Original submissionChronic spinal disorders and psychopathology: research findings and theoretical considerations☆
Introduction
Chronic spinal disorders are an increasingly costly and debilitating medical condition in industrialized countries. As more has been learned about this condition, the importance of psychological and social factors in understanding chronic spinal disorders has become increasingly recognized. Indeed, such disorders are now widely viewed as a biopsychosocial phenomenon, in which biological, psychological, and social factors dynamically interact with one another. As psychological (i.e., behavioral, cognitive, and affective) factors have been explored, it has become increasingly evident that chronic spinal disorders are associated with high rates of diagnosable psychopathology.
There are several reasons why it is important to identify psychopathology in patients with chronic spinal disorder. Most importantly, unrecognized and untreated psychopathology can significantly interfere with successful rehabilitation of these patients [1]. Rehabilitation programs without an adequate mental health component may therefore be “doomed to failure” [1]. Psychopathology may also increase pain intensity and disability, thus serving to perpetuate pain-related dysfunction 2, 3. For example, anxiety has been found to decrease pain threshold and tolerance 4, 5, anxiety and depression have been associated with magnification of medical symptoms 6, 7, 8, 9, depression has been associated with less successful treatment outcomes 10, 11, and emotional distress has been linked to physical symptoms by means of autonomic arousal, vigilance, and misinterpretation [12] or somatic amplification [13].
Section snippets
Historical overview
Research on psychopathology in the chronic spinal disorder population, conducted mostly on patients with chronic low back pain (CLBP) in the 1980s, documented increased prevalence of depression, anxiety, substance abuse/dependence, “somatization,” and personality disorders compared with the general population 14, 15, 16, 17, 18, 19, 20. For example, rates of major depressive disorder (MDD) ranged from 34% to 57% in these studies, compared with rates of 5% to 26% in the general population [21].
DSM diagnostic criteria and structured clinical interviews
More recent studies have addressed the limitations of earlier ones by using structured clinical interviews based on DSM diagnostic criteria. As early as 1983, Reich et al. [22] recommended the DSM as the most accurate means for classifying patients with chronic pain in a uniform manner. The multiaxial classification format allows users to consider both physiological and psychological components of chronic pain in a systematized manner. The first two DSM axes are comprised of the psychiatric
Psychopathology and rehabilitation
Additional research has focused on determining whether psychiatric disorders are a limiting factor in the successful rehabilitation of patients with CLBP. Gatchel et al. [35] used the SCID to assess the prevalence of current and lifetime DSM diagnoses in a sample of 152 patients with CLBP beginning an intensive 3-week rehabilitation program. These patients were then followed over time, with treatment outcome being defined as return-to-work status 1 year after program completion. Despite high
Psychopathology and chronic pain
The research findings reviewed above have answered many questions regarding psychiatric disorders and chronic spinal disorders. However, important unresolved issues remain, including the precise nature of the causal relationship between chronic pain and psychopathology. It should be noted that research investigating the relationship between chronic pain and psychopathology has not been limited to patients with CLBP. High rates of psychiatric disorders have also been found to be associated with
The diathesis-stress model
Returning to the Fishbain et al. [66] study, these authors concluded that the consequence hypothesis is most strongly supported, with additional support for the cognitive-behavioral mediation and scar hypotheses. A recent theoretical proposal by Banks and Kerns [51], when placed within the framework of Fishbain et al.'s [66] study, may help to clarify further the relationship between chronic pain and depression. After demonstrating that rates of depression appear to be higher in chronic pain
Conclusions
A large body of research has consistently documented elevated rates of psychopathology in chronic spinal disorder patients. Depressive disorders, somatoform disorders, anxiety disorders, substance use disorders, and personality disorders have been identified as the most common diagnostic categories. Although the relationship between chronic spinal disorders and psychopathology is complex, a diathesis-stress model is emerging as the dominant overarching theoretical perspective. In this model,
Acknowledgements
This work was supported in part by Grants 2 R01-M446452 and 2 KO2-MH01107 from the National Institutes of Health.
References (76)
The impact of major depression on chronic medical illness
Gen Hosp Psychiat
(1996)- et al.
The relationship of current psychiatric disorder to functional disability and distress in patients with inflammatory bowel disease
Gen Hosp Psychiat
(1996) - et al.
Somatizationthe path between distress and somatic symptoms
Am Pain Soc J
(1993) - et al.
Compensation and non-compensation chronic pain patients compared for DSM-III operational diagnoses
Pain
(1988) - et al.
Chronic pain and depression. Iclassification of depression in chronic low back pain patients
Pain
(1985) - et al.
Chronic pain and depression. IIsymptoms of anxiety in chronic low back pain patients and their relationship to subtypes of depression
Pain
(1985) - et al.
Chronic musculoskeletal pain and depressive symptoms in the general populationan analysis of the first national and nutrition examination survey data
Pain
(1990) - et al.
Dsm-IIIa new nomenclature for classifying patients with chronic pain
Pain
(1983) - et al.
Major psychological disorders in acute and chronic TMDan initial examination
J Am Dental Assoc
(1996) - et al.
The scope and significance of anger in the experience of chronic pain
Pain
(1995)
An emotional component analysis of chronic pain
Pain
Psychopathology and the rehabilitation of patients with chronic low back pain disability
Arch Phys Med Rehab
A psychiatric study of non-organic chronic headache patients
Psychomatics
Why is depression comorbid with chronic myofascial face pain? A family study of alternative hypotheses
Pain
Psychological aspects of chronic pelvic pain
J Psychosom Res
Psychiatric disorders in patients with fibromyalgiaa multicenter investigation
Psychosomatics
Screening for psychiatric morbiditythe pattern of psychological illness and premorbid characteristics in four chronic pain populations
Pain
Prevalence, onset, and risk of psychiatric disorders in men with chronic low back paina controlled study
Pain
Prospective study on the relationship between depressive symptoms and chronic musculoskeletal pain
Pain
Chronic pain and depressiona review
Comp Psychiat
Rediscovering the psychopathology of chronic pain
J Psychosom Res
Medical knowledge and the intractable patientthe case of chronic low back pain
Soc Sci Med
Psychological disorders and chronic paincause-and effect relationships
Psychiatric disorders as a factor in sick leave due to other diagnosesa general population-based study
Br J Psychiat
The effects of depression and chronic pain on psychosocial and physical functioning
Clin J Pain
The effect of experimentally induced anxiety on the experience of pressure pain
Pain
Measurement of painpatient preference does not confound pain measurement
Pain
Depression and the reporting of diabetes symptoms
Intl J Psychiat Med
Prognostic factors of spinal cord stimulation for chronic back and leg pain
Neurosurgery
Cognitive and physical capacity process variables predict long-term outcome after treatment of chronic pain
J Clin Cons Psycho
Overviewhypochondriasis, bodily complaints, and somatic styles
Am J Psychiat
Chronic painlifetime psychiatric diagnoses and family history
Am J Psychiat
DSM-III diagnoses in chronic painconfusion or clarity?
J Nerv Mental Disabil Assess
Psychiatric diagnosis of chronic pain patients
Am J Psychiat
Diagnostic and statistical manual of mental disorders
Structured clinical interview for DSM-III-R—non-patient version
Early development of physical and mental deconditioning in painful spinal disorders
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The writing of this article was supported in part by grants No. 2K02-MH01107, 2R01-MH46452, and 2R01-DE010713 from the National Institutes of Health.