In Independent Medical Assessments experts often mention the effects painful conditions have on mental health and the effects of mental health conditions on an individual’s pain. In this article, we discuss the nature of this complex interplay between physical and non-physical conditions that determine how an individual experiences pain and the central role a psychiatrist skilled in the assessment of pain has in determining the correct diagnosis, treatment, causation and the apportionment of physical and psychological factors.
Psycho-Social & Non-Organic Influences on Pain and Suffering
When an individual’s pain cannot clearly be explained, or seems disproportionate to their underlying medical condition, terms such as “psychosocial factors” or “non-organic factors” are often and loosely used in lieu of a real diagnosis to explain the gap between an expected level of pain and suffering and that which is observed. For psychiatrists through skilled interview to explore and detail the origin and nature of psychosocial factors is “bread and butter” and can provide an informed opinion as to how non-physical factors can affect a person’s pain and suffering.
For the non-clinician, psychological factors are best thought of as those factors arising from within the individual that influence an individual’s pain, whereas social factors refer to ‘external factors’ (sometimes referred to as environmental influences) on pain and suffering.
Table one psychological factors and social factors that may influence an individual’s pain and suffering.
| Psychological factors | Social factors |
|---|---|
| Co-existing mental illness, e.g. depressed mood, anxiety, post-traumatic stress, somatisation disorder | Workplace bullying |
| Cognitive processes, e.g. ‘pain means harm’ | Cultural beliefs |
| Religious beliefs | |
| Effects of pain relieving medication, e.g. long-term narcotic use | Reinforcement, e.g. family members |
| Self-esteem | Reinforcement of pain behaviours |
| Ongoing litigation |
Depression, Anxiety and Pain
Depressive disorders are the most common psychiatric disorders associated with chronic pain, closely followed by anxiety disorders, post-traumatic stress disorders and substance misuse. Over 60% of patients with chronic pain report depressive symptoms with the prevalence of major depression in patients with chronic pain is 30-40% (15% reporting suicidal thoughts).
Because persisting pain impacts negatively on work, physical activity and social role, depression in chronic pain patients is more likely to be a consequence of rather than the cause of an individual’s pain and suffering. The relationship between a person’s pain and their mental health is also bidirectional in that pain may cause worsening depression and undertreated depression and anxiety will cause an individual to experience more pain that if they were not depressed or anxious.
Undertreated depression and anxiety impair optimal response to any other pain directed treatment and should be ignored at peril. There are biological and behavioural connections between depression and anxiety and the perception of pain or ‘pain threshold’ whereby the neurochemical imbalances seen in depression and anxiety enhance the transmission and processing of painful stimuli and at the same time neuro-vegetative sequelae of depression and anxiety (disturbances in sleep, sexual function, appetite, concentration and motivation) lead to physical deconditioning, reduced pain tolerances and ‘boom and bust’ behaviour.
Implications for Independent Medical Assessments
Key to differentiating between a somatoform pain disorder and pain disorder associated with a general medical condition is for a close collaborative diagnosis between a psychiatrist (to assess the presence and relative contribution of psychological factors) and an appropriate expert physician able to assess and exclude symptoms that may be caused by any known general medical condition.
When to request a Report from a Pain Medicine Physician
| Complex Regional Pain Syndrome (CRPS) | Fibromyalgia | Mesothelioma Pain |
| Phantom Limb Pain | Sciatica, Whiplash | Nerve Damage Pain |
| Neuropathic Pain | Fear Avoidance and Abnormal Illness Behaviour | Opioid Abuse |
| Combined Pain and Psychiatric | Total and Permanent Disability | Spinal Injury Pain |
| Disorder | Central Pain Sensitisation | Nerve Blocks, Spinal Cord Stimulators |
| Intrathecal Drug Reservoirs |