Jeffrey Dersh

Chronic pain and psychopathology: research findings and theoretical considerations.

Objective Numerous studies have documented a strong association between chronic pain and psychopathology. Previous research has shown that chronic pain is most often associated with depressive disorders, anxiety disorders, somatoform disorders, substance use disorders, and personality disorders. The primary objective of this review article is to describe the nature of the relationship between chronic pain and each of these types of psychopathology. In addition, this article will explore how each of these disorders are expressed within the context of chronic pain, with a consideration of both diagnostic and treatment issues. Methods Medline and PsychLit searches of the chronic pain/psychopathology literature from 1980 through 2000 were conducted using the keywords chronic pain, psychopathology, psychiatric disorders, and psychological disorders. Results The relationship between chronic pain and psychopathology has generated substantial empirical and theoretical interest, with depressive disorders receiving much of the attention. Conclusions Although no single theoretical model can fully explain the causal relationship between chronic pain and psychopathology, a diathesis-stress model is emerging as the dominant overarching theoretical perspective. In this model, diatheses are conceptualized as preexisting, semidormant characteristics of the individual before the onset of chronic pain that are then activated and exacerbated by the stress of this chronic condition, eventually resulting in diagnosable psychopathology.

Prevalence of psychiatric disorders in patients with chronic disabling occupational spinal disorders.

Study Design. A prevalence study. Objectives. To assess the prevalence of psychiatric disorders among a large group of patients with chronic disabling occupational spinal disorders (CDOSDs), using a reliable and valid diagnostic instrument. Summary of Background Data. Although unrecognized and untreated psychiatric disorders have been found to interfere with successful treatment of CDOSD patients, little data are currently available regarding the psychiatric characteristics of patients claiming work-related injuries that result in CDOSDs. Methods. Psychiatric disorders in a consecutive group of CDOSD patients (n = 1,323) attending a tertiary referral center for patients with CDOSD were diagnosed using the Diagnostic and Statistical Manual of Mental Disorders. Results. Overall prevalence of psychiatric disorders was found to be significantly elevated in CDOSD patients compared with base rates in the general population. A majority (65%) of patients were diagnosed with at least one current disorder (not including Pain Disorder, which is nearly universal in this population), compared with only 15% of the general population. Major Depressive Disorder (56%), Substance Use Disorders (14%), Anxiety Disorders (11%), and Axis II Personality Disorders (70%) were the most common diagnoses. Conclusions. Clinicians treating CDOSD patients must be aware of the high prevalence of psychiatric disorders in this population. They must also be prepared to use mental health professionals to assist them in identifying and stabilizing these patients. Failure to follow a biopsychosocial approach to treatment will likely contribute to prolonged disability in a substantial number of these chronic pain patients.

Prevalence of psychiatric disorders in patients with chronic work-related musculoskeletal pain disability.

The cost and prevalence of chronic work-related musculoskeletal pain disability in industrialized countries are extremely high. Although unrecognized psychiatric disorders have been found to interfere with the successful rehabilitation of these disability patients, few data are currently available regarding the psychiatric characteristics of patients claiming work-related injuries that result in chronic disability. To investigate this issue, a consecutive group of patients with work-related chronic musculoskeletal pain disability (n = 1595), who started a prescribed course of tertiary rehabilitation, were evaluated. Psychiatric disorders were diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders. Results revealed that overall prevalences of psychiatric disorders were significantly elevated in these patients compared with base rates in the general population. A majority (64%) of patients were diagnosed with at least one current disorder, compared with only 15% of the general population. However, prevalences of psychiatric disorders were elevated in patients only after the work-related disability. Such findings suggest that clinicians treating these patients must be aware of the high prevalence of psychiatric disorders and be prepared to use mental health professionals to assist in identifying and stabilizing these patients. Failure to follow a biopsychosocial approach to treatment will likely contribute to prolonged pain disability in a substantial number of these patients.

Chronic spinal disorders and psychopathology: research findings and theoretical considerations

BACKGROUND CONTEXT Numerous studies have documented a strong association between chronic spinal disorders and psychopathology. However, there have been methodological shortcomings associated with much of this. PURPOSE This article reviews the relevant research literature, including methodological refinements that have resulted in improved measurement of psychopathology, in order to provide the most updated conclusions concerning the links between spinal disorders and psychopathology. STUDY DESIGN A systematic review of all Medline referenced articles on this subject during the past three decades. METHODS Previous research has shown that chronic spinal disorders are most often associated with depressive disorders, somatoform disorders, anxiety disorders, substance use disorders, and personality disorders. In addition to reviewing this research, the relationship between chronic spinal disorders and depressive disorders is examined in more detail. RESULTS Although the relationship between spinal disorders and psychopathology is complex, a diathesis-stress model is emerging as the dominant overarching theoretical model. In this model, diatheses are conceptualized as pre-existing semidormant characteristics of the individual before the onset of chronic spinal disorders, which are then activated by the stress of this chronic condition, eventually resulting in a diagnosable depressive disorder. CONCLUSIONS In the present review, a diathesis-stress model was applied specifically to the relationship between chronic spinal disorders and depressive disorders. Such a model may also be applicable to the relationship between chronic spinal disorders and other types of psychopathology, such as anxiety and substance use disorders. However, conclusive empirical support will require a prospective research design, given that these diatheses could be validly assessed only before the onset of the chronic pain condition.

Do psychiatric disorders first appear preinjury or postinjury in chronic disabling occupational spinal disorders

Study Design. An epidemiologic prevalence study. Objectives. To clarify the temporal association between work-related injury claims and psychiatric disorders in patients with chronic disabling occupational spinal disorders (CDOSDs). Summary of Background Data. Few empirical data are available regarding the “chicken-or-egg” question of which occurs first: the injury or incident culminating in the painful CDOSD or the psychiatric disturbance. Methods. Subjects attended a tertiary interdisciplinary rehabilitation program. Psychiatric disorders were assessed using the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders (SCID-DSM-IV). Psychiatric disorders were characterized as preexisting if they manifested themselves before the work-related injury claim (whether or not they resolved, continued, or reoccurred after injury). They were determined postinjury diagnoses only if they manifested for the first time after the injury claim. Results. A total of 38.7% of the present cohort had at least one preexisting major psychiatric disorder, while 98.9% developed one or more psychiatric disorders for the first time after injury onset (57.9% when pain disorder was excluded). The percentage of patients with preexisting psychiatric disorders was lower than general population base rates (48%). The first onset of certain psychiatric disorders was found to be elevated in patients only after the work-related injury; these included Pain Disorder (95.7%), Major Depressive Disorder (49.7%), and Opioid Dependence (15%). Moreover, 5 times as many patients with MDD, and 10 times as many with opioid dependence, developed these disorders for the first time after the injury. Conclusions. In general, psychiatric disturbance is not a risk factor for developing a CDOSD. Psychiatric disorders are much more likely to develop after the onset of the work injury, indicating that such injuries and accompanying stressors are likely to be precipitants, rather than consequences, of psychopathology.

The Management of Secondary Gain and Loss in Medicolegal Settings: Strengths and Weaknesses

Individuals with chronic illness and disability are among the most difficult patients to treat. The health-care provider is faced with an array of physical, psychological, and social factors, requiring adoption of a biopsychosocial approach to treatment. This approach necessitates consideration of the benefits for the patient of remaining ill and disabled. These benefits have been termed the “secondary gains” of illness, and they may serve to perpetuate disability and illness behavior. This paper focuses on secondary gain and loss issues in patients with chronic, nonprogressive illness associated with chronic disability, who are evaluated and treated in medicolegal settings. In working with this population of patients, the health-care provider is faced not only with the usual secondary gains of illness (e.g., escape from family responsibilities), but must also deal with the myriad of secondary gain issues unique to medicolegal settings (e.g., seeking financial compensation). Consequently, identifying and managing secondary gain issues can be quite challenging. A model for managing these issues is presented here, following a more general discussion of secondary gain and related concepts. This model has proven very useful when incorporated into an effective rehabilitation program, such as the functional restoration approach to treating chronic musculoskeletal disorders. However, shortcomings of this model for managing secondary gain have become apparent. These shortcomings, and methods for overcoming them, are discussed. The overall purpose of this paper is to improve the health-care providers ability to identify and manage both simple and complex secondary gain issues.

Prescription opioid dependence is associated with poorer outcomes in disabling spinal disorders.

Study Design. Prospective outcomes study involving patients with chronic disabling occupational spinal disorders (CDOSD) diagnosed with (n = 199) or without (n = 1124) postinjury opioid-dependence disorder (ODD), based on the Diagnostic and Statistical Manual of Mental Disorders–fourth edition cirteria. Objective. To determine whether prescription opioid dependence, assessed at the beginning of rehabilitation treatment, is associated with poorer treatment outcomes in patients with CDOSDs attending an interdisciplinary rehabilitation program. Summary of Background Data. Controversy exists regarding the risk of iatrogenic ODD and treatment outcomes when long-term opioid therapy is used in the treatment of chronic nonmalignant pain conditions. Methods. A consecutive sample of patients with CDOSDs [n = 1323; mean (SD) length of disability = 18.8 (20.7) months] attending a tertiary referral center received intensive physical reactivation and pain/disability management interventions, based on a functional restoration model, including detoxification from opioids. One-year outcomes included return to work, work retention, healthcare utilization, new surgeries, recurrent injuries, and disability claim settlement. Results. Prevalence of ODD in this CDOSD population on entering the rehabilitation program was 15%. Even after adjusting for relevant demographic factors and comorbid psychiatric disorders, opioid-dependent patients were 1.7 times [95% confidence interval (CI): 1.0, 2.7] less likely to return to work, 2 times (95% CI: 1.3, 3.0) less likely to retain work at the 1-year interview, and 1.7 times (95% CI: 1.2, 2.5) more likely to engage in healthcare utilization from new providers, compared with nonopioid-dependent patients. Conclusions. Iatrogenic prescription opioid dependence may be a risk factor for less successful long-term work and health outcomes, even after detoxification from opioids as part of an interdisciplinary functional rehabilitation program. Chronic prescription opioid dependence in this patient population is also associated with a significantly higher prevalence of comorbid psychiatric conditions, both axis I and II.

Strengths of the SF-36 health status survey with a chronically disabled back pain population: Strengths and limitations

The SF-36 is a widely used self-report health status survey. It has repeatedly demonstrated sound psychometric properties with regard to certain aspects of reliability and validity, and has proven effective as a means of tracking group outcomes. There were three major objectives of the present investigation: (1) to document group changes in a sample of chronically work disabled low back pain patients who underwent tertiary rehabilitation; (2) to evaluate the clinical utility of the SF-36 in measuring changes in patients as a result of treatment; and (3) to compare the SF-36 scores found for this sample to the United States norms for back pain/sciatica patients published elsewhere. All patients (n = 286) received an initial evaluation consisting of several assessment procedures, including the SF-36. First, the sample was broken down into a “completer” group (n = 188), a “noncompleter” group (n = 31), and a “nonstarter” group (n = 67). Next, the preprogram scores for the physical and mental component summary scales were compared to the norms for back pain/sciatica patients. Changes in the “completer” groups scores from preprogram to postprogram were then examined. To assess clinical utility, three additional self-report questionnaires were correlated to the eight scales and two summary scales of the SF-36. Results revealed no statistically significant differences with regard to demographics among the three groups. The preprogram scores for the physical and mental component summary scales were significantly lower when compared to the norms for back pain/sciatica patients. Further, patients who completed the program showed improvement on the SF-36 from preprogram to postprogram administration. When the correlations between SF-36 scales and other self-report questionnaires were examined, many of the highest correlations were found between the self-reported pain and disability measurements and the physical components of health on the SF-36. In terms of clinical usefulness, the SF-36 demonstrated limited clinical utility when attempts were made to use it on an individual patient basis. This is consistent with the psychometric limitations of the SF-36. Because of the brevity of each of the eight scales and the limited number of score levels, the reliability coefficients have been shown to be low in other studies (20), thereby increasing confidence intervals around an individuals scores on each of the scales.

A Randomized Clinical Trial of Treatment for Lumbar Segmental Rigidity

Study Design. A randomized single-blind clinical trial of facet injections plus exercise, versus exercise alone, in chronic disabling work-related lumbar spinal disorders (CDWRLSD), accompanied by pilot interrater reliability and facet syndrome prevalence studies. Objectives. To systematically investigate the use of facet injections as an adjunct to supervised lumbar stretching exercises in regaining lumbar range of motion (ROM) following prolonged deconditioning after work-related lumbar injuries. To assess interrater reliability of visual assessment of segmental rigidity (SR), and to evaluate the prevalence of facet syndrome in cases of lumbar SR. Summary of Background Data. Corticosteroid joint injections have often been used to reduce musculoskeletal inflammation to facilitate joint mobilization in the presence of degenerative arthritis. Lumbar segmental rigidity is a recently described entity usually associated with painful chronic spinal disorders and postoperative spine surgery. Previous work has shown that SR and lumbar ROM improves with a brief intervention consisting of facet injections followed by specific stretching exercises. No systematic study has investigated the potential benefits of a combination of facet injections and exercise over supervised exercises alone to treat lumbar SR. Similarly, no study has assessed the association between SR and the facet syndrome. Methods. From a group of consecutive patients (n = 421) with CDWRLSD referred for tertiary rehabilitation between November 1999 and January 2001, 70 were noted to have SR on intake physical examination. The first part of this study assessed interrater reliability for detecting SR, and intrarater reliability for 3-segment true lumbar ROM measurements. Patients randomly assigned to participate in supervised stretching exercises with the addition of fluoroscopically guided bilateral facet injections at the involved levels (Group A, n = 36) also underwent facet syndrome prevalence assessment at the time of injection. They were compared to a randomly allocated comparison group (Group B, n = 34) undergoing exercises alone in a single-blind design. Physical therapists saw patients an average of twice per week, providing supervision of a progressive home stretching program. Inclinometric joint ROM was measured at the time of group allocation, and again 5 to 7 weeks later. Validated questionnaires of pain (intensity VAS) and disability (Million VAS) related to the CDWRLSD were provided before and after the interventions. Results. Part 1 reliability and facet syndrome prevalence work revealed that interrater reliability for experienced examiners to detect rigid segments was excellent (Pearson’s r = 0.97, P < 0.01). Intrarater 3-joint motion measurement reliability was also good for all sagittal/coronal ROM (Pearson’s r = 0.95–0.99, P < 0.01). Only 5 of 29 subjects with SR met criteria for facet syndrome (17%), consistent with prior prevalence studies of unselected patients with low back pain. In Part 2, a large majority of patients in both groups improved from the initial to the post-treatment ROM measurements (the primary outcome criterion of the study). However, a higher proportion of Group A (injection) patients (87%–95%) showed ROM improvement, compared to Group B (exercise only) patients (64%–79%). Group A patients showed a significantly greater ROM improvement in all sagittal and coronal movements, both in absolute terms and percent of initial measurement. No significant differences in pain or disability self-report were found between groups, pre- or postintervention, but both groups showed significant improvement from pre- to postintervention in pain and disability assessments. Conclusions. The detection of SR and measurement of 3-segment true lumbar ROM by experienced examiners is highly reliable. Only 17% of CDWRLSD patients with lumbar SR met criteria for the facet syndrome, a rate approximately equal to that of unselected low back pain cohorts. This indicates that lumbar SR may be found whether or not pain of facet joint origin is present. In the randomized trial, facet injections significantly increased the percentage of patients with SR showing ROM improvement, as well as the degree of improvement in lumbar mobility after treatment. There is no evidence that facet injections increase the improvements in pain/disability report noted in both groups.

Psychiatric comorbidity in chronic disabling occupational spinal disorders has minimal impact on functional restoration socioeconomic outcomes

Study Design. A prospective study conducted at a tertiary functional restoration center for patients with chronic disabling occupational spinal disorders (CDOSDs), comparing treatment outcome status 1-year posttreatment of patients with specific diagnosed psychiatric disorders to those without. Objective. To evaluate if diagnosed psychopathology is a significant limiting factor in the successful interdisciplinary rehabilitation of CDOSD patients. Summary of Background Data. Research has demonstrated high prevalence rates of psychiatric disorders in patients with CDOSDs. Little is known about whether these disorders are associated with less successful treatment outcomes. Methods. A consecutive group of CDOSD patients (n = 1323) averaging 19 months of prerehabilitation disability were evaluated for psychiatric disorders with the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Patients participated in a functional restoration program. A structured clinical interview addressing work status, recurrent injury, healthcare utilization, and financial claims closure was administered 1 year after discharge. Logistic regression analyses were conducted to determine the unique contribution of the specific DSM-IV disorders that were significantly associated with the outcomes. Results. Patients with panic disorder, antisocial personality disorder (PD) and dependent PD were >2 times more likely to be program noncompleters. For successful program completers, those with opioid dependence disorder (ODD) were 2.7 times less likely to return to work and 2.6 times less likely to retain work. Patients with ODD were also 2.1 times more likely to seek postrehabilitation treatment from a new provider. Conclusions. Despite intensive management of psychiatric disorders during interdisciplinary functional restoration for CDOSD, several disorders were found to be associated with less successful outcomes. Poorer work outcomes were more common with specific (and comorbid) Axis I psychiatric disorders. Opioid dependence was the single disorder associated most often with less successful outcomes. Despite these findings, the large majority of patients demonstrated successful outcomes. Depression did not independently link to less successful outcomes.