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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 usefulespecially 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 helpfulif 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

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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

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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.

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