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Evaluating the Difficult Pain Patient
R. Katz, M.D., and S. Smith, M.D.,
AMA Guides Newsletter, July/August 2008
It is important to recognize that many patients with persistent somatic and/or pain complaints may have unrecognized psychiatric diagnoses which either drive or complicate their symptoms or complaints. Polatin and Gatchel found 98% of chronic low back patients had one or more psychiatric diagnoses and most commonly major depression, substance abuse, and anxiety disorder. Most psychiatric diagnoses preceded the onset of low back pain. Long had noted that 75% of persons with chronic low back pain had antecedent psychiatric illness. Low management support and low decision authority have been shown to be important factors in which patients develop neck, low back, and general musculoskeletal pain. Previous sick listing in the presence of a family member on disability is a rather important prognosticator for future sick leave and work disability. Distress, depression, and somatization are important predictors of the transition from acute to chronic low back pain and psychiatric comorbidities must be examined closely.
Anxiety is the most common psychological problem in acute pain states while depression is most common in chronic pain conditions. There are a wide variety of diagnoses that may compromise ability of chronic pain patients to function, including somatization disorder, undifferentiated somatoform disorder, conversion disorder, pain disorder, hypochondriasis, factitious disorder, malingering, substance abuse, and dependent personality disorder. Mood, anxiety, and substance abuse disorder are extremely common and each can be associated with physical and pain complaints. Anxiety is a frequent symptom of mood and substance related disorders and can prompt a physician to consider this diagnosis. Each patient should be screened for substance abuse with brief questionnaires, such as the CAGE. Mood disorders may be undetected in more than 50% of primary care populations as patients often present with physical complaints which mimic other conditions rather than expected symptoms of sadness, hopelessness, or loss of pleasure in usual activities. In a study of 500 patients presenting to a general medical clinic with physical symptoms, a mood or anxiety disorder was present 29% of the time.
Somatic symptoms are often the core feature of the depressed patient presenting to primary care physicians. 83% of depressed patients in the primary care provider population presented with somatic symptoms. Predictors of a mental disorder include recent stress, 6 or more physical symptoms, higher patient ratings of symptom severity, lower patient ratings of overall health, and physical perception of the encounter as difficult, and age less than 50.
2/3 of professed patients in a Stanford/Kaiser study had chronic pain which could include headache, chronic back pain, limb or joint pain.
Health care utilization increases dramatically in patients with mood or anxiety symptoms, even when controlled for medical comorbidity in demographic covariates.
Somatoform disorders are a spectrum of psychiatric disorders where physical complaints are driven or aggravated by psychological factors. The full-blown syndrome, somatization disorder, requires a history of many physical complaints, including 4 pain symptoms, two G.I., one sexual, and one pseudoneurological. The constellation generally begins before age 30 and markedly disrupts the patient’s lifestyle.
The key features of somatization disorder include numerous vague and dramatic physical symptoms, generally affecting different organ symptoms, which frequently wax and wane; conversion symptoms including neurologic; vague and ill-defined pain; menstrual problems; sexual problems; G.I., G.U., and cardiopulmonary complaints; and symptoms beginning in adolescence or in the 20s.
The authors refer to a new multi-somatoform disorder which has been suggested which is defined as 3 or more medically unexplained, currently bothersome physical symptoms, plus a long history of somatization. The authors note the key features of undifferentiated somatoform disorder, which includes multiple physical complaints, symptoms that cannot be fully explained by a general medical condition or drug side effects, complaints or impairments excessive in light of general medical condition, and duration of greater than 6 months.
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Does Social Pain Equal Physical Pain?
The Back Letter, vol. 24, no. 10, October 2009.
Lippincott, Williams & Wilkins, p. 111
The field of spinal medicine has consistently underestimated and even ignored the role of social influences in the etiology of back and neck pain. Yet social factors, social standing, social inclusion, social deprivation, job security, and job satisfaction appear to play a powerful role in the way individuals develop a response to pain. One can make a strong argument that organized medicine has exacerbated the modern back pain disability epidemic by not addressing the social underpinnings and social consequences.
They referred to Z. Chen, et. al, Psychological Science, 2008, in which they reported that social pain is as real as intense and intensive physical pain and social pain systems may have piggybacked on a brain structure that had evolved for physical pain. They stated that humans are dependent creatures whose survival was founded on the quality of our social bonds. When those social bonds are disrupted, this also constitutes a threat to survival. They refer to a report from UCLA noting evidence that pain of physical origin and pain of social origin employ some of the same anatomic factors. Ability to regulate pain in humans depends on the function of the brain’s MU-opioid system and its ability to buffer pain in the production of natural opioids. The ability to regulate pain through the MU-opioid system appears to vary considerably from individual to individual. Some of this variation relates to genetic structure. For instance, researchers have identified a variant of the MU-opioid receptor gene (OPRMI) that seems to confer unusual vulnerability for pain of physical origin. They found that individuals with the rare form of the OPRMI gene were shown in previous work to be more sensitive to physical pain and also reported higher levels of rejection sensitivity and showed greater activity in social pain-related regions of the brain, the dorsal anterior cingulated cortex and anterior cingula in response to being included per Eisenberger at UCLA.
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“Instinct v. Standardized Questionnaire:
The Spine Specialist’s Ability to Detect Psychological Distress.”
Michael Daubs, M.D., et. al
Spine Journal 8 (2008, 1S-191S)
Proceedings of the 23rd Annual Meeting of
the North American Spine Society,
October 15-18, 2008.
400 patients with spinal disorders were studied in a prospective blinded study. Each patient was requested to complete a Distressed Risk Assessment Method questionnaire, and 4 categories were categorized in this questionnaire. These included normal, at-risk, distressed depressive, and distressed somatic. The physicians who were part of this study were blinded to the results of the DRAM, and they performed their own clinical psychological assessment based upon their examination of the patient. These physicians were either spinal surgeons or physiatrists. 37% of these new patients were categorized as normal, 42% as at-risk, 15% distressed depressed, and 9% distressed somatic. The physiatrists correctly assessed patients 44% of the time and surgeons were correct 40% of the time. As a group, physiatrists correctly assessed patients 44% of the time, surgeons were correct 40% of the time, and non-operative specialists were correct 49% of the time. They found that non-operative specialists were better at detecting patients in the more distressed categories. The authors concluded that a number of patients with spinal disorders have significant psychological distress, and spine specialists as a group are not good at clinically assessing psychological distress. They further point out that psychological distress is a predictor for poor treatment outcomes. The authors lastly conclude that a validated questionnaire such as the DRAM that assesses psychological distress should be used routinely. They state that the results of these questionnaires should be one of the factors considered when making operative and non-operative treatment decisions.
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Psychological Factors in Chronic Back Pain
George E. Becker, M.D. and Randall Smith, Ph. D
Published in Managing Back Pain, by Kirkaldy-Willis
Churchill Livingston, 1999.
Page 112, section entitled Somatization.
Somatization is experiencing and expressing emotion in physical terms. Lipowski suggests a comprehensive, albeit succinct, definition: “ A tendency to experience and communicate somatic distress and somatic symptoms, driven by emotional and psychological factors, unaccounted for by relevant pathologic findings, to attribute them to physical illness and to seek medical help for them”.
The depressive and anxiety disorders account for the majority of cases of somatization in practice today. At least 80% of patients suffering from depression are initially seen and evaluated by primary care physicians. Most of these patients have physical complaints, such as chronic back pain. As a group, they tend to minimize, if they recognize at all, the psychological determinants of their symptoms. They are characteristically very resistant to understanding the emotional and psychological conflict that fuel their symptoms. This makes treating them difficult and challenging although not always impossible.
It is important to remember that somatization and organic pathologic states can and usual do coexist. The somatizing back pain patient usually has experienced some sort of physical injury. The injury in many cases is assessed as trivial, and prompt return to normal function is anticipated by the examining physician. It is only when the patient does not enjoy the anticipated timely recovery that the first clues to the somatization diagnosis are evident. At this point in the patient’s course, it may be noted that there are few if any objective findings to subjective complaints on an organic basis. Meanwhile, the list of complaints lengthens. In some cases, symptoms proliferation may come to involve the whole body. Somatizing patients characteristically get worse rather than better with the passage of time. They are refractory to virtually all treatment modalities, particularly those requiring active participation. They frequently experience and report undesirable side effects associated with medications, and they are particularly prone to iatrogenic prescription narcotic dependance. They may be seen as over-reactors in having motivation problems. Above all, they are a source of frustration to the physicians trying to help them back to healthy as it seems, but no matter what approach is tried it always fails.
Patients invariably repeat as a litany how independent they have always been, how they hate being unable to work and support their families, how they hate being taken care of and how intensely they want to return to work. The only problem they relate is to get rid of the pain for them and they will go back to work.
Editorial Comment: This is one of the most pertinent and relevant passages from any scientific paper or referenced text in the context of spinal care and for the back care community at large. For those healthcare providers that see accident or injury related claims, and particularly those that are involved in litigation and/or with Workers Compensation Claims, these are very important guidelines to bear in mind when evaluating the patient. Many patients do not present with somatization disorders, however, there are a sufficient number who do that make it necessary for the practitioner to be aware of these observations.
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Spine Care Providers Fall Short in Detecting Psychological Distress
The Back Letter volume 24 #2 February 2009
Studies have demonstrated that psychological distress, particularly depression and anxiety can influence the presentation of low back pain, confound its assessment in diagnosis, and hinder the recovery. They state that many or most back care providers do not use validated methods of detecting psychological distress, relying instead on their own clinical instincts in addressing these problems. The authors cited a study by Daubs et al 2008 demonstrating that physicians’ clinical instincts were no match for a short validated psychological questionnaire. This study further noted that spine specialists might be harming their patients’ chances of recovery as a result. They further quoted Dr. Daubs as stating that overall we were very poor at accurately assessing psychological distress using our instincts and our clinical skills. Psychological distress is a known predictor of poor surgical and overall treatment outcomes. Validated questionnaires should be used routinely and we need to consider the results in our decision making process. The authors recommended the utilization of DRAM, (distress risk assessment method) questionnaire.
They made reference to the question raised by Dr. Daubs regarding what you do with psychologically distressed patients who have clear surgical pathology? You still operate on these people? Dr. Daubs noted that the appropriate response to this would be that the important words in that question are “clear surgical pathology”, and acknowledging that there were some forms of surgical pathology for which a surgery would be recommended despite the presence of psychological distress which would include myelopathy and progressive motor weakness. Precautions were noted, however, regarding that most of the cases we treat are elective treatment options, and in a lot of these patients we are treating pain. Back pain is difficult to treat even when we believe that we know where the pathology is.
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