DSM-IV pain disorder in the general population. An exploration of the structure and threshold of medically unexplained pain symptoms

Not a general, symptom-unspecific, transdiagnostic marker for functional symptoms: sensorimotor processing of head control is intact in chronic pain

Introduction

Functional disorders are prevalent in all medical fields and pose a tremendous public health problem, with pain being one of the most common functional symptoms. Understanding the underlying, potentially unifying mechanism in functional (pain) disorders is instrumental in facilitating timely diagnosis, stigma reduction, and adequate treatment options. Neuroscientific models of perception suggest that functional symptoms arise due to dysregulated sensorimotor processing in the central nervous system, with brain-based predictions dominating the eventual percept. Experimental evidence for this transdiagnostic mechanism has been established in various functional symptoms. The goal of the current study was to investigate whether erroneous sensorimotor processing is an underlying transdiagnostic mechanism in chronic (functional) pain.

Method

A total of 13 patients with chronic (functional) pain [three patients with chronic (functional) pain disorder, F45.40, ICD-10; 10 patients with chronic pain disorder with somatic and psychological factors, F45.41, ICD-10]; and 15 healthy controls performed large combined eye-head gaze shifts toward visual targets, naturally and with increased head moment of inertia. We simultaneously measured participants' eye and head movements to assess head oscillations at the end of the gaze shift, which are an established indicator of (transdiagnostic) sensorimotor processing deficits of head control.

Results

Using a Bayesian analysis protocol, we found that patients with chronic (functional) pain and control participants stabilized their heads equally well (Bayes Factor 01 = 3.7, Bayes Factor exclusion = 5.23; corresponding to substantial evidence) during all sessions of the experiment.

Conclusion

Our results suggest that patients with chronic (functional) pain do not show measurable symptom-unspecific sensorimotor processing deficits. We discuss outcome parameter choice, organ system specificity, and selection of patient diagnoses as possible reasons for this result and recommend future avenues for research.

Alcoholic neuropathy associated with chronic alcohol intake

Alcoholic neuropathy (AN), a debilitating condition that mainly affects chronic alcohol drinkers, is thought to cause lesions in the peripheral nervous system leading to sensory, autonomic, and motor dysfunctions. Despite many studies, the pathogenesis of these lesions is still not completely understood. We investigated few aspects on the development of alcohol-induced peripheral neuropathy, by assessing sensory, motor and autonomic functions, as well as stereological analysis of axonal fibers and myelin sheath of the sciatic nerve. Twelve male Wistar rats were divided into Control group and Alcohol group that was submitted to Two Bottle-Choice Paradigm of intermittent and voluntary alcohol solution intake (20%; v/v) during eight weeks. At the end of treatment, three different sensorium-motor tests were applied - Tactile Sensitivity, Thermal Sensitivity, and Functional Observational Battery (FOB). Quantitative morphometric analysis of sciatic nerve structures was performed by stereological method. Alcohol concentration in the blood was measured to analyze possible correlation between availability of alcohol in the blood and the magnitude of the peripheral nerve lesion. Our data showed a peripheral effect of chronic alcohol intake associated with hyperalgesia and a process of demyelination with a strong correlation with alcohol consumption. This process was associated with increased tactile sensitivity, with behavioral reflexes such as locomotor hyperactivity, changes in gait and balance, and autonomic reflexes such as piloerection.

•

Alcoholic neuropathy and its consequences.

•

Neuropathy and sensitive and motor alterations.

•

Alcoholic neuropathy and thinner myelin sheath thickness.

[Chronic pain in elderly people during the COVID-19 pandemic]

Hintergrund

Internationale Studien belegen negative Auswirkungen der COVID-19-Pandemie auf Stimmung und Stresslevel befragter Personen. Auch konnten Zusammenhänge zwischen der Pandemie und höheren Schmerzstärken sowie stärkerer schmerzbedingter Beeinträchtigung nachgewiesen werden. Die Studienlage dazu, ob ältere Menschen besser oder schlechter mit der Pandemie und ihren Auswirkungen umgehen können als jüngere Personen, ist aber uneindeutig.

Methodik

Seit einigen Jahren bietet das Universitätsklinikum Würzburg ein multimodales Schmerztherapieprogramm für SeniorInnen an. Für die vorliegende Arbeit wurden retrospektiv klinische Routinedaten zum Zeitpunkt des interdisziplinären multimodalen Assessments von n = 75 TeilnehmerInnen in den Jahren 2018 und 2019 mit denen von n = 42 Patientinnen während der COVID-19-Pandemie 2020–2021 verglichen. Wir untersuchten Schmerz, psychische Belastung und körperliches Funktionsniveau mithilfe des Deutschen Schmerzfragebogens, klinischer Diagnostik und geriatrischer Funktionstests.

Ergebnisse

Die beiden Teilstichproben unterschieden sich nicht in demografischen Merkmalen. Bezüglich Schmerzintensität und Beeinträchtigung sowie der psychischen Belastung fanden sich ebenfalls keine signifikanten Unterschiede. Lediglich die Anzahl der schmerzbedingt beeinträchtigten Tage war vor Corona signifikant höher. Die geriatrischen Funktionstests zeigten signifikant bessere Werte während der Pandemie an.

Diskussion

Die vorliegenden Daten zeigen keine Verschlechterung von Schmerz und körperlichem sowie psychischem Wohlbefinden bei SeniorInnen vor dem Hintergrund der Pandemie. Weitere Studien sollten die möglichen Gründe dafür untersuchen. Diese könnten in einer höheren Resilienz der SeniorInnen basierend auf ihrer Lebenserfahrung, finanziellen Sicherheit oder einer geringeren Veränderung des Lebensalltags liegen.

Burden of Mental, Neurological, Substance Use Disorders and Self-Harm in North America: A Comparative Epidemiology of Canada, Mexico, and the United States

OBJECTIVE

To estimate the burden of mental, neurological, substance use disorders and self-harm (MNSS) in Canada, Mexico, and the United States.

METHOD

We extracted 2017 data from the Global Burden of Disease online database. Based on a previously developed framework to classify and aggregate the burden of specific disorders and symptoms, we reestimated the MNSS burden to include suicide, alcohol use, drug use, specific neurological, and painful somatic symptom disorders. We analyzed age-sex-specific patterns within and between countries.

RESULTS

The MNSS burden is the largest of all disorder groupings. It is lowest in Mexico, intermediate in Canada, and highest in the United States. Exceptions are alcohol use, bipolar, conduct disorders, and epilepsy, which are highest in Mexico; and painful somatic syndromes and headaches, which are highest in Canada. The burden of drug use disorders in the United States is twice the burden in Canada, and 7 times the burden in Mexico. MNSS become the most burdensome of all disorder groups by age 10, staying at the top until age 60, and show a distinct pattern across the lifetime. The top three MNSS disorders for men are a combination of substance use disorders and self-harm (United States), with the addition of painful somatic syndromes (Canada), and headaches (Mexico). For women, the top three are headaches and depression (all countries), drug use (United States), neurocognitive disorders (Mexico), and painful somatic syndromes (Canada).

CONCLUSION

MNSS are the most burdensome disease grouping and should be prioritized for funding in Canada, Mexico, and the United States.

Early maladaptive schemas in patients with somatoform disorders and somatization

Maladaptive schemas are stable relational patterns that develop through harmful childhood experiences with primary caregivers. Schemas within somatoform disorders are rarely explored even though these disorders are clinically important due to high prevalence, co-morbidity, and cost for the health care system. This study investigates schemas according to Young's schema theory in patients with somatoform disorders in comparison with healthy controls and patients with depressive or anxiety disorders. Further associations between schemas and somatization were explored. We included 134 patients with a somatoform disorder and 39 age-matched healthy controls, 83 patients with a unipolar depression, and 34 patients with an anxiety disorder. The clinical sample consists of day care patients, diagnosed with the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, but without a personality disorder. Primary measures were the Young Schema Questionnaire (YSQ-S2), the Screening for Somatoform Disorders (SOMS-7T), the Beck Depression Inventory, Second Edition, and the Childhood Trauma Questionnaire. Analyses of variance indicated that somatoform patients scored higher on almost all schemas than do healthy controls (p < 0.001, η²  = 0.148). The highest mean scores were reached for the schemas "self-sacrifice" and "unrelenting standards," with significant higher values in the patient sample. However, when compared with patients with depressive or anxiety disorders, somatoform patients scored equally or even lower. High somatization was associated with generally higher schema activation. This effect was to a great extent mediated by depressive symptoms. Only the schema "vulnerability to harm or illness" was exclusively related to somatization. These findings suggest that schemas should be systematically assessed within psychotherapy of somatoform patients.

Cortical Thickness Alterations in Chronic Pain Disorder: An Exploratory MRI Study

OBJECTIVE

Chronic pain disorder (CPD) has been associated with brain changes, especially in limbic circuits. However, in most patients with chronic pain, depression or anxiety is a common comorbidity. In this exploratory and naturalistic study, we investigated brain cortical thickness (CTh) differences between patients with CPD and healthy controls, with consideration of concurrent psychiatric symptoms.

METHODS

Twenty-three patients with CPD and 23 age- and sex-matched healthy volunteers were included in this study. CTh was estimated using Freesurfer on high-resolution three-dimensional T1-weighted images acquired with a 3T scanner. Group differences were investigated using an analysis of covariance model that included age, sex, and Beck Depression Inventory I and Trait Anxiety Inventory scores as covariates. The relationship between CTh and Toronto Alexithymia Scale (TAS-20) scores was also investigated in patients. Data were corrected for multiplicity using the False Discovery Rate approach (q < .05).

RESULTS

The comparison between groups using demographics and Beck Depression Inventory I scores as covariates showed thinner cortex in patients compared with controls, after correction for multiplicity in the left precentral (F(1,42) = 21.9, p < .05) and postcentral gyri (F(1,42) = 26.9, p < .05) and in the left inferior temporal sulcus (F(1,42) = 19.6, p < .05). Moreover, using the Trait Anxiety Inventory as covariate, a trend toward significance (p < .001 uncorrected) was seen for the left precentral gyrus (F(1,42) = 13.8), right middle frontal (F(1,42) = 14.3) and inferior parietal gyri (F(1,42) = 13.4), and right anterior temporal pole (F(1,42) = 15.9).

CONCLUSIONS

The results indicate that brain morphological differences between patients with chronic pain disorder and healthy controls are localized to regions that correspond to sensory as well as affective dimensions of pain processing.

Fronto-Insular Connectivity during Pain Distraction Is Impaired in Patients with Somatoform Pain

BACKGROUND AND PURPOSE

Somatoform pain disorder is characterized by chronic pain and various psychological symptoms including increased attention to mental and physical processes. Given that the medial prefrontal cortex (mPFC) of the default mode network (DMN) and the anterior insula of the salience network are critically involved in intrinsic and attentional processes, we investigated the involvement of these networks during the distraction from physical pain in somatoform pain patients.

METHODS

During painful and nonpainful heat stimulation, attentional distraction from physical processes was modulated with a Stroop task. Thirteen patients were investigated with functional magnetic resonance imaging (fMRI) and compared to 13 controls. Main outcomes were spatial maps of coherent fMRI activity based on independent component analysis and functional connectivity (FC) resulting from psychophysiological interaction analysis.

RESULTS

Behavioral pain intensity ratings were reduced during the distraction task in both groups. At brain level, we found deviant network activities in the DMN (particularly in the mPFC) and in the salience network (bilaterally in the anterior insula) in patients. During pain stimulation, Stroop-induced distraction decreased the FC between the mPFC and anterior insula in controls but not in patients.

CONCLUSIONS

Modulating the FC between the mPFC and the insula may be highly relevant for shifting the attention away from external stimuli, including nociceptive input. The observed alterations in somatoform pain patients may foster new strategies in cognitive behavioral training tools for these patients.

Psychological Factors Associated with Phantom Limb Pain: A Review of Recent Findings

Phantom limb pain (PLP) is a common phenomenon occurring after the amputation of a limb and can be accompanied by serious suffering. Psychological factors have been shown to play an important role in other types of chronic pain, where they are pivotal in the acquisition and maintenance of pain symptoms. For PLP, however, the interaction between pain and psychological variables is less well documented. In this review, we summarize research on the role of emotional, motivational, cognitive, and perceptual factors in PLP. The reported findings indicate that emotional factors modulate PLP but might be less important compared to other types of chronic pain. Additional factors such as the amount of disability and adjustment to the amputation appear to also play a role. Bidirectional relationships between stress and PLP have been shown quite consistently, and the potential of stress and tension reduction in PLP treatment could be further exploited. Little is known about the role of cognitive variables such as attention or expectation. Catastrophizing seems to aggravate PLP and could be targeted in treatment. Body perception is altered in PLP and poses a potential target for novel mechanistic treatments. More research on psychological factors and their interactions in PLP is needed.

High Prevalence of Physical Pain Among Treatment-Seeking Individuals With Borderline Personality Disorder

Research has demonstrated that about 30% of chronic pain patients suffer from borderline personality disorder (BPD), yet pain is not often discussed in research on the treatment of BPD. Sixty-five patients entering outpatient treatment for BPD were assessed at baseline for the prevalence of DSM-IV lifetime pain disorder, current medical problems, and the experience of current pain as measured by the McGill Pain Questionnaire. DSM-IV lifetime pain disorder diagnosis was present in 65% of patients. Current pain was experienced by 89% of participants, with intensity ranging from mild (19%) to excruciating (2%). Some individuals (21.5%) also reported experiencing daily medical problems in the past month prior to entering treatment. Physical pain is highly prevalent among treatment-seeking individuals with BPD. This pain phenomenon should be considered during treatment to help prevent a lifetime of functional impairment, including the possibility of abusing substances as a maladaptive coping mechanism.

Severe and enduring somatoform disorders: recognition and management

Patients with severe and enduring somatoform disorders (SESD) characteristically present with multiple, recurrent and frequently changing physical symptoms that have usually been present for several years before referral to a psychiatrist/psychologist. Many patients report long histories of contact with both primary and tertiary care services, have undergone repeated fruitless investigations and have high levels of disability. SESD are responsible for disproportionately high healthcare costs and are the third most common cause of workplace absence. Identification of patients with SESD by psychiatrists requires particular skills: collaboration with colleagues is vital and there are risks of iatrogenic harm. We describe the obstacles encountered in identifying these patients as well as methods of assessment and management. Treatment pathways best suited to managing this large and as yet untended group of patients are described.

Insecure attachment style and cumulative traumatic life events in patients with somatoform pain disorder: A cross-sectional study

OBJECTIVE

Current models assume somatoform pain disorder (SPD) to be the result of a complex interaction between bio- and psychosocial factors, but the etiology is still not well understood. This study aimed to investigate the distribution of attachment style and the frequency of traumatic life events, especially childhood adversities, in patients with SPD compared to healthy controls.

METHODS

We compared 65 patients with SPD (confirmed by Structured Clinical Interview, SCID-I) to 65 age- and gender-matched healthy controls. The following questionnaires were employed: Relationship Scale Questionnaire (RSQ), Essen Trauma Inventory (ETI), Childhood Trauma Questionnaire (CTQ) and Patient Health Questionnaire (PHQ-15). A logistic regression analysis was used to identify the association between SPD and psychological factors.

RESULTS

Insecure attachment was significantly more prevalent (60%) in patients with SPD compared to healthy subjects (14%; p<0.001). Overall, 70.4% of patients with SPD reported three or more traumatic events in their life, compared with healthy subjects who reported predominantly one (40%). Patients with SPD scored significantly higher in all CTQ subscales compared to the healthy controls. The factor most strongly related with SPD was the insecure attachment style (OR=11.20, 95% CI: 1.32-94.86). Other significant predictive factors were depression (OR=3.35, 95% CI: 1.84-6.11) and number of traumatic events (OR=2.04, 95% CI: 1.06-3.92). Insecure attachment, depression symptoms and the number of traumatic events explained 86.2% of the variance.

CONCLUSIONS

The high predictive value of insecure attachment style and cumulative traumatic events emphasize their importance as risk factors of SPD.

Do we understand pain from a biopsychosocial perspective? A review and discussion of the usefulness of some pain terms

Pain is a biopsychosocial phenomenon and should be assessed and managed from this perspective. However, the dualistic mind-body perspective is still present and affects the way this health situation is addressed. Following this approach, pain can either be attributed to an identifiable cause or considered as 'psychological' pain, for which there is neither an identifiable cause nor adequate treatment. Faced with this situation, first, we introduce some concepts that have been used (and are still frequently being used) to refer to pain with no identifiable cause. Next, we question the usefulness of these 'dualistic terms' and, finally, defend the biopsychosocial perspective to advance in the conceptualization of pain and avoid using terms that can foster a dualistic perspective.

Electroconvulsive therapy treatment in patients with somatic symptom and related disorders

OBJECTIVE

Medically unexplained somatic complaints are highly prevalent, and lead to significant impairment and disability. The number of effective treatment modalities for somatic symptom and related disorders (SSDs) or somatoform disorders (SDs) remains limited. To date, there is no formal indication for electroconvulsive therapy (ECT) in SSD or SD. We report on the largest case series to date regarding the effectiveness of ECT in patients with SSD and SD.

METHODS

A retrospective chart review of all patients treated with an index course of ECT at the Neuropsychiatric Program at the University of British Columbia Hospital from 2000 to 2010 was conducted. The primary outcomes consisted of changes in pseudoneurologic symptoms, pain symptoms, cardiopulmonary symptoms, and gastrointestinal symptoms. Complaints were examined pre- and post-ECT.

RESULTS

Twenty-eight participants were included in this study. Twenty-one participants received right unilateral ECT. Six received bifrontal ECT. One received bitemporal ECT. Eighteen of 21 participants reported improvement in pseudoneurologic symptoms; eleven of 14 participants reported improvement in pain symptoms; one participant reported improvement in cardiopulmonary symptoms; and one of two participants reported improvement in gastrointestinal symptoms. This paper discusses the putative mechanism of action of ECT in the treatment of SD/SSD.

CONCLUSION

This retrospective study suggests that ECT could be included as part of the existing treatment for refractory SSD and SD, particularly in refractory cases with comorbid mood disorders.

Pharmacological interventions for somatoform disorders in adults

BACKGROUND

Somatoform disorders are characterised by chronic, medically unexplained physical symptoms (MUPS). Although different medications are part of treatment routines for people with somatoform disorders in clinics and private practices, there exists no systematic review or meta-analysis on the efficacy and tolerability of these medications. We aimed to synthesise to improve optimal treatment decisions.

OBJECTIVES

To assess the effects of pharmacological interventions for somatoform disorders (specifically somatisation disorder, undifferentiated somatoform disorder, somatoform autonomic dysfunction, and pain disorder) in adults.

SEARCH METHODS

We searched the Cochrane Depression, Anxiety and Neurosis Review Group's Specialised Register (CCDANCTR) (to 17 January 2014). This register includes relevant randomised controlled trials (RCTs) from The Cochrane Library (all years), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date). To identify ongoing trials, we searched ClinicalTrials.gov, Current Controlled Trials metaRegister, the World Health Organization International Clinical Trials Registry Platform, and the Chinese Clinical Trials Registry. For grey literature, we searched ProQuest Dissertation & Theses Database, OpenGrey, and BIOSIS Previews. We handsearched conference proceedings and reference lists of potentially relevant papers and systematic reviews and contacted experts in the field.

SELECTION CRITERIA

We selected RCTs or cluster RCTs of pharmacological interventions versus placebo, treatment as usual, another medication, or a combination of different medications for somatoform disorders in adults. We included people fulfilling standardised diagnostic criteria for somatisation disorder, undifferentiated somatoform disorder, somatoform autonomic dysfunction, or somatoform pain disorder.

DATA COLLECTION AND ANALYSIS

One review author and one research assistant independently extracted data and assessed risk of bias. Primary outcomes included the severity of MUPS on a continuous measure, and acceptability of treatment.

MAIN RESULTS

We included 26 RCTs (33 reports), with 2159 participants, in the review. They examined the efficacy of different types of antidepressants, the combination of an antidepressant and an antipsychotic, antipsychotics alone, or natural products (NPs). The duration of the studies ranged between two and 12 weeks.One meta-analysis of placebo-controlled studies showed no clear evidence of a significant difference between tricyclic antidepressants (TCAs) and placebo for the outcome severity of MUPS (SMD -0.13; 95% CI -0.39 to 0.13; 2 studies, 239 participants; I(2) = 2%; low-quality evidence). For new-generation antidepressants (NGAs), there was very low-quality evidence showing they were effective in reducing the severity of MUPS (SMD -0.91; 95% CI -1.36 to -0.46; 3 studies, 243 participants; I(2) = 63%). For NPs there was low-quality evidence that they were effective in reducing the severity of MUPS (SMD -0.74; 95% CI -0.97 to -0.51; 2 studies, 322 participants; I(2) = 0%).One meta-analysis showed no clear evidence of a difference between TCAs and NGAs for severity of MUPS (SMD -0.16; 95% CI -0.55 to 0.23; 3 studies, 177 participants; I(2) = 42%; low-quality evidence). There was also no difference between NGAs and other NGAs for severity of MUPS (SMD -0.16; 95% CI -0.45 to 0.14; 4 studies, 182 participants; I(2) = 0%).Finally, one meta-analysis comparing selective serotonin reuptake inhibitors (SSRIs) with a combination of SSRIs and antipsychotics showed low-quality evidence in favour of combined treatment for severity of MUPS (SMD 0.77; 95% CI 0.32 to 1.22; 2 studies, 107 participants; I(2) = 23%).Differences regarding the acceptability of the treatment (rate of all-cause drop-outs) were neither found between NGAs and placebo (RR 1.01, 95% CI 0.64 to 1.61; 2 studies, 163 participants; I(2) = 0%; low-quality evidence) or NPs and placebo (RR 0.85, 95% CI 0.40 to 1.78; 3 studies, 506 participants; I(2) = 0%; low-quality evidence); nor between TCAs and other medication (RR 1.48, 95% CI 0.59 to 3.72; 8 studies, 556 participants; I(2) =14%; low-quality evidence); nor between antidepressants and the combination of an antidepressant and an antipsychotic (RR 0.80, 95% CI 0.25 to 2.52; 2 studies, 118 participants; I(2) = 0%; low-quality evidence). Percental attrition rates due to adverse effects were high in all antidepressant treatments (0% to 32%), but low for NPs (0% to 1.7%).The risk of bias was high in many domains across studies. Seventeen trials (65.4%) gave no information about random sequence generation and only two (7.7%) provided information about allocation concealment. Eighteen studies (69.2%) revealed a high or unclear risk in blinding participants and study personnel; 23 studies had high risk of bias relating to blinding assessors. For the comparison NGA versus placebo, there was relatively high imprecision and heterogeneity due to one outlier study. Although we identified 26 studies, each comparison only contained a few studies and small numbers of participants so the results were imprecise.

AUTHORS' CONCLUSIONS

The current review found very low-quality evidence for NGAs and low-quality evidence for NPs being effective in treating somatoform symptoms in adults when compared with placebo. There was some evidence that different classes of antidepressants did not differ in efficacy; however, this was limited and of low to very low quality. These results had serious shortcomings such as the high risk of bias, strong heterogeneity in the data, and small sample sizes. Furthermore, the significant effects of antidepressant treatment have to be balanced against the relatively high rates of adverse effects. Adverse effects produced by medication can have amplifying effects on symptom perceptions, particularly in people focusing on somatic symptoms without medical causes. We can only draw conclusions about short-term efficacy of the pharmacological interventions because no trial included follow-up assessments. For each of the comparisons where there were available data on acceptability rates (NGAs versus placebo, NPs versus placebo, TCAs versus other medication, and antidepressants versus a combination of an antidepressant and an antipsychotic), no clear differences between the intervention and comparator were found.Future high-quality research should be carried out to determine the effectiveness of medications other than antidepressants, to compare antidepressants more thoroughly, and to follow-up participants over longer periods (the longest follow up was just 12 weeks). Another idea for future research would be to include other outcomes such as functional impairment or dysfunctional behaviours and cognitions as well as the classical outcomes such as symptom severity, depression, or anxiety.

Chronic pain prevalence and associated factors in a segment of the population of São Paulo City

A cross-sectional epidemiologic survey was performed to determine the prevalence of chronic pain (CP) and to identify associated factors in a random sample of persons 15 years or older from a segment of the population of São Paulo City, Brazil. A total of 1,108 eligible participants were randomly selected, and face-to-face interviews were performed with 826 individuals (74.5%) between December 2011 and February 2012. Chronic Pain Grade, Hospital Anxiety and Depression Scale, and EuroQol-5D were used to verify pain characteristics and the associated signs of psychological distress. A prevalence of 42% (95% confidence interval, 38.6-45.4) was observed for CP, and the participants with CP had an average pain intensity of 5.9 (standard deviation = 1.9) and a pain-related disability of 4.1 (standard deviation = 3.2) on a 0 to 10 scale. Persistent pain was present in 68.6% of those with CP, and 32.8% of the population sample had high-intensity or high-interference pain (Chronic Pain Grade II, III, and IV). Quality of life was significantly worse among the CP individuals. The following factors were independently associated with CP: female gender, age 30 years or older, ≤ 4 years of education, symptoms consistent with anxiety, and intense physical strain. Indicators of pain severity increased with pain grades.

PERSPECTIVE

CP is highly prevalent in the city of São Paulo and has a considerable impact on health-related quality of life. Demographic, socioeconomic, and psychological factors are independently associated with this condition.

Pain, pain catastrophizing, and past mental healthcare utilization

OBJECTIVE

Pain symptoms have been associated with a number of psychiatric disorders, particularly mood and anxiety disorders as well as personality disorders. However, to our knowledge, no study to date has examined pain symptoms in terms of participants' past mental healthcare utilization--the focus of the present study.

METHODS

Using a cross-sectional approach and a self-report survey methodology in a sample of 242 consecutive internal medicine outpatients, we examined pain symptoms at assessment, over the past month, and over the past year as well as pain catastrophizing in relationship to 4 mental healthcare variables (i.e., ever seen a psychiatrist, ever been in a psychiatric hospital, ever been in counseling, and ever been on medication for "nerves").

RESULTS

Only three of the four mental-healthcare-utilization variables were analyzed due to response rate (i.e., ever been hospitalized in a psychiatric hospital was infrequently endorsed and not analyzed), and each demonstrated statistically significant relationships with self-reported pain levels at all three time-points and with pain catastrophizing at the p<.001 level.

CONCLUSIONS

In this study, primary care outpatients with histories of mental health treatment evidenced statistically significantly higher levels of pain as well as statistically significantly higher levels of pain catastrophizing than their peers.

Abdominal pain is associated with anxiety and depression scores in a sample of the general adult population with no signs of organic gastrointestinal disease

BACKGROUND

Abdominal pain is common in the community, but only a subset meet diagnostic criteria for irritable bowel syndrome (IBS). Although anxiety and depression have been linked to IBS, the role of mood disturbances in the remainder with symptoms remains unclear. We aimed to study the associations between abdominal pain, anxiety, depression, and quality of life in the general population who were free of organic colonic disease by colonoscopy.

METHODS

Two hundred and seventy-two randomly selected subjects from the general population, mean age 54 years (27-71), were clinically evaluated, had a colonoscopy and laboratory investigations to exclude organic gastrointestinal (GI) disease. All subjects completed GI symptom diaries for 1 week, the Rome II modular questionnaire, the Hospital Anxiety and Depression Scale, and Short Form 36.

KEY RESULTS

Twenty-two subjects were excluded due to organic disease; 1532 daily symptom records were available for analysis in the remainder. Thirty-four percent (n = 83) recorded at least one episode of abdominal pain on the diary. Twelve percent fulfilled Rome II criteria for IBS. Both anxiety and depression scores were higher in subjects who reported abdominal pain vs those who did not (P < 0.0005 and P < 0.0005). Anxiety and depression scores independently from IBS diagnosis (Rome II) predicted pain reporting and also correlated positively with pain burden. Quality of life scores were generally lower in subjects with abdominal pain.

CONCLUSIONS & INFERENCES

Anxiety and depression are linked to functional abdominal pain, not only in subjects with IBS but also in otherwise healthy people with milder, subtle GI symptoms.

The trade-off between costs and quality of care in the treatment of psychosomatic patients with somatoform pain disorder

BACKGROUND

The introduction of efficiency-oriented provider payment systems in inpatient mental healthcare in various Western countries may lead to the use of less healthcare resources in the treatment of patients. To avoid unintended effects on quality of care that may result from reductions in resource utilization, it is essential for decision and policy makers to know whether there is a trade-off between costs and quality of care.

AIM OF THE STUDY

The aim of this study was to investigate and quantify the relationship between costs and outcomes in psychosomatic inpatients with somatoform pain disorder.

METHODS

The inclusion criteria for patient selection (n = 101) were (i) a main diagnosis of somatoform pain disorder according to International Classification of Diseases-10 (ICD-10) [F45.4, F45.40, F45.41]; (ii) complete data on the mental component summary reflecting overall functioning of mental health (MCS-8) measured with the Short Form-8 Health Survey (SF-8) within 3 days of the admission and discharge dates; and (iii) treatment at Charité Universitaetsmedizin (Berlin, Germany) during the period January 2006-June 2010. The change in the MCS-8 score incurred over the treatment period was used as an indicator of quality of care. Treatment costs were calculated from the provider's perspective, mainly using bottom-up micro-costing. The year of valuation for cost calculation was 2008 (with no inflation adjustment); for costs provided by the accounting department for services consumed by the patient, the valuation year was based on the year of service provision. We hypothesized that the outcome 'change in MCS-8 score' was a function of the independent variable costs, patient characteristics, socio-demographic variables, pain-related variables, co-morbidities and subjective illness attribution, i.e. whether patients attributed the origin of pain mainly to a somatic cause or not. An interaction term between costs and illness attribution was included to control for the hypothesized differing effects of resource input or costs on the outcome variable conditional on patients' illness attribution. Hausman tests indicated that endogeneity was not present, thus, ordinary least squares regression (OLS) was conducted. We assessed whether the change in the MCS-8 score was clinically meaningful and perceptible by the patient, using the minimal clinical important difference (MCID). For Short Form Health Surveys, the MCID for changes in the mental component summary is typically around 3 points.

RESULTS

We found a trade-off between costs and outcome for patients without or with only minor somatic illness attribution (77 % of the sample). This patient group improved 0.4 points in outcome after every 100 <euro> increase in total costs per case (F 1,77 = 13.836, t(77) = 3.72, p = 0.0004). For patients with mainly somatic illness beliefs (23 % of the sample), we did not find a trade-off between costs and outcome.

CONCLUSION

For the majority of patients, we found a trade-off between costs and health outcome, thus, it seems advisable to carefully monitor outcome parameters when applying cost containment measures.

The costs and consequences of adequately managed chronic non-cancer pain and chronic neuropathic pain

BACKGROUND

Chronic pain is distressing for patients and a burden on healthcare systems and society. Recent research demonstrates different aspects of the negative impact of chronic pain and the positive impact of successful treatment, making an overview of the costs and consequences of chronic pain appropriate.

OBJECTIVE

To examine recent literature on chronic noncancer and neuropathic pain prevalence, impact on quality and quantity of life, societal and healthcare costs, and impact of successful therapy.

METHODS

Systematic reviews (1999 to February 2012) following PRISMA guidelines were conducted to identify studies reporting appropriate outcomes.

RESULTS

Chronic pain has a weighted average prevalence in adults of 20%; 7% have neuropathic pain, and 7% have severe pain. Chronic pain impeded activities of daily living, work and work efficiency, and reduced quality and quantity of life. Effective pain therapy (pain intensity reduction of at least 50%) resulted in consistent improvements in fatigue, sleep, depression, quality of life, and work.

CONCLUSION

Strenuous efforts should be put into obtaining good levels of pain relief for people in chronic pain, including the opportunity for multiple drug switching, using reliable, validated, and relatively easily applied patient-centered outcomes. Detailed, thoughtful and informed decision analytic policy modeling would help understand the key elements in organizational change or service reengineering to plan the optimum pain management strategy to maximize pain relief and its stream of benefits against budgetary and other constraints. This paper contains the information on which such models can be based.

Association of somatoform disorders with anxiety and depression in women in low and middle income countries: a systematic review

BACKGROUND

Across cultures, women are more likely than men to report somatoform disorders (SD), depression and anxiety. The aim of this article is to describe the co-morbidity of SD with depression/anxiety and to investigate the possible mechanisms of this relationship in women in low and middle income countries (LMIC).

METHODS

We reviewed two databases: MEDLINE and PsycINFO from 1994 to 2012 for studies which assessed the association between any SD and depression/ anxiety in women from LMIC. Our focus was on community and primary healthcare based studies. Both quantitative and qualitative studies were included.

RESULTS

A total of 21 studies covering eight LMICs were included in our analysis. Our findings suggest a strong association between SD and depression/anxiety (with odds ratios ranging from 2.5-3.5), though we also observed that the majority of women with SD did not have depression/anxiety. The likely mechanisms for this association are multidimensional, and may include shared aetiologies, that both conditions are in fact variants of the same primary mental disorder, and that one disorder is a risk factor for the other. Anthropological research offers a number of frameworks through which we can view these mechanisms.

CONCLUSION

The current evidence indicates that service providers at the primary care level should be sensitized to consider SD in women as variants of CMD (Common Mental Disorders) and address both groups of disorders concurrently. Further research should explicitly seek to unpack the mechanisms of the relationship between SD and CMD.

Prevalence of somatoform disorders and medically unexplained symptoms in old age populations in comparison with younger age groups: a systematic review

OBJECTIVE

To review current knowledge regarding the prevalence of somatization problems in later life by level of caseness (somatoform disorders and medically unexplained symptoms, MUS) and to compare these rates with those in middle-aged and younger age groups.

METHOD

A systematic search of the literature published from 1966 onwards was conducted in the Pubmed and EMBASE databases.

RESULTS

Overall 8 articles, describing a total of 7 cohorts, provided data of at least one prevalence rate for somatoform disorders or MUS for the middle-aged (50-65 years) or older age (≥65 years) group. Prevalence rates for somatoform disorders in the general population range from 11 to 21% in younger, 10 to 20% in the middle-aged, and 1.5 to 13% in the older age groups. Prevalence rates for MUS show wider ranges, of respectively 1.6-70%, 2.4-87%, and 4.6-18%, in the younger, middle, and older age groups, which could be explained by the use of different instruments as well as lack of consensus in defining MUS.

CONCLUSION

Somatoform disorders and MUS are common in later life, although the available data suggest that prevalence rates decline after the age of 65 years. More systematic research with special focus on the older population is needed to understand this age-related decline in prevalence rates.

Emerging themes in the revision of the classification of somatoform disorders

The somatoform disorders, as currently defined in DSM-IV and ICD-10, have been criticized for their complexity and poor clinical utility. In this paper we consider these criticisms as well as the conceptual question of whether there is sufficient evidence for classifying them as mental and behavioural disorders. The review suggests that, as currently defined, somatoform disorders do not fulfil a recently articulated set of criteria for mental and behavioural disorders. In particular, the disorders are not defined according to positive psychological and behavioural disorders and evidence is sparse to support their classification as different and distinct diagnoses. Any revision of the disorders should not be based on 'medically unexplained' symptoms. Rather, the relevant diagnoses should include a combination of bothersome somatic symptoms with several other psychological features including beliefs about somatic symptoms and evidence of marked concerns about health and illness. Finally, the review presents a set of proposals for the revision of these disorders, by the Somatic Disorders and Dissociative Disorders Working Group of the WHO International Advisory Group for the Revision of ICD-10 Mental and Behavioural Disorders, which attempt to take account of the criticisms and current understanding of somatic experiences.

Primary care prescribing psychologists in the Indian Health Service

Some of the largest health care disparities are those related to services for American Indians and Alaska Natives (AI/ANs), who show significantly greater prevalence for diabetes, coronary heart disease, smoking, obesity, heavy alcohol use, depression, and PTSD than the general population. Given the recognition of the behavioral components of all of these conditions, the Indian Health Service, the federal agency responsible for providing comprehensive health care services to AI/ANs, has been focusing on increasing the integration of behavior health and primary care. One innovation has been to hire prescribing psychologists on primary care teams. This paper describes the role of a prescribing psychologist on three treatment teams at an IHS facility in Montana. Prescribing psychologists in the Indian Health Service can serve as valuable members of comprehensive care teams, providing exceptional wrap-around care for some of our most vulnerable and underserved citizens. This model could be an example of how a prescribing psychologist could contribute to primary care clinics in a variety of other settings.

Non-specific, functional, and somatoform bodily complaints

BACKGROUND

4-10% of the general population and 20% of primary care patients have what are called "non-specific, functional, and somatoform bodily complaints." These often take a chronic course, markedly impair the sufferers' quality of life, and give rise to high costs. They can be made worse by inappropriate behavior on the physician's part.

METHODS

The new S3 guideline was formulated by representatives of 29 medical and psychological specialty societies and one patient representative. They analyzed more than 4000 publications retrieved by a systematic literature search and held two online Delphi rounds and three consensus conferences.

RESULTS

Because of the breadth of the topic, the available evidence varied in quality depending on the particular subject addressed and was often only of moderate quality. A strong consensus was reached on most subjects. In the new guideline, it is recommended that physicians should establish a therapeutic alliance with the patient, adopt a symptom/coping-oriented attitude, and avoid stigmatizing comments. A biopsychosocial diagnostic evaluation, combined with sensitive discussion of signs of psychosocial stress, enables the early recognition of problems of this type, as well as of comorbid conditions, while lowering the risk of iatrogenic somatization. For mild, uncomplicated courses, the establishment of a biopsychosocial explanatory model and physical/social activation are recommended. More severe, complicated courses call for collaborative, coordinated management, including regular appointments (as opposed to ad-hoc appointments whenever the patient feels worse), graded activation, and psychotherapy; the latter may involve cognitive behavioral therapy or a psychodynamic-interpersonal or hypnotherapeutic/imaginative approach. The comprehensive treatment plan may be multimodal, potentially including body-oriented/non-verbal therapies, relaxation training, and time-limited pharmacotherapy.

CONCLUSION

A thorough, simultaneous biopsychosocial diagnostic assessment enables the early recognition of non-specific, functional, and somatoform bodily complaints. The appropriate treatment depends on the severity of the condition. Effective treatment requires the patient's active cooperation and the collaboration of all treating health professionals under the overall management of the patient's primary-care physician.

Alcohol dependence as a chronic pain disorder

Dysregulation of pain neurocircuitry and neurochemistry has been increasingly recognized as playing a critical role in a diverse spectrum of diseases including migraine, fibromyalgia, depression, and PTSD. Evidence presented here supports the hypothesis that alcohol dependence is among the pathologies arising from aberrant neurobiological substrates of pain. In this review, we explore the possible influence of alcohol analgesia and hyperalgesia in promoting alcohol misuse and dependence. We examine evidence that neuroanatomical sites involved in the negative emotional states of alcohol dependence also play an important role in pain transmission and may be functionally altered under chronic pain conditions. We also consider possible genetic links between pain transmission and alcohol dependence. We propose an allostatic load model in which episodes of alcohol intoxication and withdrawal, traumatic stressors, and injury are each capable of dysregulating an overlapping set of neural substrates to engender sensory and affective pain states that are integral to alcohol dependence and comorbid conditions such as anxiety, depression, and chronic pain.

Psychiatric morbidities, sleep disturbances, suicidality, and quality-of-life in a community population with medically unexplained pain in Korea

We examined the psychiatric morbidities, sleep disturbances, suicidality, quality-of-life, and psychological distress of community-dwelling subjects in Korea who had medically unexplained pain. A total of 6510 subjects (age 18-65 years) participated in this study. A medically unexplained pain symptom (MUS-pain) was defined as pain lasting for 6 months or longer that was sufficiently severe to cause significant distress or to materially interfere with normal activities in the previous year, and that could not be explained by a medical condition or substance use/abuse. Diagnostic assessments were based on responses to the Composite International Diagnostic Interview, which was administered by lay colleagues. The presence of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) disorders, sleep disturbances, suicidal tendency, quality-of-life issues, and psychological distress was determined in subjects with and without MUS-pain. There were significant positive associations between MUS-pain and nicotine dependence and withdrawal, alcohol dependence, major depressive disorder, dysthymic disorder, bipolar disorder, post-traumatic stress disorder, social phobia, generalized anxiety disorder, and psychotic disorder. In addition, subjects with MUS-pain reported more sleep disturbances, suicidality, psychological distress, and a poorer quality-of-life than did subjects without MUS-pain. The results of this study suggest that clinicians should carefully evaluate and treat comorbid psychiatric problems in individuals with MUS-pain.

Diagnosis and treatment of somatoform disorders

Many patients with somatoform disorders present to the neurology clinic, often after extensive evaluation that has left the patient and multiple other physicians frustrated. Knowledge of the typical characteristics of particular disorders enables the clinician to arrive at a positive diagnosis and facilitate referral to appropriate services. Using a series of representative cases, we review the DSM-IV-TR somatoform disorders most likely to present to the practicing neurologist, highlighting the epidemiologic features, typical presentations, and possible therapeutic approaches to each condition.

A cluster analysis-derived classification of psychological distress and illness behavior in the medically ill

BACKGROUND

The classification of psychological distress and illness behavior in the setting of medical disease is still controversial. Current psychiatric nosology does not seem to cover the spectrum of disturbances. The aim of this investigation was to assess whether the joint use of DSM-IV categories and the Diagnostic Criteria for Psychosomatic Research (DCPR), that provide identification of syndromes related to somatization, abnormal illness behavior, irritable mood, type A behavior, demoralization and alexithymia, could yield subtyping of psychosocial variables in the medically ill.

METHOD

A cross-sectional assessment using both DSM-IV and the DCPR was conducted in eight medical centers in the Italian Health System. Data were submitted to cluster analysis. Participants were consecutive medical out-patients and in-patients for whom a psychiatric consultation was requested. A total of 1700 subjects met eligibility criteria and 1560 agreed to participate.

RESULTS

Three clusters were identified: non-specific psychological distress, irritability and affective disturbances with somatization.

CONCLUSIONS

Two-step cluster analysis revealed clusters that were found to occur across clinical settings. The findings indicate the need of expanding clinical assessment in the medically ill to include the various manifestations of somatization, illness behavior and subclinical distress encompassed by the DCPR.

Magical thinking in somatoform disorders: an exploratory study among patients with suspected allergies

BACKGROUND

In order to reconceptualize somatoform disorders (SFDs), the psychological characteristics of SFD patients are increasingly investigated. The cognitive style of magical thinking (MT) has not been studied so far in patients with SFDs.

SAMPLING AND METHODS

In a cross-sectional study, 201 allergy workup patients were interviewed using the Structured Clinical Interview for DSM-IV; they answered a set of self-report questionnaires including the Schizotypal Personality Questionnaire subscale for MT and the Patient Health Questionnaire (PHQ). The expression of MT was explored in 61 patients with SFDs compared to 140 patients without SFDs.

RESULTS

Patients with SFDs reached higher scores of MT, also when controlled for gender, depression, and anxiety. In particular, they stated more frequently that they were believers in telepathy (64 vs. 44%) and clairvoyance (43 vs. 16%). MT correlated only weakly with somatization/somatic symptom severity, depression, and anxiety.

CONCLUSIONS

Among allergy workup patients with SFDs we found considerable MT. This indicates that SFD patients may tend to mistake correlation for causality in a more general way, and not just in an illness-related context. The relation to indicators of illness severity (somatic symptom severity/somatization, depression, and anxiety) was relatively weak. Possible implications for research, diagnostics, and therapy are discussed.

Assessment and further development of RDC/TMD Axis II biobehavioural instruments: a research programme progress report

A symposium was held in Toronto, 2008, in which research progress regarding the biobehavioural dimension of the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) was presented. An extended workshop was held in April 2009 in which further recommendations were made from an expert panel, using the 2008 symposium material as a base. This paper is a summary of the 2008 symposium proceedings with elaborations based on further developments. Seven studies were conducted between 2001 and 2008, in which the following were investigated: (i) basic properties of Axis II instruments, (ii) reliability and criterion validity of Axis II instruments, (iii) expansion of predictors, (iv) metric equivalence of the depression and non-specific physical symptoms subscales in the RDC/TMD, (v) laboratory investigation of oral behaviours, (vi) field data collection of oral behaviours, and (vii) functional limitation of the jaw. Methods and results for each of these studies are described. Based on the results of these studies that have been published, as well as the direction of interim results from the few studies that await completion and publication, the biobehavioural domain of the RDC/TMD, as published in 1992, is reliable and valid. These results also provide strong evidence supporting the future growth of the biobehavioural domain as the RDC/TMD matures into subsequent protocols for both clinical and research applications.

Prevalence and characteristics of chronic pain in the general population of Hong Kong

Western studies document the prevalence of chronic pain in the general adult population to be between 2 and 55%. Knowing the prevalence of chronic pain among Chinese populations provides important comparative perspective: To determine the prevalence of chronic pain in the general population of Hong Kong; evaluate the relationship of chronic pain with sociodemographic and lifestyle factors; and describe the pain characteristics among chronic pain sufferers. A total of 5,001 adults aged ≥ 18 years (response rate 58%) drawn from the general population of Hong Kong completed the Chronic Pain Grade (CPG) questionnaire, providing information on chronic pain and sociodemographic status using telephone interviews. Overall 34.9% reported pain lasting more than 3 months (chronic pain), having an average of 1.5 pain sites; 35.2% experienced multiple pain sites, most commonly of the legs, back, and head with leg and back being rated as the most significant pain areas among those with multiple pain problems. The CPG criteria classified 21.5% of those with chronic pain symptoms as Grade III or above. Fully adjusted stepwise regression analyses identified being female, older age, divorced/separated, having part-time employment, existing long-term health problems, higher HADS Anxiety scores, poor QoL (mental health component), and low self-perceived health to be significantly associated with chronic pain.

PERSPECTIVE

Our data evidenced that chronic pain is common in the general population of Hong Kong, and the prevalence is highest among women and middle-aged adults.

[Determinants of quality of life in patients with somatoform disorders with pain as main symptom - the case for differentiating subgroups]

OBJECTIVES

What impact do the degree of somatization and the presence of a comorbid psychological disorder have on health-related quality of life in patients with pain-dominated somatoform disorders?

METHODS

282 consecutive patients (57.6 %) from a total population of N=490 patients fulfilling the criteria of somatoform pain disorders were included in the study following a thorough interdisciplinary diagnostic process at a German university hospital. Structured interviews (SKIDI and SKID-II) to assess comorbid psychological disorders as well as a structured biographical interview to assess chronification factors were conducted. We employed the Screening for Somatoform Disorders form (SOMS) to discover the extent and distribution of somatic symptoms and the SF-36 to determine the health-related quality of life.

RESULTS

The patients exhibited a multiplicity of further somatic complaints apart from pain. 69 % had a comorbid psychological disorder. The health-related physical and psychological quality of life was clearly impaired in patients with "small", "substantial" and "pronounced" somatization. Regression analysis explained 48 % of the variance of the body-related and 35 % of the variance of the psychological quality of life: Besides the extent of somatization, older age, duration of pain-associated hospitalizations and the subjective amount of occupational impairment proved to be important. With regard to the psychological (but not the somatic) health-related quality of life, the presence of a current comorbid psychological disorder was also relevant.

CONCLUSION

Patients with pain-dominated somatoform disorders are substantially impaired in their quality of life. Because 31 % of the patients with such disorders have no additional comorbid psychic disorder and the existence of a comorbid psychic disorder impacts only the psychological domain of their health-related quality of life, the results appear to strongly support maintaining the diagnostic category of somatoform disorders in ICD-11 and DSM-V. They also support the grading of the severity of the somatization similar to the grading of depressive disorders.

Fibromyalgia: Moderate and substantial pain intensity reduction predicts improvement in other outcomes and substantial quality of life gain

Chronic pain is associated with a range of other problems, including disturbed sleep, depression, anxiety, fatigue, reduced quality of life, and an inability to work or socialise. We investigated whether good symptom control of pain (using definitions of moderate and substantial benefit) is associated with improvement in other symptoms. Individual patient data from four randomised trials in fibromyalgia (2575 patients) lasting 8-14weeks were used to calculate percentage pain reduction for each completing patient (1858), divided into one of five groups according to pain reduction, irrespective of treatment: substantial benefit - 50% pain reduction; moderate - 30% to <50%; minimal - 15% to <30%; marginal - 0% to <15%; worse - <0% (increased pain intensity). We then calculated change from baseline to end of trial for measures of fatigue, function, sleep, depression, anxiety, ability to work, general health status, and quality-adjusted life year (QALY) gain over a 12-month period. Substantial and moderate pain intensity reductions were associated with statistically significant reduction from baseline by end of trial in all measures, with values by trial end at or approaching normative values. Substantial pain intensity reduction resulted in 0.11 QALYs gained, and moderate pain intensity reduction in 0.07 QALYs gained over a 12-month period. Substantial and moderate pain intensity reduction predicts broad beneficial outcomes and improved quality of life that do not occur without pain relief. Pain intensity reduction is a simple and effective predictor of which patients should continue treatment, and which should discontinue and try an alternative therapy.

Pain associated with specific anxiety and depressive disorders in a nationally representative population sample

OBJECTIVE

To examine in a nationally representative sample (a) the differential association of specific anxiety and depressive disorders defined according to DSM-IV with pain disorder (PD) and pain symptoms, and (b) whether pain-associated anxiety and depressive disorders and their comorbidity have different implications in terms of impairment, disability, health care utilization, and substance use.

METHOD

A nationally representative community study was conducted in Germany. Symptoms, syndromes and diagnoses of mental disorders, and pain were assessed in N = 4,181 participants aged 18-65 years using the DSM-IV/M-CIDI.

RESULTS

Logistic regressions revealed that pain is associated with both specific anxiety and depressive disorders, with increasing significant odds ratios (OR) for medically explained pain symptoms (EPS; OR range: 1.9-2.0), to unexplained pain symptoms (UPS; OR range: 2.4-7.3), to PD (OR range: 3.3-14.8). PD and UPS persistently showed associations after adjusting for comorbid other anxiety and depressive disorders and physical illnesses. All types of pain, particularly PD/UPS, are associated with decreased quality of life, greater impairment in role functioning, disability, health care utilization, and substance use. Depressive disorders, even more so anxiety disorders and their comorbidity account for a substantial proportion of variance in these functional correlates.

CONCLUSIONS

Pain is strongly associated with specific anxiety and depressive disorders. In light of the individual and societal burden due to pain, and the demonstrated role of comorbid anxiety or/and depression, our results call for further investigation of the underlying mechanisms for this association as well as targeted treatments for these comorbidities.

The short- and long-term effect of duloxetine on painful physical symptoms in patients with generalized anxiety disorder: results from three clinical trials

Generalized anxiety disorder (GAD) is associated with painful physical symptoms (PPS). These post hoc analyses of previous trial data assessed PPS and their response to duloxetine treatment in GAD patients. Studies 1 and 2 (n=840) were 9- to 10-week efficacy trials; study 3 (n=887) was a relapse prevention trial comprising a 26-week open-label treatment phase and a 26-week double-blind, placebo-controlled treatment continuation phase. Mean baseline visual analog scale scores (VAS, 0-100; n=1727) ranged from 26 to 37 for overall pain, headache, back pain, shoulder pain, interference with daily activities, and time in pain while awake. In studies 1 and 2, improvement on all VAS scores was greater in duloxetine-treated than in placebo-treated patients (p<or=0.01). In study 3, pain symptoms worsened in responders switched to placebo compared with those maintained on duloxetine (p<or=0.02). In conclusion, duloxetine was efficacious in the short- and long-term treatment of PPS, which are common in GAD patients.

Patients with pain disorder show gray-matter loss in pain-processing structures: a voxel-based morphometric study

OBJECTIVE

To investigate whether the functional changes in pain disorder might be reflected by structural brain changes. Pain disorder assessed with the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) criteria is characterized by persistent and distressing chronic pain at one or more body sites which cannot be fully explained by a physiological process or somatic disorder. Psychological factors are thought to play a major role. Recent neuroimaging studies evidenced altered pain processing in patients suffering from this disorder.

METHODS

Fourteen right-handed women fulfilling the DSM-IV criteria for pain disorder and 25 healthy age-matched women were investigated with magnetic resonance imaging. In the voxel-based morphometry analysis, we compared both groups for changes of gray-matter density. We included age and Beck Depression Inventory scores as nuisance variables to minimize possible confounding effects of age or depressive comorbidity.

RESULTS

In the patient group, we found significant gray-matter decreases in the prefrontal, cingulate, and insular cortex. These regions are known to be critically involved in the modulation of subjective pain experiences.

CONCLUSIONS

In the context of similar results in patients with other functional pain syndromes, such as fibromyalgia and chronic back pain, we suggest that structural changes in fronto-limbic brain circuits represent not only an objective marker of these pain syndromes but also constitute a critical pathophysiological element. These findings represent a further proof of the important role of central changes in pain disorder.

Epidemiology of the association between somatoform disorders and anxiety and depressive disorders: an update

OBJECTIVE

To review the available epidemiological evidence on associations between somatoform disorders with anxiety and depressive disorders.

RESULTS

Clinical and population-based studies have found that the co-occurrence of some types of somatoform disorders (e.g., somatization disorder, somatic-symptom-index (SSI)4,6, and pain disorder) and anxiety and depressive disorders is common. These findings may suggest either a causal relationship between these disorders or that they share some common etiological factors. For other forms of somatoform disorders, empirical evidence about co-occurrence is even thinner or not available at all, especially from non-western settings.

CONCLUSION

Some implications of how these findings, or the absence of them, can help us understand better the etiology of somatoform disorders and improve the classification of mental disorders as a whole are discussed.