Psychological Effects of Pain and on Pain
Pain management clearly does not exist in a vacuum without reference to a person’s psychological status. Treatment paradigms excluding the effects of depression, somatization, schizophrenia, conversion disorders, etc. will ultimately result in failure. Therefore, a patient entering a pain management program will often be asked to complete certain psychological evaluation tools and sometimes participate in at least an initial psychological interview.
Effects of psychological conditions (PC) on pain perception
Many PC result in a decrease in serotonin levels in the brain and spinal cord. The effects may be directly produced or indirectly through sleep disturbances which further decreases serotonin in the brain and spinal cord. Reduction of these levels of serotonin results in uninhibited neural transmission of painful signals to the brain, whereas in those without PC, the signals are interrupted or modulated so that the degree of perceived pain is less. Depression, anger, hostility, sleep disturbances all result in increase pain transmission to the brain. In one study of primary care physician patients being treated for chronic pain, there was an incidence of the following psychological conditions: (J Pain Symptom Manage 2001 Sep;22(3):791-6): Depression/affective disorders were reported in 36% of the patient charts, anxiety/panic disorders (15%), drug abuse (6%),and alcohol abuse (3%). Another study demonstrated a direct correlation between pain scores and depression scores (Rev Esc Enferm USP 2000 Mar;34(1):76-83) while another demonstrated a direct correlation with psychiatric symptoms and degree of pain (Med Confl Surviv 2001 Apr-Jun;17(2):102-11). In another study (Gen Hosp Psychiatry 2001 Jul-Aug;23(4):193-7) There was a 18% prevalence of borderline personality among primary care patients with chronic pain.
Obviously, these psychiatric conditions are not present to such degrees in the general population, therefore the question becomes whether pain caused PC or PC caused pain. The incidence of pain in populations with the above conditions is higher than normal, but is nowhere near the degrees seen in the above studies. This suggests that pain is not due to psychiatric conditions but results in secondary psychiatric conditions. But these conditions do influence pain due to the effects on the norepinephrine and serotonin systems.
Effects of Pain on the Physical and Psyche
In one study cited above, the effects of pain over several years resulted in a 73% incidence of psychological aberrations. The effects of pain are very real, resulting in depression, loss of sleep, loss of self worth, anxiety over the pain itself and also how the patient is perceived by their family and peers, loss of employment, anger directed outward in a generalized manner, and in some cases, suicide. Those affected by chronic pain begin to believe (erroneously) that only more narcotic medicine is needed to take away the pain, when in fact substance abuse and addiction develops in as much as 25%. (Pain Physician, Vol 4, No 4, Oct. 2001). Those who are weak believe it is up to others to “fix” them and will take little ownership of their own rehabilitation. Some unfortunates believe only in a nociceptive framework for their pain….ie. that there is still something causing the pain and all we need do is correct the problem to solve all the pain problems. It has been well documented that while addressing the pain generators is necessary in any comprehensive pain management program, that in and of itself is insufficient to permit total recovery towards the norm. Partially this is due to the reverberating circuits and changes in spinal cord neuron activation. In a chronically painful state of existence, neurons which are not active such as wide dynamic range neurons in the spine. These perpetuate the pain even after elimination of the source. Also learned behavior and habits become imbedded in the psyche of some patients such that elimination of both wide dynamic range neuron activation and pain generators would not result in any significant perceivable improvement. Some of these habits such as smoking, have been demonstrated conclusively to increase chronic pain from many sources, yet this information will rarely be sufficient so as to promote smoking cessation.
Sexual dysfunction is common with chronic pain, partially due to medications, but also due to the distance a pain patient feels with their spouse and positional pain during intercourse.Clin J Pain 2001 Jun;17(2):138-45 Sexual difficulties of chronic pain patients Seventy-three percent of respondents had pain-related difficulty with sexual activity; most had several, in various combinations of problems with arousal, position, exacerbating pain, low confidence, performance worries, and relationship problems. Furthermore, these findings were unrelated to mood or motivation. Psychological responses to pain are often predictable based on the social, financial, and relational decay that occurs with chronic pain. Weight gain is almost universal, sometimes significantly, since the patient has not been instructed or is incapable of modifying their eating habits in spite of a sedentary lifestyle. Self image is poor partly due to decaying imagery of body habitus, but also due to lack of self worth due to inability to help with family financial contribution. Depression and anxiety are very common. Sleep disturbances due to chronic pain are above 80%.