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9
Psychiatric Aspects of
Chronic Pain
The previous chapter dealt with normal social
and psychological processes that influence the
course and expression of chronic pain. There is also evidence that
chronic pain is associated with mental disorders and substance abuse,
although the nature of the relation, especially in terms of cause and
effect, is often unclear. Just as there is diversity among chronic pain
patients in general, so, too, are individuals with chronic pain and
psychiatric disorders a heterogeneous group: many have affective
disorders (particularly depression); others super from substance abuse,
personality disorders, and various somatoform disorders such as con-
version, hypochondriasis, and somatization disorder (not to be con-
fused with "somatization" as a normal process, as discussed in Chapter
81. In some patients, certain of these varied disorders may be secondary
to chronic pain, but in others they predate the onset of pain or reflect
alternative expressions of the same underlying psychobiological disor-
der. Whatever their etiological significance, each of these psychiatric
disorders may exacerbate the pain condition and impede recovery.
Identification and treatment of any mental disorder or substance abuse
problem that may be present is essential to the successful rehabilita-
tion of individuals with chronic pain. At the same time, clinicians must
be careful not to presume that chronic pain complaints that cannot be
accounted for readily by physiological findings are due to psychiatric
disorders. As discussed in Chapter 10, clinical assessments performed
very early in the course of a disease may not reveal the underlying
cause of pain. Thus, it is important to pursue both physiological and
165
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166 INFLUENCES ON PAIN AND PAIN BEHAVIOR
psychological assessments to make certain not to overlook important
diagnoses that may account for the pain either alone or in combina-
tion.
EPIDEMIOLOGY OF CERTAIN PSYCHIATRIC DISORDERS
Depression is one of the most pervasive and, paradoxically, least
well diagnosed and treated conditions confronting medical practition-
ers. As a syndrome it is often associated with symptoms of anxiety. The
National Institute of Mental Health (NIMH) Epidemiological Catch-
ment Area (ECA) project, a community population survey conducted in
five areas of the United States using a structured diagnostic interview
with community residents, has provided useful data on the prevalence
of various mental disorders (Regier et al., 1984; Myers et al., 1984; Robins
et al., 1984; Blazer et al., 1985~. Six-month prevalence of affective
disorders ranged from 4.6 to 6.5 percent in three ECA sites; prevalence of
anxiety/somatoform disorders varied far more widely, from 6.6 to 14.9
percent (largely because of differences across sites in rates of phobic
disorders). We can thus conclude that depression is a common illness.
Anxiety and somatoform disorders are even more common.
Several studies from the ECA project show that individuals with
affective disorders seek medical care more often than individuals
without psychiatric disorders, they often seek care for medical or
somatic symptoms (including pain) rather than for psychiatric symp-
tams, and they often are only seen in the general medical care sector
(Shapiro et al., 1984; Horgan, 1975; Regier et al., 1978). Weissman et
al. (1981) also have identified increased use of both general health and
mental health services by those with depression, but they noted that
the overall proportion of those who receive any treatment at all
directed toward their mental disorder is low. Keller et al. (1982) report
that even among those who do receive some treatment for depression it
is likely to be inadequate. Finally, those with depression who do not
receive treatment for their emotional problems make relatively fre-
quent visits to nonpsychiatric physicians. Depressed individuals use
health and mental care services more than most individuals with other
diagnosable psychiatric disorders.
Surveys of medical clinic populations corroborate the findings from
the epidemiological studies. For example, in one study of a primary
care clinic, 35 percent of the study group exhibited at least one
psychiatric disorder at one of two interviews conducted 6 months apart
(Kessler et al., 19851. Various studies have identified between 10 and
40 percent of ambulatory medical patients as depressed on standard-
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PSYCHIATRIC ASPECTS OF CHRONIC P~N 167
ized rating scales or structured diagnostic interviews (Glass et al.,
1978; Nielsen and Williams, 1980; Goldberg, 19791. The higher rates
may be associated with the use of screening instruments that score
somatic symptoms as part of depression (see last section of this
chapter). The highest reported rates (approaching 50 percent of pa-
tients seen in ambulatory practice) probably reflect an intermixture of
depressive, anxiety, and somatic symptoms. Studies using standard-
ized diagnostic interviews, such as the Schedule for Affective Disorders
and Schizophrenia (SADS), report a Tower but still significant preva-
lence of major depression in medical clinic populations. Despite differ-
ences in the methodologies, all of these studies document that psychi-
atric disorders, when present in patients seen in medical clinics, are
not routinely diagnosed or appropriately treated. It appears that like
their patients, physicians in these settings tend to focus on "medical"
or somatic symptoms rather than recognizing emotional factors or
psychiatric disorders.
CHRONIC PAIN, DEPRESSION, AND ANXIETY
A substantial amount of research has explored the possible relation
between depressive disorders and chronic pain (Gupta, 19861. Studies
have reported widely varying prevalence of both depressive symptoms
and diagnosable depression in pain patients (1~87 percent), as well as
widely varying prevalence of pain symptoms in clinically depressed
patients (27-100 percent) (Romano and Turner, 19851. Discrepancies
in the reported prevalence of depression in patients with chronic pain
result from the use of different instruments to measure depression
with varying sensitivity and specificity (Rodin and Voshart, 19861.
These discrepancies also result from a failure to distinguish between
the presence of various depressive symptoms (e.g., tearfulness, laciness,
diminished interest in activities, etc.) and the presence of a specific
affective disorder, particularly diagnosable major depression (a rela-
tively well-defined syndrome characterized by prolonged disturbance
of mood or pervasive lack of interest or pleasure; the presence of many
other cognitive, vegetative, and psychological symptoms of depression
associated with alterations of brain neurotransmitters and hormonal
systems; as well as disturbances of the autonomic nervous system,
circadian rhythm, and rapid eye movements during steep) (American
Psychiatric Association, 1980~. In a recent study of 283 consecutive
admissions to a comprehensive pain center, extensive psychiatric
evaluations based on the Diagnostic and Statistical Manual of Mental
Disorders (DSM-lII) (American Psychiatric Association, 1980) re-
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168 INFLUENCES ON PEN ED PEN BEHAVIOR
vealed that half of the men and almost two-thirds of the women
suffered from affective disorders and that anxiety disorders were
present in 59 percent of men and 66 percent of women (Fishbain et al.,
19861. Thus, the preponderance of studies suggest that there is a
considerable association between chronic pain, depressive symptoms,
and major depression (Romano and Turner, 19851. This association can
be conceptualized in a number of different ways.
Chronic Pain, Depression, and Somatoform Disorders
The essential features of somatofor~n disorders "are physical symp-
toms suggesting physical disorder. . . for which there are no demon-
strable organic findings or known physiological mechanisms and for
which there is positive evidence, or a strong presumption, that the
symptoms are linked to psychological factors or conflicts" (American
Psychiatric Association, 1980~. Several specific syndromes are ciassi-
fied as somatoform disorders, including hypochondriasis, conversion
disorder, psychogenic pain disorder, and somatization disorder. Unlike
malingering, the symptom production in somatoform disorders is not
under voluntary control.
One way of conceptualizing the association between chronic pain
and depression is to consider chronic pain as a particular type of
somatization the expression of feelings through bodily complaints,
including pain; somatization often occurs in the absence of conscious
awareness of the underlying feelings. Blumer and Heilbronn (1982)
describe a "pain prone disorder" as a variant of a depressive disorder.
They identify a constellation of (1) somatic complaints, including
continuous pain of obscure origin, hypochondriacal preoccupation, and
desire for surgery combined with (2) depression as evinced by anergia,
fatigue, ~nhedonia, insomnia, and depressed or despairing mood with
(3) certain personality factors. They characterize these patients as
solid citizens who deny conflicts, idealize self and family, and were
"workaholics" prior to the onset of pain. Further, such individuals tend
to have a family history of depression and alcoholism and commonly
have family members who are handicapped or afflicted with chronic
pain.
Chronic pain is considered by some authors to be the most common
form of somatization in American society (Katon et al., 19841. As
discussed in the previous chapter, everyone somatizes to some extent,
but in some individuals and cultural groups the tendency to somatize
is more exaggerated than in others. This tendency to somatize is
different from somatization disorder, a specific clinical syndrome.
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PSYCHIATRIC ASPECTS OF CHRONIC PAIN 169
Somatization disorder (formerly subsumed under the term hysteria)
is a chronic psychiatric condition beginning before age 30, more
commonly in women than men, in which the sick person has many
physical complaints and impairments either in the absence of organic
pathology or greatly in excess of the degree of pathology. Somatization
disorder has rather rigid and lengthy diagnostic criteria (14 symptoms
from various body systems). The symptoms are multiple, shifting, and
often vague, affecting a number of organ systems (gastrointestinal,
cardiopulmonary, neurological, or reproductive). Pain is a frequent
complaint, as are depressive symptoms. Usually the affected person
repeatedly seeks medical care (American Psychiatric Association,
19801. Many chronic pain patients involved in the disability process
have traits of this disorder without meeting the full DSM-Ill criteria.
Fishbain and his colleagues (1986) made the diagnosis of somatization
disorder in 0.6 percent of men and 8 percent of women in their study of
283 admissions to the University of Miami Comprehensive Pain
Clinic. Similarly, Reich and colleagues (1983) diagnosed somatization
disorder in none of the men and in 12 percent of the women in a series
of 43 consecutive chronic pain patients who had not responded well to
conventional treatment.
In the absence of coexisting major depression, clinicians have found
that pharmacological interventions and psychodynamic psychothera-
pies are often of little value in the treatment of somatization disorder.
There are reports, however, that certain modifications in psycho-
dynamic psychotherapy do seem useful—especially in the treatment
for patients with alexithymia (an inability to perceive and express the
mental component of their feeling state) (Krystal, 19791. A cognitive
and behavioral approach may also be helpful (Katon et al., 1982a,b). A
central goal in the management of somatization disorder is to keep
these patients from unnecessary surgery, expensive and potentially
dangerous tests, and polypharmacy with untoward side effects and
potential addiction to analgesics or sedatives. Such an approach
requires primary care physicians to be well-informed, empathic, and
protective. The utility of making the diagnosis of somatization disorder
is to prevent these problems as well as unnecessary costs to the patient
and the medical care system.
Several other somatoform disorders may be present in patients
with pain. Some people with conversion disorder (characterized by an
involuntary "loss or alteration in physical functioning that suggests
physical disorder but which instead is apparently an expression of a
psychological conflict or need"; American Psychiatric Association,
1980) have chronic pain as a symptom, although if pain were the only
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170 INFLUENCES ON PEN ED PEN BEHAVIOR
symptom, the diagnosis would not be appropriate. In Fishbain and his
colleagues' (1986) study, this was the most common somatoform
disorder diagnosed (42 percent of men and 32 percent of women). On
the other hand, Reich and colleagues (1983) found only 2 cases out of
their series of 43 pain patients (less than 5 percent).
A predominant complaint of pain "in the absence of adequate
physical findings and in association with evidence of the etiological
role of psychological factors," but without other mental disorder, is the
essential feature of psychogenic pain disorder. There has been consid-
erable controversy about the implications of this diagnosis when used
in clinical care; it will be replaced with the more neutral term
"somatoform pain disorder" when DAM- is revised by the American
Psychiatric Association in 1987. Because the establishment of the
diagnosis rests heavily on the exclusion of all organic causes for pain,
there is great variability in the frequency with which it is used. For
example, at the University of California at Davis, 20 percent of men
and 32 percent of women with chronic pain were diagnosed with
psychogenic pain disorder (Reich et al., 19831. However, at the Uni-
versity of Miami, where 85 percent of pain patients were given an
"organic treatment diagnosis" of myofascial pain syndrome, none of
the women and only 0.6 percent of the men were classified as having
psychogenic pain disorder (Fishbain et al., 19861. On the basis of their
own clinical experience, members of the Commission on the Evalua-
tion of Pain and of the Institute of Medicine (IOM) study committee
believed this diagnosis to be relatively uncommon in adults and not
often very useful. Furthermore, the Social Security A~ninistration
(SSA) reports that the diagnosis of psychogenic pain is rarely the basis
for disability determinations.
Nypochondriasis is another somatoform disorder that may involve
pain. "The essential feature is a clinical picture in which the predom-
inant disturbance is an unrealistic interpretation of physical signs or
sensations as abnormal, leading to preoccupation with the fear or
belief of having a serious disease" (American Psychiatric Association,
19801. Thus, hypochondriasis is distinguished from somatization dis-
order by the fear of disease rather than the amplification and genera-
tion of symptoms. What Pilowsky (1967, 1978) terms "abnormal illness
behavior" is an extreme form of hypochondriasis produced primarily
by the social environment. Although it is widely considered to be a
common disorder in general medical practice, less than 1 percent of the
patients in the Miami pain center study were given this diagnosis
(Fishbain et al., 19861. Seven percent of the patients in the California
study met the criteria for this disorder (Reich et al., 19831.
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PSYCHIATRIC ASPECTS OF CHRONIC PAIN 171
As noted previously, all of these conditions are distinguished from
factitious disorder and malingering. Somatoform disorders involve the
involuntary (i.e., not consciously motivated) production of symptoms,
but in factitious disorders and malingering the patient experiences
voluntary control of symptoms. Factitious disorder involves the inten-
tional production or feigning of physical or psychological symptoms,
including pain. There is a psychological urge to make oneself ill and
assume the sick role. Often these patients migrate from one medical
agency to another. Unlike malingering there are no external incen-
tives for this behavior, such as economic gain. It is a rare cause of
chronic pain. Long-term psychotherapy may be helpful—if the person
will stay in it~because such patients usually have severe personality
disorders or other mental disorders.
Malingering is the intentional production of false symptoms moti-
vated by external incentives, such as avoiding military duty or work,
obtaining financial compensation or drugs, and so on. Pain experts
believe malingering is uncommon and can be detected, but there is
virtually no systematic research on this topic.
The taxonomy of somatoform disorders is controversial, and the
criteria for these diagnoses are being revised by the American Psychi-
atric Association. They represent a group of empirically derived
diagnoses with somewhat arbitrary symptoms, they are not theoreti-
cally based, and they all assume that a thorough and adequate
physical examination has ruled out organic disease or anatomical
abnormalities that would account for the symptomatology. Further-
more, clinical experience with chronic pain patients suggests that the
diagnoses are not very useful or appropriate. Most chronic pain
patients have some physical findings, even if they are only minimal.
Their very presence, however, makes the diagnosis of psychogenic pain
disorder inappropriate. Because few chronic pain patients have
nosophobia, the diagnosis of hypochondriasis is inappropriate. Very
few pain patients meet the stringent criteria for somatization disorder.
That leaves a catch-al1 category atypical somatoform disorders that
has no criteria and therefore is not a useful diagnosis.
A Neurobiological View of Chronic Pain and Depression
An alternative, although perhaps complementary, way of conceptu-
aTizing the relation between chronic pain and depression is to regard
them as having common neurobiological mechanisms. Alterations in
the neurotransmitters serotonin and norepinephrine have been impli-
cated in various forms of depressive illness. These also have been
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172 INFLUENCES ON PAIN AND PAIN BEHAVIOR
shown to play critical roles in the mediation of opiate- and stimulation-
produced analgesia in pain modulation. For example, manipulations
that decrease serotonergic function also decrease analgesia (Samanin
et al., 1970; Messing et al., 1976; Aki] and Mayer ~ 9721. Conversely,
enhanced serotonergic function also increases antinociceptive effects
(Samanin and Valzelli, 1971; Sewell and Spencer, 1974, Sternbach et
al., 1976; Modigh, 19731. The effects of norepinephrine are different in
the brain than in the spinal cord. In the brain, norepinephrine appears
to have effects on analgesia that are opposite to serotonin: Decreased
noradrenergic function causes increased analgesia, whereas decreased
analgesia results from direct intracerebroventricular injection of nor-
epinephrine (AkiT and Liebeskind, 1975~. Studies with agonists and
antagonists of dopamine, from which norepinephrine is synthesized,
indicate that it has analgesia-enhancing effects (Pasternak, 19821.
There is also evidence implicating other neurotransmitters and
neuropeptides (e.g., acetylcholine, y-aminobutyric acid, and substance
P) (Gebhart, 19831. Research in this area is yielding important
insights about the neurobiology of pain and depression. Studies of
family members of patients with chronic pain could be particularly
useful in determining the extent to which chronic pain and depression
share common neurobiological mechanisms.
Depression as a Consequence of Chronic Pain
In addition to depression as a contributory cause of pain and
depression as a neurobiological companion to pain, a third way of
conceptualizing the relation between chronic pain and depression is to
regard depression as resulting from inescapable chronic pain that is,
depression results from learned helplessness and demoralization. PeIz
and Merskey (1982) demonstrated that for some chronic pain patients
there are long-term psychological effects, including depression, and
that the rates and nature of these effects are not different in patients
either receiving or not receiving disability payments. The findings in
one study (Blumer et al., 1982) that patients with chronic pain from
rheumatoid arthritis suffered less depression than patients with idio-
pathic chronic pain might argue against this interpretation because
both groups suffered from prolonged pain. It is possible, however, that
the rheumatoid arthritis patients suffered less pain, received more
relief from treatment, and received fewer opiates than patients with
idiopathic chronic pain. Additionally, rheumatoid arthritis patients
may be somewhat protected from demoralization and adverse social
consequences because the diagnosis and source of their pain is known.
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PSYCHIATRIC ASPECTS OF CHRONIC PEN 173
Prospective studies of the incidence of depression (the new occurrence
of depression) in chronic pain patients with no previous history of
depressive episodes would help to determine the extent to which
depression is secondary to chronic pain.
Depressive Symptoms as a Consequence of Drug Therapy
Because chronic pain is often so difficult to diagnose and treat
effectively, patients frequently seek care from multiple providers and
are likely to become involved in polypharmacy. Indeed, as discussed in
Chapter 12, often the first step in rehabilitation in multidisciplinary
pain clinics is to wean patients from their multiple and high doses of
drugs. Drugs clearly can be useful in the treatment of chronic pain
(Portenoy and Foley, 1986), often providing the relief needed to carry
on normal activities, but they may also produce side effects, which at
the very least should be monitored and which may be cause to alter
therapeutic regimens.
Many patients experience depressive symptoms, sometimes of great
severity, as the inadvertent result of the medication prescribed to
relieve their pain and related symptoms (Hall et al., 1980; Pert et al.,
1980~. Depressed mentation, mental clouding, and sedation are com-
mon. The three types of medication with a substantial risk of adverse
alterations of mood and functioning are opiate analgesics, benzo-
diazepines, and barbiturate and nonbarbiturate hypnotics. Overuse of
opiate analgesics, even when it does not lead to frank addiction, may
cause depressed mood and other untoward side effects. When
benzodiazepines are used (to relieve muscle tension, anxiety, or insom-
nia) the ejects on mood and functioning may go undetected by health
care personnel. Vigilance about drug dependence, adverse side effects,
and prolonged withdrawal syndromes is a well-established practice in
the prescription of opiates and barbiturates but is much less so with
other classes of drugs used with pain patients. For example, many
people in pain have a very Biscuit time sleeping and greatly overuse
nighttime sedative-hypnotic drugs. Some of these drugs, especially
certain benzodiazepines, are very long acting and can adversely affect
daytime mood, cognition, and coordination. Once again, the patient
and physician may not be alert to this possibility, because the medi-
cation is prescribed at night and is not one of the heavily controlled
"dangerous" substances like the opiate analgesics, which are classified
as narcotics (Institute of Medicine, 1979; Solomon et al., 1979; Busto et
al., 1986; Hendler, 19811. (See Chapter 10 for additional information
about commonly prescribed drugs for pain.)
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174 INFLUENCES ON PEN ED PEN BEHAVIOR
TREATMENT OF DEPRESSIVE DISORDERS IN THE CHRONIC
PAIN PATIENT
Even if depression in patients with chronic pain is only a fortuitous
finding (resulting from a referral bias), which seems unlikely, treat-
ment of depression in chronic pain patients may be an essential
component of successful rehabilitation (Aronoff, 19811. An untreated
major depression is likely not only to exacerbate the chronic pain but
also to interfere with the success of other treatments for pain. Consid-
eration of the various ways of conceptualizing the relation between
chronic pain and depression has important implications for treatment.
For example, to the extent that depression results from demoralization
and learned helplessness, both of which are frequent concomitants of
chronic pain, successful treatment of pain would be expected to
ameliorate depression (Kramlinger et al., 19831.
Psychotherapeutic Treatment
Numerous psychotherapeutic approaches have been used with de-
pressed patients, including those with chronic pain. Although detailed
discussion of these techniques goes beyond the scope of this volume,
several approaches deserve mention. In recent years there has been a
growing interest in the development of short-term psychotherapeutic
treatment with well-defined therapeutic goals and techniques that can
be evaluated by specific criteria and that allow for comparisons among
various approaches. For example, the NIMH Collaborative Study of
Depression compared the effectiveness of drug treatment and brief
psychotherapy in a randomized controlled study. At the end of 16 weeks
there were no statistically significant differences between a fixed dose of
Imipraniine, interpersonal psychotherapy, and cognitive therapy for the
out patient treatment of depression. hnipramine was superior to placebo
treatment, and all three treatments were superior to 'Youtine clinical
management." While hnipramine worked faster than the psycho-
therapeutic modalities to relieve depressive symptoms, ultimately all
three modalities achieved similar results (Elkin et al., 1986~.
Interpersonal therapy is based on a model postulating that depres-
sion results from difficulties in interpersonal relationships. The task of
interpersonal therapy is to identify the specific, current relationship
difficulties or patterns of relating that are damaging to the patient's
self-esteem, and to enable the patient to learn alternative ways of
interacting that may lead to improved relationships and to an im-
proved mood.
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PSYCHIATRIC ASPECTS OF CHRONIC PEN 175
Cognitive therapy is based on a model that views depression as
resulting from faulty cognitions about the self and others (including
negative self-images) and faulty beliefs about the future. The task of
cognitive therapy is to identify these faulty cognitions, to enable the
patient to recognize that the thoughts are mistaken, and to substitute
alternative cognitive structures that can lead to improved affective
and behavioral responses. In combination with behavioral therapies,
cognitive therapy has been found useful in the treatment of chronic
pain patients (Turner, 1982; Turner and Chapman, 1982~. The cogni-
tive-behavioral approach to chronic pain teaches patients specific
cognitive skills (e.g., anticipating the occurrence of pain and diverting
attention to nonpainful thoughts) and helps the patient to become
aware of psychosocial influences that affect the pain experience, all of
which may allow better coping with pain (Turk and Meichenbaum,
1984; Weisenberg, 19841.
Clinical practice suggests that the combined use of various
psychotherapeutic techniques aimed at ameliorating specific diffl-
culties (e.g., self-image, faulty cognitive structures, and interpersonal
difficulties), in addition to pharmacological interventions aimed at
ameliorating vegetative symptoms, is efficacious (Klerrnan et al., 1984;
Hamburg et al., 19821.
Psychopharmacological Treatment of Pain
It is often observed clinically that when pain occurs as a symptom of
a primary psychiatric disorder, successful pharmacological treatment
directed at the disorder itself is accompanied by alleviation of the pain.
Response of a primary depressive disorder to antidepressant drugs, for
example, will generally include a parallel improvement in any pain-
related complaints that may be symptomatic manifestations of the
depression. Thus, in their conceptualization of"pain prone disorder" as
a variant of depression, Blumer and Heilbronn (1982) view the
response of the pain to antidepressants as related to the response of the
syndrome as a whole to these drugs. Similarly, improvement in
psychotic symptoms that take the form of pain-related complaints (e.g.,
somatic delusions or tactile hallucinations) accompanies the global
response of psychotic syndromes to neuroleptic (antipsychotic) drugs.
Apart from their efficacy in relieving pain that is clearly secondary to
primary psychiatric disorders, psychotropic drugs have been found to
have more general benefits in the relief of chronic pain (Goodman and
Charney, 1985~. The adaptation of newer strategies from mainstream
psychopharmacology, such as the systematic evaluation of combination
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176 INF[UENCESONP~N~DP~N BEHAVIOR
and augmentation approaches (Price, in press), promises to further
enhance the therapeutic arrnamentarium against pain disorders.
The most widely used psychotropic drugs in the management of
chronic pain are antidepressants, primarily of the tricyclic class. Both
uncontrolled and controlled studies support the efficacy of these agents
in a variety of pain syndromes (France et al., 19841. Efficacy has been
demonstrated both concurrently with and independent of antidepres-
sant actions per se (Feinmann, 19851. In most cases, the analgesic
effects of antidepressants occur more rapidly and at lower doses than
the antidepressant actions. The profound effects of these drugs on the
serotonergic and noradrenergic systems, both implicated in pain me-
diation, probably account for their analgesic properties. However,
some antidepressants may interact more directly with endogenous
opioid systems (Isenberg and Cicero, 19841.
Psychopharmacological treatment of chronic anxiety associated with
pain has led to the use of a variety of agents, both on the basis of their
phenomenological effects (anxiety reduction) and their neurochemical
actions. For example, anxiolytic drugs, particularly benzodiazepines,
are used adjunctively in the management of many medical and
psychiatric disorders in which anxiety is prominent. There is little
controlled evidence to support their efficacy in treating pain condi-
tions, except for short-term muscle relaxation. Clinical authorities are
virtually unanimous in cautioning against their long-term use
(Stimmel, 1983; Hendler, 19811. Used inappropriately, these drugs can
cause cognitive impairment in conjunction with physiological and
psychological dependence, thereby complicating other phaxmacologi-
cal and nonpharmacological treatment interventions. In selected
cases, however, the circumscribed use of benzodiazepines for manag-
ing concomitant anxiety may be justified. The use of barbiturates and
related compounds for this purpose is rarely warranted, given the
greater potential for abuse and toxicity of these agents (Worz, 19831.
Neuroleptics (antipsychotic drugs), particularly phenothiazines and
butyrophenones, have been proposed as analgesic and anesthetic
adjuvants since their discovery. Although many anecdotal reports of
efficacy have been published, the number of controlled studies is
surprisingly small (Foley, 1985; Stimmel, 1983~. (One phenothiazine,
methotrimeprazine, is specifically marketed as an analgesic and may
have some unique properties in this regard, although even here the
evidence is weak.) Dopamine antagonism is believed to underlie the
action of these drugs in relieving symptoms of psychosis, but their
analgesic properties may depend more on their interactions with
pain-modulation pathways in the central nervous system, especially
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PSYCHIATRIC ASPECTS OP CHRONIC PEN 177
the serotonergic, noradrenergic, and endogenous opioid systems (Geb-
hart, 1983).
Sporadic reports have claimed analgesic efficacy for other classes of
psychotropic drugs, such as lithium and stimulants, but their clinical
use for this indication is not common. Suggestions that amine precur-
sors, such as tryptophan and -Dope, might also be of benefit are
presently unsubstantiated.
ADDICTION AND ALCOHOLISM
Significant rates of alcoholism and drug abuse are found among
chronic pain patients (Schottenfeld, 19861. Maruta et al. (1979) at the
Mayo Clinic reported that 24 percent of a consecutive series of patients
referred for the treatment of chronic pain were addicted to prescription
drugs and another 41 percent Here misusing medication to such an
extent that they were classified as drug abusers. In a recent Scandi-
navian study (Sandstrom et al., 1984), 50 patients with chronic low
back pain were compared ~ ith a group matched for age, sex, and socio-
economic status. Of 34 male chronic pain patients, 14 had previously
sought alcohol treatment (41 percent) as contrasted to only 6 of 34
controls (18 percent). Low back pain patients, particularly men, are
often found to have higher rates of alcoholism than control popula-
tions; and disabled low back pain patients have higher rates than
nondisabled patients. Longitudinal studies would be useful to deter-
mine whether alcoholism contributes to disability, is an associated
noncontributory factor, or increases with disability duration.
Patients with substance abuse disorders often have associated de-
pression (Weissman et al., 1977; Rounsaville et al., 1982; Kamerow et
al., 19861. Weissman and Myers (1980) identified 15 percent of alco-
holics as having coexisting major depression. Of those patients, they
identified approximately 40 percent as having depression secondary to
the alcoholism. The prevalence of major depression in a study of 533
opiate addicts was 24 percent (Rounsaville et al., 19821. The data
indicate clearly that these problems are interconnected~epression
and anxiety states, depression and drug dependency, substance abuse
and depression, and all of these with chronic pain. However, the role of
alcohol and other substance abuse in the genesis and maintenance of
chronic pain is poorly understood.
Treatment considerations regarding alcoholism or drug abuse and/or
dependency in patients with chronic pain are similar to the consider-
ations for the treatment of depression in these patients. Regardless of
whether substance abuse is a cause, an effect, or merely a fortuitous
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178 INFLUENCES ON PEN ED PEN BEHAVIOR
concomitant feature of chronic pain, recognition and treatment of
substance abuse disorders is likely to be an essential component of
successful rehabilitation of the chronic pain patient. Depressive symp-
toms are likely to resolve spontaneously after relatively short (1
month) periods of abstinence from the abused substance (Jaffe and
Ciraulo, 19861. Mutual help groups like Alcoholics Anonymous and
family or group therapy may be helpful in treatment. Use of
naltrexone (a pure opiate antagonist) in the treatment of formerly
opiate-addicted chronic pain patients is more controversial both be-
cause of the theoretical possibility that opioid blockade might exacer-
bate chronic pain (by disabling the endogenous mechanisms for pain
modulation) and because of the practical difficulty in convincing some
patients with chronic pain to accept complete abstinence from any use
of opiate analgesics.
PERSONALITY FACTORS AND CHRONIC PAIN
Personality and chronic pain are certainly interactive. Yet as is true
of the relation between other psychological and psychiatric factors
discussed in this chapter and elsewhere in this volume, the nature of
the association is not well understood. The extent to which well-
defined personality factors in chronic pain patients precede the devel-
opment of symptoms or are highlighted and amplified by pain and
reflect learned behaviors remains unclear. There is a fairly large
psychodynamic literature that suggests that certain personality traits
and mental mechanisms (e.g., dependence, identification, and low
self-esteem) place people with particular personality types at risk for
chronic pain and other problems of somatization (Engel, 1959; Blumer
and Heilbronn, 19811. This literature emphasizes that pain and its
relief are essential elements in the caregiver-child interaction, and
that this interaction around the child's pain, distress, and crying may
form the prototype for later interactions. Although learning theorists
and proponents of operant conditioning for the treatment of chronic
pain focus on rewards and sanctions for pain behavior in current
relationships, old patterns of interaction deriving from early childhood
(e.g., sympathetic identification with significant others) may persist
with great saliency and continue to affect pain behavior in adult life.
There is evidence that in families in which there is physical and/or
sexual abuse, children grow up being more susceptible to symptoms o
depression. These children may develop persistent personality pat-
terns reflecting somatic preoccupation, feelings of inadequacy, and
anxiety (Robins, 1983~.
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PSYCHIATRIC SPECK OF CHRONIC PEN 179
There has been little systematic research on the relation among
childhood experience, personality development, and chronic pain,
although numerous studies have found significant correlations be-
tween chronic pain and various personality traits and psychodynamics
currently operating in the individual, such as unconscious guilt.
Investigators have consistently noted that disabled patients with low
back pain have abnormally high scores on the hypochondriasis and
hysteria subscales of the Minnesota Multiphasic Personality Inventory
(MMPl) (Chapman and Brena, 1982; Southwick and White, 1983; Trief
and Stein, 19851. Attempts have been made to correlate disability
status to these subscales of the MMPI as well. At least one study found
that disabled low back pain patients scored higher on these subscales
than nondisabled low back patients (Frymoyer et al., 19851. Scores on
the MMPT have also been used to predict treatment responses. Higher
levels of hysteria and hypochondriasis are associated with poorer
outcomes in a number of studies of rehabilitation and surgery
(Southwick and White, 1983~.
Clinical data and psychological tests have been used to describe
various personality factors associated with chronic pain. Again, these
data do not identify whether the personality factors antedate or result
from the pain experience. On the basis of a comprehensive literature
review of the use of psychological tests with chronic back pain patients,
Southwick and White (1983) identified a composite psychological
profile of these patients that differentiates them from others. They are
described as being more extroverted, more demanding, somatically
preoccupied, dependent, anxious, and as feeling inadequate and infe-
rior. Whittington (1985) described such patients as dependent but
noncompliant, passive, and as feeling a sense of entitlement. He claims
that many patients are bitter, even paranoid, and often abuse drugs
and alcohol. As mentioned earlier, Blumer and Heilbronn identify
their pain prone syndrome as occurring in "solid citizens" who deny
conflicts, idealize family relationships, and are workaholics until the
onset of pain. They also identify these patients as having excessive
unmet dependency needs. Blazer (198~1981) describes the tendency
for individuals with strong investments in themselves, their appear-
ance, and their body to decompensate after an injury that threatens
their sense of invulnerability that is, to regress and become with-
drawn, demanding, dependent, and angry.
From these studies emerge common personality factors associated
with chronic pain, particularly in those patients who respond poorly to
treatment. It is not known the extent to which the described behaviors
reflect exaggerated preexisting personality factors or a more complex
OCR for page 180
180 INFLUENCES ON PEN ED PEN BEHAVIOR
interaction between the underlying condition, sociopsychological fac-
tors, and learned behaviors that lead to similar personality types as a
result of chronic pain.
Psychodynamic psychotherapy is currently the treatment of choice
for many of the personality disorders, but for chronic pain patients,
who tend to be focused on their pain and reluctant to view problems
psychologically, psychodynamic psychotherapy may not be possible.
Chronic pain patients may be more amenable to "supportive"
psychotherapies, which encourage patients to use their previous cop-
ing strategies and defenses against feelings of inadequacy and vuiner-
ability and that enable patients to reestablish a stable sense of
self-esteem and to recognize and tolerate conflicts around dependency
and aggression. Pilowsky (1976) has suggested that traditional
psychotherapeutic techniques have considerable utility in the treat-
ment of chronic pain patients. These techniques may be particularly
helpful in breaking the cycle, so often seen for help-rejecting patients,
of clinicians becoming increasingly frustrated and angry and ulti-
mately rejecting the patient because of the patient's failure to improve.
Most of the cognitive and behavioral approaches to treatment may be
facilitated in the context of a supportive psychotherapy.
RESEARCH ON PSYCHIATRIC ASPECTS OF CHRONIC PAIN
Assessment of the contribution of psychiatric disorders to disabling
chronic pain conditions is limited by shortcomings in the methods and
instruments used. The MMPI, the Cornell Medical Index, and the
Hopkins Symptom Checklist-90, for example, are relatively widely
used but nonspecific instruments for measuring psychological traits
and emotional distress. The definitions of various types of psychologi-
cal distress in many of the scales in these instruments include the
presence of somatic symptoms, thus confounding, rather than ciarify-
ing, the relation between psychological and physical symptoms. In
other words, a person suffering from chronic pain will automatically
score high on a number of psychological measures of distress, including
many depression scales.
Endicott (1984) has developed criteria specifically designed for medical
patients to more accurately assess depression in cancer patients. Simi-
larly, Clark and his colleagues (1983) have identified special cognitive
and affective symptoms of depression that discriminate severe depression
in a medical sample. Over the past decade the field of psychiatric
epidemiology has begun to change dramatically as there has been a shift
away from nonspecific instruments to instruments that enable one to
OCR for page 181
PSYCHIATRIC ASPECTS OF CHRONIC PAIN 181
focus on specific diagnostic conditions. Adapting such instruments to
studies of medical patients, especially pain patients, may lead to more
precise identification of psychiatric factors in patients with chronic pain.
Studies of depression in pain patients are often further confounded by
imprecision in diagnosis (including inadequate distinctions between
symptoms and disorder) and by sampling bias. Studies of personality
factors often suffer from the same sources of error.
Throughout this volume the lack of prospective cohort studies is
noted. Such studies are crucial to determining causal relations among
the many variables that influence the chronic pain/disability trajec-
tory. Current attempts to prescribe effective treatment interventions
(Feinmann, 1985; Morris and Randolph, 1984; Turner and Romano,
1984) for the admixture of symptomatic, characterological, and sub-
stance abuse problems are impeded by an insufficient understanding of
the extent to which these conditions are either the cause or the
consequence of pain and disability. Furthermore, the problem of
sorting out the interactions between chronic pain and psychiatric
factors is further confounded by the impact of the many soc~ocultural,
economic, job-related, and normal psychological factors related to the
chronic pain and disability process discussed in Chapter 8. All of these
factors together influence the process and help account for the extraor-
d~nary diversity found In this group of patients.
REFERENCES
Akil, H., and Liebeskind, J.D. Monoamine mechanisms of stimulation-produced anal-
gesia. Brain Research 94:27~296, 1975.
Akil, H., and Mayer, D. Antagonism of stimulation-produced analgesia by p-CPA, a
serotonin synthesis inhibitor. Brain Research 44:692~96, 1972.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Dzsor-
ders, 3rd Ed. Washington, DC: APA, 1980.
Aronoff, G.M. A holistic approach to pain rehabilitation: the Boston Pain Unit. In: New
Approaches to Treatment of Chronic Pain: A Review of Multi-Dzsciplinary Pain
Centers (Ng, L., ed.). Rockville, MD: NIDA Research Monograph 36, 1981.
Blazer, D. Narcissism and the development of chronic pain. International Journal of
Psychiatry in Medicine 10(1):6~77, 198~1981.
Blazer, D., George, L.K., Landerman, R., Pennybacker M., Melville, M.L., Woodbury, M.,
Manton, K.G., Jordan, K., and Locke, B. Psychiatric disorders: a rural/urban
comparison. Archives of General PsycEzatry 41:971-978, 1985.
Blumer, D., and Heilbronn, M. Chronic pain as a variant of depressive disease: the
pain-prone disorder. Journal of Nervous and Mental Disease 170:381~06, 1982.
Blumer, D., and Heilbronn, M. The pain-prone disorder: a clinical and psychological
profile. Psychosomatics 22:395~02, 1981.
Blumer, D., Zorick, F., Heilbronn, M., and Roth, T. Biological markers for depression in
chronic pain. Journal of Nervous and Mental Disease 170:425~28, 1982.
OCR for page 182
182 INFLUENCES ON PEN ED PEN BEHAVIOR
Busto, U., Sellers, E.M., Naranjo, C.A., Cappell, H., Sanchez-Craig, M., and Sykora, K.
Withdrawal reaction after long-term use of benzodiazepines. New England Journal of
Medicine 315:85~860, 1986.
Chapman, S.L., and Brena, S.F. Learned helplessness and responses to nerve blocks in
chronic low back pain patients. Pain 14:35~364, 1982.
Clark, D., Cavanaugh S.V., and Gibbons, R. The core symptoms of depression in medical
and psychiatric patients. Journal of Nervous and Mental Disorders 171:70~713,
1983.
Elkin, I., Shea, T., Imber, S., Pilkonis, P., Sotsky, S., Glass, D., Watkins, J., Leber, W.,
and Collins, J. NIGH treatment of depression collaborative research program: initial
outcome findings. Presented at the American Association for the Advancement of
Science Annual Meeting, Philadelphia, May 25, 1986.
Endicott, J. Measurement of depression in patients with cancer. Cancer 53:224~2249,
1984.
Engel, G.L. Psychogenic pain and the pain-prone patient. American Journal of Medicine
26:89~918, 1959.
Feinmann, C. Pain relief by antidepressants: possible modes of action. Pain 23:1-8,
1985.
Fishbain, D.A., Goldberg, M., Meagher, B.R., and Rosomoff, H. Male and female chronic
pain patients categorized by DSM-lII psychiatric diagnostic criteria. Pain
26:181-198, 1986.
Foley, K.M. Adjuvant analgesic drugs in cancer pain management. In: Evaluation and
Treatment of Chronic Pain (Aronoff, G.M., ed.). Baltimore, MD: Urban &
Schwarzenberg, 1985.
France, R.D., Houpt, J.L., and Ellingwood, E.H. Therapeutic effects of antidepressants in
chronic pain. General Hospital Psychiatry 6:55~;3, 1984.
Frymoyer, J.W., Rosen, J.C., Clements, J., and Pope, M.H. Psychological factors in low
back pain disability. Clinical Orthopedics 195:178-184, 1985.
Gebhart, G.F. Recent developments in the neurochemical bases of pain and analgesia.
In: Contemporary Research in Pain and Arzalgesza, 1983 (NIDA Research Monograph
45), (Brown R.M., Pinkert, T. M., and Ludford, J. P., eds.). Washington, DC: U.S.
Department of Health and Human Services, 1983.
Glass, R.M., Allan, A.T., Uhlenhuth, E.H., Kimball, C.P., and Borinstein, D.I. Psychi-
atric screening in a medical clinic. Archives of General Psychiatry 35:1189-1195,
1978.
Goldberg, D. Detection and assessment of emotional disorders in a primal care setting.
International Journal of Mental Health 8:30~8, 1979.
Goodman, W.K., and Charney, D.S. Therapeutic applications and mechanisms of action
of monoamine oxidase inhibitor and heterocyclic antidepressant drugs. Journal of
Clinical Psychiatry 46(10):~22, 1985.
Gupta, M.A. Is chronic pain a variant of depressive illness? A critical review. Canadian
Journal of Psychiatry 31:241-248, 1986.
Hall, R.C.W., Stickney, S.K., and Gardner, E.R. Behavioral toxicity of nonpsychiatric
drugs. In: Psychiatric Presentations of Medical Illness (Hall, R.C.W., ed.). New York:
Spectrum Publications, 1980.
Hamburg, D.A., Elliott, G.R., and Parron, D.L. Health and Behavior: Frontiers in the
Biebehavioral Sciences. A Report of the Institute of Medicine. Washington, DC:
National Academy Press, 1982.
Hendler, N. Diagnosis and Nonsurgical Management of Chronic Pain. New York: Raven
Press, 1981.
OCR for page 183
PSYCHIATRIC SPECK OF CHRONIC PEN 183
Horgan, C.AI. Specialty and general ambulatory mental health services: comparison of
utilization and expenditures. Archives of General PsycEzatry 42:565~72, 1975.
Institute of Medicine. Sleeping Pills, Insomnia, and Medical Practice. Washington, DC:
National Academy of Sciences, 1979.
Isenberg, K.E., and Cicero, T.J. Possible involvement of opiate receptors in the
pharmacological profiles of antidepressant compounds. European Journal of Pharma-
cology 103:57~3, 1984.
Jaffe, J.lI., and Ciraulo, D.A. Alcoholism and depression. In: Psychopathology and
Addictive Disorders (Meyer, R.E., ed.). New York: Guilford Press, 1986.
K~merow, D.B., Pincus, H.A., and MacDonald, D.I. Alcohol abuse, other drug abuse and
mental disorders in medical practice: prevalence, costs, recognition and treatment.
Journal of the American Medical Association 255:205~2057, 1986.
Katon, W., Kleinman, A., and Rosen, G. Depression and somatization: a review, Part 1.
American Journal of Medicine 72:127-135, 1982a.
Katon, W., Kleinman, A., and Rosen, G. Depression and somatization: a review, Part 2.
American Journal of Medicine 72:241-247, 1982b.
Katon, W., Ries, R.K., and Kleinman, A. The prevalence of somatization in primary care.
Comprehensive Psychiatry 25(2):20~215, 1984.
Keller, M.B., Kler~nan, G.L., Lavori, P.W., Fawcett, J.A., Coryell, W., and Endicott, J.
Treatment received by depressed patients. Journal of the American Medical Associ-
ation 248:184~1855, 1982.
Kessler, L.G., Cleary, P.D., and Burke, J.D. Psychiatric disorders in primary care:
results of a follow-up study. Archives of General Psychiatry 42:583~87, 1985.
Klerman, G., Weissman, M., Rounsaville, B., and Chevron, E. Interpersonal Psychother-
apy of Depression. New York: Basic Books, 1984.
Kramlinger, K.G., Swanson, D.W., and Maruta, T. Are patients with chronic pain
depressed? American Journal of Psychiatry 140:747-749, 1983.
Krystal, H. Alexithymia and psychotherapy. American Journal of Psychotherapy
33:17~1, 1979.
Maruta, T., Swanson, D.W, and Finlayson, R.E. Drug abuse and dependency in patients
with chronic pain. Mayo Clinic Proceedings 54:241-244, 1979.
Messing, R.B., Fisher, L.A., Phebus, L., and Lytle, L.D. Interaction of diet and drugs in
the regulation of brain ~hydroxyindoles and the response to painful electric shock.
Life Science 18:707-714, 1976.
Modigh, K. Effects of clomipramine (Anafranil) on neurotransmission in brain mono-
amine neurons. Journal of Inz~err=l Medzcine Research 1:27~290, 1973.
Morris, A., and Randolph, J.W. Back rehabilitation programs speed recovery of injured
workers. Occupational Health and Safety 53:53 55, 64~68, 1984.
Myers, J.K., Weissman, M.M., Tischler, G.L., Holzer, C.E., Leaf, P.J., Orvaschel, H.,
Anthony, J.C., Boyd, J.H., Burke, J.D., Kramer, M., and Stoltzman, R. Six-month
prevalence of psychiatric disorders in three communities. Archives of General PsycEz-
a*y 41:95~967, 1984.
Nielsen, A.L., and Williams, T.A. Depression in ambulatory medical patients. Archives
of General Psychiatry 37:99~1004, 1980.
Pasternak, G.W. Psychotropic drugs and chronic pain. In: Diagnosis and Treatment of
Chronic Pain (Hendler, N.H., Long, D.M., and Wise, T.N., eds.). Boston: John
Wright-PSG, 1982.
Pelz, M., and Merskey, H. A description of the psychological effects of chronic painful
lesions. Pain 14:293 301, 1982.
Pert, M., Hall, R.C.W., and Gardner, E.R. Behavioral toxicity of psychiatric drugs. In:
OCR for page 184
184 INFLUENCES ON PEN ED PEN BEHAVIOR
Psychiatric Presentations of Medical Illness (Hall, R.C.W., ed.). New York: Spectrum
Publications, 1980.
Pilowsky, I. Pain as abnormal illness behavior. Journal of Human Stress 4:2~27, 1978.
Pilowsky, I. The psychiatrist and the pain clinic. American Journal of Psychiatry
133:75~756, 1976.
Pilowsky, I. Dimensions of hypochondriasis. British Journal of Psychiatry 113:89-93,
1967.
Portenoy, R.K., and Foley, K.M. Chronic use of opioid analgesics in non-malignant pain:
report of 38 cases. Pain 25:171-186, 1986.
Price, L.H. Lithium augmentation oftricyclic antidepressants. In: Treatment of Tricyclic
ResistantDepression (Extein, I., ed.). Washington, DC: American Psychiatric Press, in
press.
Regier, D.A., Goldberg, I.~., and Taube, C.A. The de facto US Mental Health Service
System: a public health perspective. Archives of General Ppychiat' y 35:68~693, 1978.
Regier, D.A., Myers, J.K., Kramer, M., Robins, L.N., Blazer, D.G., Hough, R., Eaton,
W.W., and Locke, B.Z. The NIMH Epidemiologic Catchment Area Program. Archives
of General Psychiatry 41:93~941, 1984.
Reich, J., Tupin, J.P., and Abramowitz, S.I. Psychiatric diagnosis of chronic pain
patients. American Journal of Psychiatry 140:149~1498, 1983.
Robins, L. Continuities and discontinuities in the psychiatric disorders of children. In:
Handbook of Health, Health Care, and the Health Professions (Mechanic, D., ed.). New
York: Free Press, 1983.
Robins, L.N., Helzer, J.E., Weissman, M.M., Orvaschel, H., Gruenberg, E., Burke, J.D.,
and Regier, D.A. Lifetime prevalence of specific psychiatric disorders in three sites.
Archives of General Psychiatry 41:94~958, 1984.
Rodin, G., and Voshart, K. Depression in the medically ill: an overview. American
Journal of Psychiatry 143:69~705, 1986.
Romano, J.H., and Turner, J.A. Chronic pain and depression: does the evidence support
a relationship? Psychological Bulletin 97:18~4, 1985.
Rounsaville, B.J., Weissman, M.M., Kleber, H.D., and Wilber, C.H. Heterogeneity of
psychiatric diagnosis in treated opiate addicts. Archives of General Psychiatry
39:161-166, 1982.
Samanin, R., Gumulka, E., and Valzelli, L. Reduced erect of morphine in midbrain
rapine lesioned rats. European Journal of Pharmacology 40:339 343, 1970.
Samanin, R., and Valzelli, L. Increase of morphine induced analgesia by stimulation of
the nucleus rapine dorsalis. European Journal of Pharmacology 16:298 302, 1971.
Sandstrom, J., Andersson, G.B., Grid Wallerstedt, S. The role of alcohol abuse in working
disability in patients with low back pain. Scandinavian Journal of Rehabilitative
Medicine 16:147-149, 1984.
Schottenfeld, R. Psychiatric factors in compensable spine injury. Grant Application to
Robert Wood Johnson Foundation, 1986.
Sewell, R.D.E., and Spencer, P.S.J. Modification of the antinociceptive activity of
narcotic agonists and antagonists by intraventricular injection of biogenic amines in
mice. British Journal of Pharmacology 51:140-141, 1974.
Shapiro, S., Skinner, E.A., Kessler, L.G., Von Korea, M., German, P.S., Tischler, G.L.,
Leaf, P.J., Bender, L., Cottler, L., and Regier, D.A. Utilization of health and mental
health services. Archives of General Psychiatry 41:971-978, 1984.
Solomon, F., White, K., Parron, D., and Mendelson, W. Sleeping pills, insomnia and
medical practice. New England Journal of Medicine 300:80~808, 1979.
Southwick, S.M., and White, A.A. Current concepts review: the use of psychological tests
OCR for page 185
PSYCHIATRIC ASPECTS OF CHRONIC PAIN 185
in the evaluation of low back pain. Journal of Bone and Joint Surgery 65:556~65,
1983.
Sternbach, R., Janowsky, D., Huey, L., and Segal, D. Effects of altering brain serotonin
activity on human chronic pain. In: Advances in Pain Research arid Therapy, Vol. 1
(Bonica, J.J., and Albe-Fessard, D., eds.). New York: Raven Press, 1976.
Stimmel, B. Pain, Analgesia, arid Addiction: The Pharmacologic Treatment of Pain. New
York: Raven Press, 1983.
Trief, P., and Stein, N. Pending litigation and rehabilitation outcome of chronic back
pain. Archives of Physiology and Medical Rehabilitation 66:95-99, 1985.
Turk, D.C., and Meichenbaum, D. A cognitive-behavioral approach to pain manage-
ment. In: Textbook of Pain (Wall, P.D., and Melzack, R., eds.). New York: Churchill
Livingstone, 1984.
Turner, J.A. Comparison of group progressive relaxation training and cognitive-
behavioral group therapy for chronic low back pain. Journal of Consulting and
Clinical Psychology 50:757-765, 1982.
Turner, J.A., and Chapman, C.R. Psychological interventions for chronic pain: a critical
review. Part 2: operant conditioning, hypnosis and cognitive-behavioral therapy. Pain
12:23~6, 1982.
Turner, J.A., and Romano, J.~. Review of prevalence of coexisting chronic pain and
depression. In: Advances in Pain Research and Therapy, Vol. 7 (Benedetti, C.,
Chapman, C.R., and Moricca, G., eds.). New York: Raven Press, 1984.
Weisenberg, M. Cognitive aspects of pain. In: Textbook of Pain (Wall, P.D., and Melzack,
R., eds.). New York: Churchill-Livingstone, 1984.
Weissman, M.~., and Myers, J.K. Clinical depression in alcoholism. American Journal
of Psychiatry 137:372~73, 1980.
Weissman, M.M., Myers, J.K., and Thompson, D. Depression and its treatment in a US
urban community. Archives of General Psychiatry 38:417-421, 1981.
hTeissman, M.M., Pottenger, M., Kleber, H., Ruben, H.L., Williams, D., and Thompson,
W.D. Symptom patterns in primary and secondary depression: a comparison of
primary depressives with depressed opiate addicts, alcoholics and schizophrenics.
Archives of General Psychiatry 34:854~62, 1977.
Whittington, H.G. The biopsychosocial model applied to chronic pain. Journal of
Operational Psychiatry 16:2-8, 1985.
Worz, R. Effects and risks of psychotropic and analgesic combinations. American Journal
of Medicine 75(5A):139~140, 1983.
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Representative terms from entire chapter:
pain patients
