been added to DSM-5 because many individuals after transition no longer meet criteria for gender dysphoria.2 Chronic pain has been found to have a negative impact on an individual’s gender identity, or their subjective sense of being a man or a woman.20 In a study led by Bernardes et al, both laypeople and nurses perceived men with chronic pain as less masculine and more feminine; women with chronic pain as more masculine and less feminine; and the men and women were more perceived as similar to each other than other men/women.21 When it comes to transgender and/or gender nonbinary individuals, increased pain, especially in the areas of the body that change as a result of cross-sex hormone treatment, is often experienced.22 A research study by Alioisi et al, found that about 30% of male-to-female patients reported headaches, breast, and musculoskeletal pain, while about 62% of female-to-male patients reported pain that improved after testosterone administration.22

Paraphilic Disorders

These disorders include voyeuristic, exhibitionistic, frotteuristic, sexual masochism, sexual sadism, pedophilic, fetishistic, and transvestic disorders.23-28 Paraphilias (eg, an erotic focus on a person or a sexual act) are not in themselves mental disorders. There is a distinction, for example, between paraphilias and “paraphilic disorders.” The DSM-5 does not automatically label nonnormative sexual behavior as psychopathological. A paraphilic disorder is a paraphilia that is currently causing distress or impairment to the individual or a paraphilia whose satisfaction has entailed personal harm or risk of harm to others.2

Information about the relationship between paraphilic disorders and chronic pain is lacking. In regards to paraphilias, however, it is estimated that 29% of men with pain were not able to fantasize about a sexually attractive person; erotic parts of a body; erotic or romantic situations; caressing, touching, undressing, or foreplay; and/or sexual intercourse, oral sex, touching to orgasm.29

“Process” or Behavioral Addictive Disorders

There are two disorders in the DSM-5 considered to be “process” addictive disorders: gambling disorder (found in the substance use and addictive disorder chapter) and internet gaming disorder (found in the under conditions for further study chapter).2,30 However, other addictive conditions may be found in the literature, such as video game, food, shopping/spending, exercise, and sex addiction. There is some evidence that these behaviors activate the brain reward system with effects similar to those of substance use (reinforcing behaviors and producing memories).2 These addictive behaviors may produce an intense activation of that system, which then triggers the reward pathways and causes a “high,” leaving normal brain activities neglected. Little has been documented regarding problematic internet usage.31 Some addiction recovery institutions have begun to treat those suffering from internet addiction after seeing the power of screening for other process addictions, especially gambling.31

Managing Mental Health Disorders and Chronic Pain Together

A first step in addressing any of these conditions is to ask open-ended questions about them while taking a patient history or doing an assessment. Frontline providers may steer away from addressing these conditions because it is difficult to find the balance between sensitivity and truth when speaking about perceived polarizing, or “taboo” topics. Providers may best be able to address concerns related to these topics when they listen without judgment, express empathy, stay concise, and keep a check on their body language. Prescribing for pain should be approached with caution at all times, but especially more so in the presence of these conditions due to their potential effects. Thus, medical providers need to screen their patients who suffer from pain for these psychological conditions, and facilitate a referral to a mental health professional for treatment if needed.

Each of the diagnostic categories listed herein requires a slightly different approach to treatment. Supportive services, for example, are the most common and effective for individuals with neurodevelopmental disorders. These services may include behavioral therapy, education, speech therapy, physical or occupational therapy, and family or supportive counseling.32 When it comes to ADHD, the strongest research support is for cognitive behavioral therapy (CBT).33

Feeding and eating disorder treatment may include psychotherapy, nutrition education, medication (eg, antidepressants), hospitalization or day programs, and ongoing treatment for other health problems (eg, dental, bone density, menstruation).34 For anorexia nervosa, there is modest but controversial research support for CBT. On the other hand, bulimia nervosa and binge-eating disorders have strong research support for CBT and interpersonal psychotherapy; bulimia nervosa also has modest support for family-based treatment.33 The most common treatments for elimination disorders include behavioral therapy, reward systems (eg, moisture alarms and sensors), dietary changes, and/or pharmacological options.35

Different services may be offered to address sexual dysfunction, including: sex education; coaching;36 sensate focus (ie, discovering erogenous zones through non-genital stimulation);37 vacuum devices and intracavernosal injections;38 and pharmacological agents and herbs.39 To be clear, gender dysphoria is neither a sexual dysfunction nor a paraphilia. It is managed with a combination of psychotherapy, hormone therapy, social gender role transition, and/or surgery.40 Treatment for paraphilic disorders may include psychotherapy, pharmacology, and/or historically surgical intervention.41

With clinical impulse control disorders such as gambling and internet gaming addiction, psychotherapy, medications, and self-help groups may help.42 Twelve-step programs may also be utilized.

The prevailing psychotherapeutic approach for all of these conditions is CBT. Cognitive behavior therapy provides a structured, time-limited, present-focused approach to helping patients engage in an active coping process aimed at changing maladaptive thoughts and behaviors that may otherwise serve to maintain and exacerbate the experience of their mental health condition and chronic pain. CBT protocols introduce cognitive concepts, such as automatic thinking and cognitive restructuring, and behavioral strategies, such as relaxation techniques. At the end of the intervention, patients create a plan on how to use the skills learned when they become aware they have relapsed.

Last updated on: September 5, 2018
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