|Year : 2019 | Volume
| Issue : 1 | Page : 44-49
Prevalence and correlates of psychiatric comorbidity in chronic pain patients: A hospital-based study
Archana Jawdekar, Vishal Patel, Suprakash Chaudhury, Daniel Saldanha
Department of Psychiatry, Dr. D Y Patil Medical College, Hospital and Research Centre, Dr. DY Patil Vidyapeeth, Pune, India
|Date of Submission||06-Apr-2018|
|Date of Acceptance||03-Aug-2018|
|Date of Web Publication||22-Jan-2019|
Department of Psychiatry, Dr. D Y Patil Medical College, Dr. D Y Patil University, Pimpri, Pune - 411 018, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: There is a paucity of information on psychiatric comorbidity in chronic pain patients in developing countries like India. The present study was undertaken in this context. Aim: The aim of this study is to assess the psychiatric comorbidity in chronic pain patients. Materials and Methods: Fifty adult chronic pain patients without organic cause of more than 6 months duration attending outpatient departments were included in the study with their informed consent. Psychiatric comorbidity was assessed by the Schedules for Clinical Assessment in Neuropsychiatry. Results: Majority (80%) of patients was between 18 and 50 years of age, came from nuclear families (88%), and was married (82%). Majority (76%) of patients had pain <2 years; 56% had moderate pain severity and 54% had moderate functional impairment due to pain. In chronic pain patients, 78% had psychiatric comorbidity; the most common disorder was depression (36%) followed by generalized anxiety disorder (18%), somatoform disorder (16%), and panic disorder (8%) patients indicating that patients with chronic pain are more likely to have mood disorder than other psychiatric disorders. A significant association was seen between psychiatric comorbidity and pain severity but not with sociodemographic characteristics. Psychiatric comorbidity was associated with severity of pain. Head and neck and back pain patients reported high prevalence of depression (39.5% and 36%), while chest pain and limb pain patients had high prevalence of generalized anxiety disorder (45.5% and 33.3%). There was high prevalence of nonspecific symptoms such as localized tension pain (90%) and worry (82%) in chronic pain patients. Conclusion: The high prevalence of psychiatric comorbidity in patients suffering from chronic pain disorders emphasize the need to screen these patients for psychiatric disorders, particularly depression and anxiety. Diagnosis and treatment of comorbid psychiatric disorders will greatly improve the management of chronic pain patients.
Keywords: Chronic pain, depression, generalized anxiety disorder, panic disorder, psychiatric comorbidity, somatoform disorder
|How to cite this article:|
Jawdekar A, Patel V, Chaudhury S, Saldanha D. Prevalence and correlates of psychiatric comorbidity in chronic pain patients: A hospital-based study. Med J DY Patil Vidyapeeth 2019;12:44-9
|How to cite this URL:|
Jawdekar A, Patel V, Chaudhury S, Saldanha D. Prevalence and correlates of psychiatric comorbidity in chronic pain patients: A hospital-based study. Med J DY Patil Vidyapeeth [serial online] 2019 [cited 2019 Feb 16];12:44-9. Available from: http://www.mjdrdypv.org/text.asp?2019/12/1/44/250443
| Introduction|| |
The International Association for the Study of Pain defines pain as, “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” Pain is frequently classified as acute pain and chronic pain. Acute pain typically has a sudden onset, recedes during the healing process, lasting >6 months, and considered as “good pain.” As opposed to this chronic pain is “bad pain” because it persists long after recovery from an injury, often refractory to common analgesic agents and opiates, lasts more than 6 months. Chronic pain is one of the most ubiquitous problems in the world. The impact of pain is far-reaching, adversely affects vocational endeavors and contributes significantly to disability. The economic impact of chronic pain is enormous when one considers health-care costs (estimated at over $70 billion annually) as well as the costs of absenteeism, reduced productivity, and disability compensation (estimated at over $150 billion annually). In addition, pain interferes with individual's activities, interests, relationships, and limits the enjoyment of life. Patients with chronic pain not only suffer loss of income but also more importantly suffer from restriction on autonomy. As a result, they develop feelings of guilt and may even blame themselves for their inability to overcome the pain.
Numerous studies have shown a strong association of chronic pain with age, females, lower socioeconomic status, general psychiatric morbidity, and specific psychiatric disorders such as depression, anxiety, somatoform, substance abuse, and personality disorders.,,,, However, the relationship between chronic pain and psychiatric disorders is still a controversial issue and is of great research interest. Patients suffering from chronic pain have increased risk of disease burden, disability, higher medical costs, mental and physical comorbidities, and poor quality of life. Patients with chronic pain and psychiatric comorbidity have higher medical service costs than chronic pain alone. With the help of multidisciplinary treatment involving anesthesiology, neurology, psychiatry, and psychology, patients get symptomatic pain relief, reducing affective distress, and improving adaptive functioning and quality of life. Few studies have been conducted in India to assess the psychiatric comorbidity in patients suffering from chronic pain. The majority of studies concerning depression and chronic pain have utilized continuous self-report measures. It carries its limitations. None of the studies from India have assessed psychiatric comorbidity in chronic pain patients using standard tools such as Schedule for Clinical Assessment of Neuropsychiatry (SCAN). In view of the paucity of studies in this field, especially from India, the present work was undertaken to assess the psychiatric comorbidity in patients suffering from chronic pain utilizing the SCAN.
| Materials and Methods|| |
This cross-sectional, descriptive, hospital-based study was carried out on patients with chronic pain attending medicine, orthopedic, and psychiatry outpatient departments in a large tertiary care hospital situated in a suburban area with a population of about 7 million over a period of 1½ years. The proposal for the study was approved by the Institutional Ethical Committee.
The study sample was selected by convenience sampling and consisted of 50 patients attending psychiatry outpatient department or referred from medicine or orthopedic departments and meeting the following inclusion and exclusion criteria.
The inclusion criteria were:
- Nonmalignant musculoskeletal pain more than 6 months
- Males and females in the age group of 18 and 60 years.
The exclusion criteria were:
- Overtly psychotic patients
- Malignant and visceral pain
- Age <18 and more than 60 years.
Initially, patients were informed that their participation would be entirely voluntary and was not necessary for treatment. Those who volunteered for the study were included after obtaining written informed consent. Routine investigations such as hemogram, urine examination, liver function tests, and chest and spine X-ray were done as per the physicians and orthopedics advice and those with the abnormal results were excluded. Sociodemographic data of these patients was recorded and they were interviewed with the SCAN. SCAN was developed by the World Health Organization to provide comprehensive, accurate, and technically specifiable means of describing and classifying phenomenon in order to make comparisons. The presence of psychotic and cognitive disorders was ruled out using “Screen for items in Part 2” (Section 14) of SCAN text. The severity of symptoms was assessed in terms of duration and frequency of symptoms, degree of interference with mental function, social and occupational impairment, and other people's reactions. The data collected were tabulated and analyzed using appropriate statistical tests of significance.
| Results|| |
Mean ± SD age of the 50 patients with chronic pain was 38.26 years (±11.64). Range of age was 20–60 years. The age and sex distribution of the study patients is shown in [Table 1]. The demographic and clinical characteristics of the study sample are given in [Table 2]. Psychiatric comorbidity was present in 39 (78%) of chronic pain patients and consisted of depression (36%), generalized anxiety disorder (18%), somatoform disorder (16%), and panic disorder (8%). There was no significant association between gender, age, and site of pain with psychiatric comorbidity [Table 3], [Table 4], [Table 5]. There was a significant association between pain severity and nonspecific symptoms with psychiatric comorbidity in chronic pain patients [Table 6] and [Table 7].
|Table 3: Association between gender and psychiatric comorbidity in chronic pain patients|
Click here to view
|Table 4: Association between age and psychiatric comorbidity in chronic pain patients|
Click here to view
|Table 5: Association between location of pain and psychiatric comorbidity in chronic pain patients|
Click here to view
|Table 6: Association between pain severity and psychiatric morbidity in chronic pain patients|
Click here to view
| Discussion|| |
The present study was conducted to assess the psychiatric comorbidity in patients suffering from chronic pain without any organic basis. A major strength of the present study was that psychiatric comorbidity was assessed using the SCAN. SCAN-Present State Examination interview, although substantially structured, retains the features of clinical examination. It allows changes in order and wording of questions according to the way the interview is going. The flexibility of this approach was found helpful during the interview. Probe questions help to discover the phenomenon along with its severity. Hence, patients in whom depressive and anxiety symptoms were subthreshold can be differentiated from syndromal disorders. Thus, this tool does not overdiagnose the cases of depression or anxiety disorders.
Most of the study participants (80%) were between 18 and 50 years of age [Table 1]. This is in agreement with an earlier Indian study. Males outnumbered females, 26 males and 24 females. Similar finding was noted by some earlier studies, though other studies report the opposite, that is, more females seek medical help for chronic pain than males. A little less than half (46%) of the patients were employed of which only 3 were female and 21 were male. Most of the females were homemakers (42%) [Table 2]. This is similar to the findings of an earlier study. Little more than three-fourth (82%) of the patients were married. Nine participants were unmarried. The majority of the study population (88%) hailed from nuclear type of family, which is congruent with an earlier Indian study. Three-fourth (76%) of the study participants were having pain <2 years, while one-fourth of the study participants had pain more than 2 years [Table 2]. Similar findings were noted by previous Indian studies., More than half of patients (56%) had moderate pain and 4% of patients had severe pain. 54% of the study participants had moderate functional impairment due to pain and 6% had no functional impairment due to pain. This findings highlight the fact that majority of patients with chronic pain have functional impairment.
Psychiatric comorbidity was found in 78% chronic pain patients. The results are higher than the finding of two studies that found 62% and 67% chronic pain patients met ICD-10 diagnostic criteria for psychiatric disorder., However, it is much lower than another study which reported DSM-III diagnosis in 98% of chronic pain patients.
The lack of significant association between any of the sociodemographic factors and psychiatric morbidity in the present study is in agreement with an earlier Indian study. Although the prevalence of psychiatric comorbidity in female group (83.33%) was higher than among male groups (73.08%), the difference was not statistically significantly. Higher prevalence of psychiatric comorbidity in females having chronic pain has been observed in number of earlier studies.,, In the present study, psychiatric comorbidity was not common in any particular age group. This finding is in agreement with the finding of few earlier studies, though other reports indicate rising psychiatric morbidity with increasing age., The present study shows that the universality of pain being uniform in all age groups. One needs to understand the language of pain in its entirety by a detailed inquiry into ones personality and biological makeup.
Analysis of the association between pain severity and psychiatric comorbidity among the study participants revealed that the severity of pain was significantly associated with the presence of psychiatric comorbidity. Higher prevalence of psychiatric comorbidity was positively correlated with increasing pain severity and is in agreement with some earlier studies.,,,
Presence of psychiatric comorbidity in head and neck patients revealed that out of 38 patients, 39.5% had depression, 20.5% had generalized anxiety disorder, 7.9% had panic disorder, and 18.4% had somatoform disorder [Table 7]. This is in agreement with an earlier report which found that persons with chronic back or neck pain are more likely to have mood disorders than persons without pain conditions. Analysis of psychiatric comorbidity in chest pain patients revealed that out of 11 cases with chest pain, 45.5% had generalized anxiety disorder, 36.4% had panic disorder, 9.1% had depression, and 9.1% had somatoform disorder [Table 5]. In agreement with our findings, an earlier study reported that 40% of 86 females with chest pain, but without significant coronary obstruction as assessed with angiography, met criteria for anxiety neurosis.
Out of 25 cases with back pain, 36% had depression, 12% had generalized anxiety disorder, 4% had panic disorder, and 20% had somatoform disorder. The findings of the present study are comparable with an earlier study of psychiatric comorbidity in back pain patients which found the prevalence of depression to be 21%, panic attacks 13%, and generalized anxiety disorder 6.2%. Association of limb pain and psychiatric comorbidity revealed that 33.3% had generalized anxiety disorder, 16.7% had panic disorder, and 33.3% had somatoform disorder [Table 5]. These findings are comparable to the prevalence of depression in 18.2%, panic attacks in 11.2%, and generalized anxiety disorder in 5.6% of 588 arthritis patients.
Worry is perhaps the most ubiquitous psychiatric symptom but with no diagnostic significance in itself. It has three central principles, namely, pain and unpleasant thoughts which cannot be consciously controlled and often out of proportion to the topic worried about. This phenomenon was present in 82% of patients with chronic pain [Table 7]. Out of 11 patients with no psychiatric comorbidity, 5 patients reported that they are often worried for no apparent reason. Worry aims to place problems at the forefront of one's attention to encourage problem-solving. However, attempts at problem-solving may be “misdirected” if the difficulties are badly defined, as in the constant search for respite from pain. The “misdirected problem-solving model” of worry postulates that patients suffering from chronic pain are ensnared in a “perseverance loop,” whereby they are repeatedly and actively searching for solutions to the wrong problem. Therapies that enable patients to escape from the “perseverance loop” and change the problem frame may be more helpful than interventions that support the patient's view of the predicament as one that can only be unraveled by relief from pain.
Nervous tension is a feeling of inner restlessness or unease experience in terms such as “nerves,” “being on the edge,” and “being keyed-up.” It is a state of arousal that has three basic principles as worry. This phenomenon was present in 24% patients with chronic pain. General muscular tension is an unpleasant tension in one or more group of muscles with inability to relax voluntarily. This symptom is often associated with nervous tension. Hence, all the patients who reported nervous tension also reported general muscular tension. Localized tension pain is “muscular tension” localized to a particular group of muscle. Common localizations are head, back, neck, and the shoulders. This phenomenon was present in 45 patients with chronic pain and 9 patients with no psychiatric comorbidity. Muscular tension causes distress and can be treated by muscular relaxation therapy or by cognitive distraction by exercises or listening to music which can easily be tried in every patient. Restlessness is described subjectively. It is shown by fidgeting and inability to sit down. Restlessness is experienced as unpleasant, not under voluntary control, and inappropriate to the situation respondents find themselves in. It was reported by 18% of patients. Sensitivity to noise was reported by 17 patients. Irritability is overreadiness to respond to minor annoyance “being up inside” and “boiling up inside.” The respondent usually recognizes that the response is excessive, out of proportion to the circumstances, and difficult to control. The experience is unpleasant. In agreement with earlier studies, irritability was reported by 40% of patients with chronic pain and 18.2% of patients with no psychiatric comorbidity.
Limitations of the study
The study was conducted in a tertiary care hospital attached to a medical college where mainly assessment of severely ill patients is done and the sample size was modest.
Personality characteristics were not measured though these might be relevant to the perception of pain experience and expression of psychiatric symptoms.
| Conclusion|| |
Patient with chronic pain have high prevalence (78%) of comorbid psychiatric disorders, most common being depression (36%), followed by generalized anxiety disorder (18%), somatoform disorder (16%), and panic disorder (8%). Patients with chronic pain are more likely to have mood disorder than other psychiatric disorders. Psychiatric comorbidity in chronic pain patients is associated with severity of pain. Chronic pain patients also report a high prevalence of nonspecific symptoms such as localized tension pain (90%) and worry (82%). Comprehensive therapy of chronic pain should also address these symptoms along with treatment of comorbid psychiatric disorders.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Barrett KE, Barman SM, Boitano S, Brooks HL. Ganong's Review of Medical Physiology. 23rd
ed. Mumbai: Tata McGraw Hill; 2010.
Leo RL. Clinical Manual of Pain Management in Psychiatry. Washington DC: American Psychiatric Publishing; 2007.
Schopflocher D, Taenzer P, Jovey R. The prevalence of chronic pain in Canada. Pain Res Manag 2011;16:445-50.
Tsang A, Von Korff M, Lee S, Alonso J, Karam E, Angermeyer MC, et al.
Common chronic pain conditions in developed and developing countries: Gender and age differences and comorbidity with depression-anxiety disorders. J Pain 2008;9:883-91.
Pergolizzi J, Ahlbeck K, Aldington D, Alon E, Coluzzi F, Dahan A, et al.
The development of chronic pain: Physiological CHANGE necessitates a multidisciplinary approach to treatment. Curr Med Res Opin 2013;29:1127-35.
van Hecke O, Torrance N, Smith BH. Chronic pain epidemiology and its clinical relevance. Br J Anaesth 2013;111:13-8.
Rajmohan V, Kumar SK. Psychiatric morbidity, pain perception, and functional status of chronic pain patients in palliative care. Indian J Palliat Care 2013;19:146-51.
] [Full text]
Li CT, Chou YH, Yang KC, Yang CH, Lee YC, Su TP, et al.
Medically unexplained symptoms and somatoform disorders: Diagnostic challenges to psychiatrists. J Chin Med Assoc 2009;72:251-6.
Jensen MP, Turner JA, Romano JM. Changes in beliefs, catastrophizing, and coping are associated with improvement in multidisciplinary pain treatment. J Consult Clin Psychol 2001;69:655-62.
Farmer A, Chubb H, Jones I, Hillier J, Smith A, Borysiewicz L, et al.
Screening for psychiatric morbidity in subjects presenting with chronic fatigue syndrome. Br J Psychiatry 1996;168:354-8.
Wing JK, Babor T, Brugha T, Burke J, Cooper JE, Giel R, et al.
SCAN. Schedules for clinical assessment in neuropsychiatry. Arch Gen Psychiatry 1990;47:589-93.
Chaturvedi SK. Depressive psychosis presenting as chronic pain disorder. Indian J Psychiatry 1987;29:235-8.
] [Full text]
Varma VK, Malhotra A, Chaturvedi SK, Chari P. Sociodemographic study of patients with chronic pain. Indian J Psychiatry 1986;28:119-25.
] [Full text]
McWilliams LA, Cox BJ, Enns MW. Mood and anxiety disorders associated with chronic pain: An examination in a nationally representative sample. Pain 2003;106:127-33.
van Hecke O, Torrance N, Smith BH. Chronic pain epidemiology and its clinical relevance. Br J Anaesth 2013;111:13-8.
Agarwal P, Khastgir U, Bhatia MS, Bohra N, Malik SC. Psychological profile of females with chronic pelvic pain. Indian J Psychiatry 1996;38:212-6.
] [Full text]
Varma VK, Chaturvedi SK, Malhotra A, Chari P. Psychiatric aspects of chronic intractable pain. Indian J Psychiatry 1983;25:173-9.
] [Full text]
Ita D, Keorney M, O'Slorain L. Psychiatric disorder in a palliative care unit. Palliat Med 2003;17:212-8.
Polatin PB, Kinney RK, Gatchel RJ, Lillo E, Mayer TG. Psychiatric illness and chronic low-back pain. The mind and the spine - Which goes first? Spine (Phila Pa 1976) 1993;18:66-71.
Arnow BA, Hunkeler EM, Blasey CM, Lee J, Constantino MJ, Fireman B, et al.
Comorbid depression, chronic pain, and disability in primary care. Psychosom Med 2006;68:262-8.
Munce SE, Stewart DE. Gender differences in depression and chronic pain conditions in a national epidemiologic survey. Psychosomatics 2007;48:394-9.
Ohayon MM, Schatzberg AF. Chronic pain and major depressive disorder in the general population. J Psychiatr Res 2010;44:454-61.
Kachhwaha SS, Chadda VS, Singhwal AK, Bhardwaj P. Psychiatric morbidity in patients with chronic abdominal pain. Indian J Psychiatry 1994;36:170-2.
] [Full text]
Réthelyi JM, Berghammer R, Kopp MS. Comorbidity of pain-associated disability and depressive symptoms in connection with sociodemographic variables: Results from a cross-sectional epidemiological survey in Hungary. Pain 2001;93:115-21.
Currie SR, Wang J. Chronic back pain and major depression in the general Canadian population. Pain 2004;107:54-60.
Bair MJ, Robinson RL, Katon W, Kroenke K. Depression and pain comorbidity: A literature review. Arch Intern Med 2003;163:2433-45.
Demyttenaere K, Bruffaerts R, Lee S, Posada-Villa J, Kovess V, Angermeyer MC, et al.
Mental disorders among persons with chronic back or neck pain: Results from the world mental health surveys. Pain 2007;129:332-42.
Huffman JC, Pollack MH. Predicting panic disorder among patients with chest pain: An analysis of the literature. Psychosomatics 2003;44:222-36.
McWilliams LA, Goodwin RD, Cox BJ. Depression and anxiety associated with three pain conditions: Results from a nationally representative sample. J Pain 2004;111:77-83.
Eccleston C, Crombez G. Worry and chronic pain: A misdirected problem solving model. Pain 2007;132:233-6.
Pluess M, Conrad A, Wilhelm FH. Muscle tension in generalized anxiety disorder: A critical review of the literature. J Anxiety Disord 2009;23:1-1.
Holtzman S, O'Connor B, Barata P, Stewart D. A brief new scale to assess irritability: Validation in a chronic pain sample. J Pain 2012;13:Suppl. S20.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]