Psychologic (affective and cognitive) factors can impact the multidimensional experience of pain by serving to decrease or increase the subjective perception of pain and adjustment to ongoing pain-related disability. Affective factors usually include more negative emotions, such as depression, pain-related anxiety, and anger. Cognitive factors include catastrophizing, fear, helplessness, decreased self-efficacy, pain coping, readiness to change, and acceptance.1,9
Under theDiagnostic and Statistical Manual of Mental Disorders, 5th Edition(DSM-5), individuals with pain disorders can now be diagnosed with a somatic symptom disorder with predominant pain, adjustment disorder, mood disorder (depression or anxiety) associated with a medical condition, or psychologic factors that affect other medical conditions.1-3
Predisposing factors include genetics, neurobiology, and cognitive and social functioning (ie, as described by the biopsychosocial model).4,5
Precipitating factors include illness, infection, trauma, or abuse.
Perpetuating factors include primary and secondary gain and physiologic processes (eg, inflammation).
All appear to play a role in etiology of this condition.3,6,7
Epidemiology including risk factors and primary prevention
Chronic pain significantly predicts onset of new depression, and depression significantly predicts onset of new chronic pain and other medical complaints.8The prevalence estimates of major depression in chronic pain vary from 5% to 87%. In general, most systematic reviews on the relationship between pain and depression suggest that chronic pain precedes depression.8,9
In addition to depression, anxiety related to pain is an important factor involved in maladaptive responses, behavioral interference, and affective distress and is closely related to avoidance activities, which promote ongoing pain. Pain beliefs (pain-related fear and self-efficacy), anger, and passive coping are important affective factors and contribute to maladaptive behaviors.9The prevalence of anxiety disorders in chronic pain is 18% to 21%.10,11
Psychoneuroimmunology suggests that activation of the proinflammatory cytokine network (both at the periphery and central nervous system) can lead to a constellation of sickness behaviors, including alterations in pain sensitivity, such as exaggerated pain response (hyperalgesia), sleep disturbance, and fatigue. The activation of proinflammatory cytokines, possibly acting in concert with stress, might lead to an increased sensitization of the central nervous system, which serves as a possible neuronal substrate for amplification of normative bodily sensations6and affects both serotonin and norepinephrine neurotransmitter systems that appear to exert effects via spinal pathways, subsequently playing a modulating role in pain, sleep, and fatigue.6-8
Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)
In the acute setting, the pain condition may lead to negative thoughts and subsequent maladaptive responses by the patient. Pain beliefs (pain-related fear, self-efficacy), anger, and passive coping can significantly affect pain response further. Then, the presence of chronic pain might be related to longer durations of mood symptoms. Chronic patients with mental disorders can report higher levels of pain and be less active, contributing to greater disability and life interference.9
The common feature of these disorders is the chronicity, social dysfunction, occupational difficulty, increased health care use, and high level of dissatisfaction for both the clinician and patient.12
Specific secondary or associated conditions and complications
The differential diagnoses in individuals with chronic pain and mental disorders include the following:
- Depression: patient suffers from lowering of mood, reduction of energy, and decrease in activity. Capacity for enjoyment, interest, and concentration is reduced, and marked tiredness after even minimum effort is common. Sleep is usually disturbed, and appetite is diminished. Self-esteem and self-confidence are almost always reduced and, even in mild form, some ideas of guilt and worthlessness are often present.7
- Anxiety: dominant symptoms are variable but include complaints of persistent nervousness, trembling, muscular tension, sweating, lightheadedness, palpitations, dizziness, and epigastric discomfort.13
- Hypochondrias: under DSM-5, it is now conceptualized as illness anxiety disorder, where anxiety and preoccupied thoughts of having or acquiring a serious illness must be present for a minimum of 6 months, with minimal or no somatic symptoms. If somatic symptoms are significant, the diagnosis of somatic symptom disorder would be more appropriate.1-3
- Posttraumatic stress: typical features include episodes of repeated reliving of trauma in intrusive memories (flashbacks), dreams or nightmares occurring against a persistant background of a sense of numbness and emotional blunting, detachment from other people, unresponsiveness to surroundings, anhedonia, and avoidance of activities and situations reminiscent of the trauma. There is usually a state of autonomic hyperarousal with hypervigilance, an enhanced startle reaction, and insomnia.13
- Munchausen syndrome (also known as factitious disorder): patient feigns symptoms repeatedly for no obvious reason and may even inflict self-harm in order to produce symptoms or signs. Motivation is obscure and presumably internal with the aim of adopting the sick role. Disorder is often combined with marked disorders of personality and relationships.13
- Malingering: DSM-5 does not consider this as a psychiatric disorder.3Person also feigns illness (with obvious motivation and/or external incentives). This excludes Munchausen syndrome, in which self-harm is a feature.13
- Somatic symptom disorder: key feature is the presence of prominent somatic symptoms with distressing thoughts, feelings, and behaviors about illness lasting more than 6 months. Related disorders include conversion disorder (functional neurologic symptom disorder), illness anxiety disorder, and psychologic factors affecting medical conditions.3
- Adjustment disorder: key feature is the presence of maladaptive psychologic and behavioral symptoms resulting directly from the presence of a medical illness.3
2. ESSENTIALS OF ASSESSMENT
Evaluations are generally based on 3 sources of information: (1) observation and interview of the patient; (2) information from others (eg, family, significant others, other clinicians) that corroborates, refutes, or elaborates on the patient’s report; and (3) medical records.14
The primary assessment tool is direct face-to-face interview of the patient. Evaluations based solely on review of records and interviews of persons close to the patient are inherently limited by a lack of the patient’s perspective. Furthermore, the clinical interview provides a sample of the patient’s interpersonal behavior and emotional processes and can either support or qualify diagnostic inferences from the history.
Key information that should be derived from the interview should include the following:
- Are symptoms minimized or exaggerated by the patient or others?
- Does the patient appear to provide accurate information?
- Do particular questions evoke hesitation or signs of discomfort?
- Is the patient able to communicate about emotional issues?
- How does the patient respond to the clinician’s comments and behaviors?14
Medical history (significant medical problems or prior hospitalizations, history of head trauma), current medications (including psychotropic use), psychiatric history (illnesses, treatment received, outcomes), risk of harm to self or others, legal history, history of alcohol and other substance use, psychosocial history, and review of systems (including other psychiatric symptoms) should also be included.14
The physical examination should be thorough because, even if there are no neurologic findings, a systemic illness may be present that is producing psychiatric symptoms. Vital signs and a detailed musculoskeletal and neurologic examination, including a mental status exam, are of particular importance. Components of a mental status examination include appearance, behavior, speech, attitude, mood, affect, thought process and content, perception, cognition, insight, and judgment.3
Close involvement in the patient’s general medical evaluation and ongoing care can also improve the patient’s care by promoting cooperation, facilitating follow-up, and permitting prompt reexamination of symptomatic areas when symptoms change.14
Structured assessment of physical and instrumental function may be useful in assessing strengths and disease severity. Functional assessments include assessment of physical activities of daily living (eg, bathing, dressing) and instrumental activities of daily living (eg, driving, taking medication as prescribed, shopping, keeping house, caring for a child or other dependent).14The Pain Disability Questionnaire was developed as a measure of functional status of patients with pain and is based on the biopsychosocial approach to pain.4,20
There are no specific guidelines about which tests should be routinely done. Several studies have demonstrated the limited utility and higher cost of ambulatory screening. Patients on psychotropic medications should be monitored for side effects specific to that therapy. When substance use is suspected, determining blood alcohol levels or screening for substances of abuse may be especially important.14,15Examples of tools available for screening for substance abuse/use include the Opioid Risk Tool (ORT), Screener and Opioid Assessment for Patients with Pain (SOAPP), and the CAGE.21
Specialized modalities (eg, computerized scanning, magnetic resonance imaging) can be used to screen for possible causes of delirium (eg, fever, metabolic abnormalities) or neurologic conditions with behavioral manifestations that could be mistaken for a psychiatric disorder (eg, patient with a brain tumor in the frontal lobes might present with a mood disorder).3
Several neuroimaging studies suggest that specific neural networks modulate aspects of emotional behavior and are implicated in the pathophysiology of mood disorders: medial prefrontal cortex and closely related areas in the medial and caudolateral orbital cortex, amygdala, hippocampus, and ventromedial parts of the basal ganglia.16
Supplemental assessment tools
The current methodology and content of psychiatric diagnosis, growing specificity of treatment planning in regard to both medication and psychosocial interventions, and nature of the health care delivery system all influence the context that determines the use of clinical rating scales and neuropsychologic tests to inform assessment and treatment planning.17
Examples of functional domains to be measured and corresponding clinical rating scales include the following: (1) quality of life (eg, Quality of Life Enjoyment and Satisfaction Questionnaire), (2) mental health status and functioning (eg, Clinical Global Impression Scale, Global Assessment of Functioning Scale, Social and Occupational Functioning Assessment Scale), (3) cognitive disorders (Delirium Rating Scale Revised-98, Mini-Mental State Examination), (4) alcohol use disorder (CAGE Questionnaire), (5) mood disorders (Beck Depression Inventory Second Edition, Hamilton Depression Rating Scale, Patient Health Questionnaire, Geriatric Depression Scale), and (6) anxiety disorder (Hamilton Anxiety Rating Scale).14
Neuropsychologic testing has a broad range of application, but the decision to order neuropsychologic testing for an individual patient remains a matter of clinical judgment. Neuropsychologic testing may be requested when cognitive deficits are suspected or there is a need to grade for severity or progression of deficits over time and for distinguishing between cognitive disorders (eg, dementia) and malingering or factitious disorders.14
Early predictions of outcomes
Age (younger age at pain onset), sex (women > men), number of pain areas, frequency and severity of pain, psychosocial problems (problems with social and leisure activities), unemployment, and compensation are mediating factors in the course and prognosis of individuals with chronic pain and mental disorders.3,9,8,10
According to theInternational Classification of Functioning, Disability and Health, environmental factors that can influence the functioning of individuals with mood disorder and chronic widespread pain include the following: medication use, immediate family/friends, health professionals, individual attitudes of family/friends/health professionals, and availability of social security services/systems (ie, aimed at providing income support).18,19
Social role and social support system
An assessment of family, peer networks, cultural identity, and other support systems plays an important part in the psychiatric evaluation because of the potential role of these systems in ameliorating or augmenting the patient’s signs and symptoms of illness. This is particularly true when evaluating individuals with complex biopsychosocial challenges or serious psychiatric or general medical conditions.14
Throughout the assessment, useful clinical information is obtained by being sensitive to issues of development, culture, and the clinician’s own possible biases or prejudices about patient’s subculture, race, ethnicity, primary language, health literacy, disabilities, sex, sexual orientation, familial/genetic patterns, religious and spiritual beliefs, and social class influencing the patient’s symptoms and behavior.14
3. REHABILITATION MANAGEMENT AND TREATMENTS
See Part 2.
4. CUTTING EDGE/EMERGING AND UNIQUE CONCEPTS AND PRACTICE
See Part 2.
5. GAPS IN THE EVIDENCE-BASED KNOWLEDGE
See Part 2.
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Armando S. Miciano, MD
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