Chronic Pain and Psychoapathology


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Chronic Pain and Psychoapathology

  1. 1. Psychopathology of Chronic Pain Grand Rounds, NYU Pain Management Division, NYU Langone Medical Center Sept. 25, 2012 Matthew B. Smith, M.D. Faculty, NYU School of Medicine General Adult psychiatryLiaison Psychiatrist, NYU Pain Management Team Liaison Psychiatrist, NYU Palliative Care Team©Matthew B. Smith 2012. All rights reserved. Donot reproduce without express written permission
  2. 2. Chronic Pain: AHydra of Many Heads • Multifactorial • Complex, convoluted, elu sive, disturbing
  3. 3. Psychopathology of Chronic Pain: Deconstruction • Aversion • Central Sensitization • Psychiatric Comorbidity • Personality • Extrinsic (Interpersonal and System) • Chronic Illness • Transference and Countertransference
  4. 4. Aspects of Pain• Neutral Sensation• Unpleasantness• Aversion
  5. 5. Aversion• Motivational Salience • E.g., Itching, bowel or bladder urgency, phobia• Adaptive in Acute Pain • Maladaptive in Chronic Pain • Frustrated aversion • Not useful • Worsening of Pain
  6. 6. Aversion: A Complex, DerivativeNeuropsychological Function Cognitive and Social Executive Function AVERSION Functions Activity Emotions and Behavior
  7. 7. Reward/Aversion System
  8. 8. Reward/Aversion System • Related to addiction • Overlap • Inverse of “Craving” • Dopamine, glutamate, opioid systems • Mu, kappa receptors • Amygdala, nucleus accumbens • Analgesia as reward Seymour B, ODoherty JP, Koltzenburg M, et al. Opponent appetitive-aversive neural processes underlie predictive learning of pain relief. Nat Neurosci. 2005;8(9):1234–1240.
  9. 9. Pain and Aversion: Attention• “Interruption by pain is an inescapable fact of life: Pain will emerge over other demands for attention....Chronic pain can usefully be redefined as chronic interruption by pain. Coping with chronic pain can be understood as the ongoing attempt to recover from chronic interruption by repeatedly switching between pain and other demands in the environment.” Eccleston et al. Pain demands attention: a cognitive-affective model of the interruptive function of pain. Psychological bulletin (1999) vol. 125 (3) pp. 356-66
  10. 10. Pain and Aversion:Cognitive and Executive Function • Memory • Speed • Mental flexibility • Verbal Deficits • Likely others Kreitler. Cognitive Impairment in Chronic Pain. Pain Clinical Updates (2007) pp. 4
  11. 11. Pain, Emotions Aversion Fear Anger Disgust
  12. 12. Pain, Anxiety, Fear TextNeugebauer et al. The amygdala and persistent pain. The Neuroscientist : a review journal bringing neurobiology, neurology and psychiatry (2004) vol. 10 (3) pp. 221-34
  13. 13. Chronic Pain and Aversion: Anxiety, Fear• Catastrophizing• Phobic, avoidant• Generalizes• Of illness, injury, complication • “Illness Conviction• Of more pain• Of anything
  14. 14. Pain and Aversion: FearColloca et al. Nocebo hyperalgesia: how anxiety is turned into pain. Current opinion in anaesthesiology (2007) vol. 20 (5) pp. 435-9
  15. 15. Chronic Pain, Anger • Quiet frustration • Grumpiness, irritability • Hostility • Primitive rageSecondary Management: suppression, withdrawal, self-hate
  16. 16. Chronic Pain And Aversion: Disgust• Pain as foreign body, parasit eBenuzzi F, Lui F, Duzzi D, Nichelli PF, Porro CA. Does it look painful or disgusting? Ask your parietal andcingulate cortex. J Neurosci. 2008;28(4):923–931.
  17. 17. Pain, Aversion: Impulse, Movement• Arousal/activation• Akathisia-like aspect
  18. 18. Pain and Aversion:• Behaviors I Wincing, frowning• Moaning, sighing, grunting• Rubbing, touching, holding• Guarding, splinting, bracing, rigidly holding• Shifting, flexing• Anticipatory, antalgic posture and gait, limping• Activity restriction• Pacing Problems
  19. 19. Pain and Aversion: Behaviors II• Protective• Communicative• Role Commitment• Environmental Reinforcement• Deconditioning• Function and Subjective Experience
  20. 20. Pain and Aversion: LonelinessImage of My PainShin: Alone with Pain Resendez SLS, Kuhnmuench MM, Krzywosinski TT, Aragona BJB. κ-Opioid receptors within the nucleus accumbens shell mediate pair bond maintenance. Journal of Neuroscience. 2012;32(20):6771–6784.
  21. 21. Psychopathology of Chronic Pain: Deconstruction • Aversion • Central Sensitization • Psychiatric Comorbidity • Personality • Extrinsic (Interpersonal and System) • Chronic Illness • Transference and Countertransference
  22. 22. Central Sensitization • Malignant process of up- regulation, pain begetting more pain, becoming autonomous
  23. 23. • Hyperalgesia• Central Sensitization Hyperpathia• Paresthesia• Centrifugal spread• Referred pain• Bilateralization• Persistence, longer after-sensations• Spontaneous, unpredictable exacerbations• DNIC reversal• Reduced gate control• Cross-modality• movement effects• Anhedonia• Lack of Motivation
  24. 24. Central Sensitization:Psychological Effects I • Amplified Aversion • Cognitive/executive • Fear • Anger • Disgust • Activity, Behaviors • Social longing
  25. 25. Central Sensitization: Psychological Effects II• Pain comes to dominate subjective experience, activity• Pain becomes psychic funnel, organizer, director• Pain becomes developmental nidus and trajectory• Pain as core element of self
  26. 26. Central Sensitization:Psychological Effects III• Helplessness, “Frustated aversion” • Reduced control, predictability, understanding• Mortification, self-blame• Egocentricity• Regressed relating to others• Disturbed Self-image
  27. 27. Chronic Pain and Self• Pain as a trait, not a state• Pain as an essential, not accidental, attribute
  28. 28. Somatosensory Cortex • Homunculus • Prominence of painful sites • Routine persistence • Body SchemaElbert T et al. Reorganization of Flor et al. Extensive reorganizationhuman cerebral cortex: the range of primary somatosensory cortexof changes following use and injury. in chronic back pain patients.The Neuroscientist (2004) vol. 10 Neurosci Lett (1997) vol. 224 (1)(2) pp. 129-41 pp. 5-8Schmidt-Wilcke et al. Affective Yang et al. Noninvasive detection ofcomponents and intensity of pain cerebral plasticity in adult humancorrelate with structural differences somatosensory cortex. Neuroreportin gray matter in chronic back pain (1994) vol. 5 (6) pp. 701-4patients. Pain (2006) vol. 125 (1-2)pp. 89-97 Dykes. Mechanisms controlling neuronal plasticity in somatosensory cortex. Can J Physiol Pharmacol (1997)
  29. 29. Self, Identity Values Conscience Ego-Ideal Wished-for Self Self- Identifications Self- Confide Esteem nce Gender Body Image Identity Self-Image IdentityThe ego is first and foremost a bodily ego....If we wish to find an anatomical analogy for it we canbest identify it with the “cortical homunculus” of the anatomists, which stands on its head in thecortex, sticks up its heels, faces backwards and, as we know, has its speech-area on the left-handside. -- Freud
  30. 30. Central Sensitization: Changes in “Self”• Damaging to “Self” • Loss of “Self” • Damaged “Self” • Broken “Self” • Fragmented Self • Unintegrated Self • Unstable Self
  31. 31. The Chronic Pain ConundrumPain is a part Pain cannot beof self, and accepted as amust be part of self.accepted.
  32. 32. Psychopathology of Chronic Pain: Deconstruction • Aversion • Central Sensitization • Psychiatric Comorbidity • Personality • Extrinsic (Interpersonal and System) • Chronic Illness • Transference and Countertransference
  33. 33. Chronic Pain as Precipitant• Mood disorders• Anxiety disorders• Addiction Disorders
  34. 34. Chronic Pain, Depression• Potentiation of depression neurochemistry • Norepinephrine • Serotonin • Dopamine• Likely 50-75%• Clinical recognition problems• Treatment problems • Opioid resistance • Reduced motivation
  35. 35. Depression Makes Pain Worse • Augmented pain perception • Subjective amplification of negative • Poor self-care • Physical inactivity • Further sleep impairment • Constriction of compensating, positive thoughts and activitiesStrigo et al. Association of Major Depressive Disorder With Altered Functional Brain Response During Anticipation …. Arch Gen Psychiatry (2008) Klauenberg et al. Depression and changed pain perception: Hints for a central disinhibition mechanism. Pain (2008) vol. 140 (2) pp. 332-343
  36. 36. ChronicPain, Mania, Hypomania, Mixed • Not euphoric • Irritable or dysphoric • Not hyperactive • Compensated • Pain as partial stabilizer • Opiates as partial behavioral control
  37. 37. Chronic Pain, Bipolar Spectrum • Unknown Prevalence • SNRI’s • TCA’s • SSRI’s • Stimulants
  38. 38. Chronic Pain, Anxiety Disorders • 25% • GAD • Panic Disorder
  39. 39. Chronic Pain: Psychiatric Antecedents• Very common• Multiple bases for vulnerability to chronic pain• Multiple pathways of pathogenesis
  40. 40. Chronic Pain, Addiction I• Addiction: • Craving • Compulsive use • Characteristic modifications in the brain reward/aversion system
  41. 41. Chronic Pain, Addiction II• Højsted J, Sjøgren P. Addiction to opioids in chronic pain patients: A literature review. European Journal of Pain. 2012;11(5):490–518. • Overall review of 24 studies • 0-50% risk • Criteria needed, rarely used • ICD-10 • Portnoy
  42. 42. Chronic Pain, Addiction III• Fishbain et al. What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuse/addiction and/or aberrant drug- related behaviors? A structured evidence-based review. Pain medicine (Malden, Mass) (2008) vol. 9 (4) pp. 444- 59 • Those with no prior history of addiction: • ADR 0.6% • Addiction 0.2%
  43. 43. Chronic Pain, Addiction Risks • Highest with • Hx of substance abuse or addiction • Concurrent psychiatric disorder • Noncompliant patient • Otherwise, risk is present, but low • Still requires managementCarroll I, Barelka P, Wang CKM, et al. A Pilot Cohort Study of the Determinants of Longitudinal Opioid UseAfter Surgery. Anesth Analg. 2012;115(3):694–702. Available at:
  44. 44. Chronic Pain, Addiction• Prevalence of chronic pain syndromes among patients with addiction disorders • Sheu R, Lussier D, Rosenblum A, et al. Prevalence and characteristics of chronic pain in patients admitted to an outpatient drug and alcohol treatment program. Pain Medicine. 2008;9(7):911–917. • 29% • Rosenblum A, Joseph H, Fong C, Kipnis S, Cleland C, Portenoy RK. Prevalence and characteristics of chronic pain among chemically dependent patients in methadone maintenance and residential treatment facilities. JAMA. 2003;289(18):2370–2378. • 37%
  45. 45. Chronic Pain, Addiction: History of Addiction • Prone to relapse by “cues” • “No treatment” is not ethically acceptable • Special precautionsSavage SR, Kirsh KL, Passik SD. Challenges in using opioids to treat pain in persons withsubstance use disorders. Addict Sci Clin Pract. 2008;4(2):4–25.Compton P, Athanasos P. Chronic pain, substance abuse and addiction. Nursing Clinics ofNorth America. 2003.
  46. 46. Psychopathology of Chronic Pain: Deconstruction • Aversion • Central Sensitization • Psychiatric Comorbidity • Personality • Extrinsic (Interpersonal and System) • Chronic Illness • Transference and Countertransference
  47. 47. Personality Factors• Coping deficiencies• Problems with impulse or affect control • Volatile, overreactive • Alexithymic• Somatizing tendencies• Unmet psychological needs • Dependence • Guilt, punishment • Loss • Identification • Sexual, aggressive impulses
  48. 48. Chronic• AlexithymiaPain, Personality Traits• Somatic Preoccupation• Reward Dependence• Harm Avoidance• Neuroticism• Counterdependency• Guilt trends, moral masochism• Histrionic Features• Some Narcissistic Styles
  49. 49. Chronic Pain: Regression• Resembles borderline personality disorder
  50. 50. Developmental Factors • Early psychological trauma, especially violent or sexualRingel et al. Effect of Abuse History on Pain Reports and Brain Responses to Aversive Visceral Stimulation: An …. Gastroenterology (2008)
  51. 51. Chronic Pain, Early Abuse I • Pain Clinic • 104 women • 40% childhood abuse • 59% sexual • 33 % continuing abuse • 79% both sexual and physicalGreen et al. The role of childhood and adulthood abuse among women presenting for chronic pain management. The Clinical journal of pain (2001) vol. 17 (4) pp. 359-64
  52. 52. Chronic Pain, Early Abuse II • OB/GYN Clinic • 36 women with chronic pelvic pain • 36% sexual abuse before age 15Lampe et al. Chronic pelvic pain and previous sexual abuse. Obstetrics and gynecology (2000) vol. 96 (6) pp. 929-33
  53. 53. Chronic Pain: Vicious Circles PAINDEPRESSION ANXIETY Early Life Abuse PERSONALITY
  54. 54. Chronology?(Abuse) Personality Stressor Axis I Stressor Pain Chronic Trauma, Axis I Chronic Disorder Disorder Syndrome Pain Regression Disorder Pain Syndrome Syndrome Trauma, Regression Pain SyndromePersonality Chronic Disorder Pain Syndrome Stressor Axis I Disorder (Abuse)
  55. 55. Psychopathology of Chronic Pain: Deconstruction • Aversion • Central Sensitization • Psychiatric Comorbidity • Personality • Extrinsic (Interpersonal and System) • Chronic Illness • Transference and Countertransference
  56. 56. Chronic Pain: Interpersonal and System Factors PainFamily Legal Occupational Medical, Insurance System
  57. 57. Psychopathology of Chronic Pain: Deconstruction • Aversion • Central Sensitization • Psychiatric Comorbidity • Personality • Extrinsic (Interpersonal and System) • Chronic Illness • Transference and Countertransference
  58. 58. Chronic Pain: Pain as Central Psychological and• Attachment to pain itself Developmental Organizer • “Pain is part of what and who I am.• Pain and patient role as identity • Self-image with pain • Narcissistic defenses• Attachment to, investment in • Sick role, disability role • IP role (family)• Secondary attachments • People, money, activities• Treatment as threat
  59. 59. Abused Child Transference Stalemate• Repetition from a provider (parental figure)• Idealization and mistrust of physician as nurturer and abuser• Pain, punishment as love (investment in pain)• Pain, illness as dependence, nurturance (Investment in illness)• Suffering as disempowering the rescuer-abuser by guilt-tripping, defiance
  60. 60. Chronic Pain Treatment Team• Complexity: limited effectiveness of simple unimodal approaches• Team Approach • Physical management and monitoring • Rehab • Psychiatry and Psychology • Social Work • Group support• Prognosis
  61. 61. Psychopathology of Chronic Pain• ©Matthew B. Smith 2012. All rights reserved. Do not reproduce without express written permission