Legal Update #21 Pain Re-visited
NLBC LEGAL UPDATE: January, 2005 - Issue #21
Sam Goldstein, Ph.D., Editor.
Complimentary Service of the Neurology, Learning and Behavior Center
BRIEF LEGAL UPDATES
The Neurology, Learning and Behavior Center provides multi-disciplinary, clinical and forensic assessment, case management, trial consultation and treatment services for children and adults with brain injury and dysfunction, Attention-Deficit Hyperactivity Disorder, language disorders, learning disability, developmental delay, emotional disorders, Autism and adjustment problems. The Center is dedicated to the provision of treatment services.
PAIN RE-VISITED
The comorbidity of cognitive, emotional and physical health problems is well documented, particularly for individuals with chronic illness. Physical and psychological symptoms typically increase together in a linear fashion. Further, individuals with anxiety and depression tend to have more diffuse physical symptoms and that as the number of physical symptoms increases so does the likelihood of an anxiety or depressive disorder. This is true for physical symptoms with or without a diagnosed cause. In this Legal Update, I will briefly summarize the current research demonstrating the powerful relationship between chronic pain, cognitive functioning and mental health.
Chronic pain, cognitive functioning and mental health clearly have a tri-directional relationship. That is, each affects the other in ways that are still not well understood. Forensic neuropsychologists failing to appreciate the role pain may have in influencing cognitive and emotional functioning will likely find themselves in scientifically indefensible situations, particularly when concluding that absence of significant neuropsychological test data in the face of daily complaints must simply be the result of unrelated psychological disturbance.
The powerful role pain plays in influencing emotional functioning was well-demonstrated in 2001 in a study completed by the World Health Organization involving over 5,000 individuals in fourteen countries. Of the 22% of patients who reported persistent pain for more than six months there was a four fold increase in associated anxiety or depressive disorders. These relationships were consistent across cultures. As Dr. Robert Gatchel of the University of Texas at Arlington points out in his work, nowhere do psychiatric and medical problems interface more prominently than in pain disorders. Pain has been reported to account for more than 80% of all physician visits. Pain is reported to in some way affect an excess of fifty million Americans and costs more than seventy billion dollars annual in health care costs and lost productivity. In 1995, Market Data Enterprises, reported that over 175,000 individuals sought treatment at pain centers in the United States alone. Pain is reported to cause an enormous cost to society involving lost earnings, decreased productivity and increased health care utilization. In 2000, Drs. Gatchel and Mayer reported that the annual cost of chronic low back pain was between twenty billion and sixty billion dollars per year when measures of lost productivity and social security disability benefits were calculated along with treatment costs. The prevalence and cost of pain in the United States has become such a significant issue that the Joint Commission on Accreditation of Health Care Organizations now requires that physicians consider pain the "fifth vital sign." In 2001, Congress designated the following ten years as the Decade of Pain Control and Research.
Increasingly, pain related problems are understood through a biopsychosocial approach. There is an appreciation that physical, emotional and cognitive factors contribute to the experience of pain, course of illness and response to treatment for individuals with pain disorders. A biopsychosocial model views physical disorders such as pain as the result of an interaction between physiologic, psychological and social factors, recognizing that each individual experiences pain uniquely.
I have long referred to the unfortunate combination of physical, emotional and cognitive problems individuals may experience in an accident as the "unholy trinity." Physical problems leading to chronic pain cause disruption in life, alters the homeostasis and physiological operation of the body, creates a sense of uncertainty and impairs daily functioning, including memory and concentration. Traumatic brain injury also causes similar problems. Finally, the stressful emotional experience of being involved in an event in which one perceives potential loss of life also appears to trigger a stress related reaction in the body, placing some individuals at significant risk to develop a host of psychological and emotional problems absent any physical injuries post accident. All three of these phenomena contribute to problems with daily functioning and cognitive efficiency. All three will lead individuals to experience daily life as impaired post accident. In combination, these three can be significantly disabling. Even absent a defined traumatic brain injury, the combination of chronic pain and an adverse emotional reaction following injury can and does cause significant disruption in every day life, such that an individual with these two conditions will report marked daily problems with concentration, memory and thinking.
Chronic pain is a stressor that taxes the stress regulation system. One important measure of the pain-stress cycle is cortisol. Cortisol plays a central role and is responsible for producing and maintaining high levels of glucose for behavioral response. Cortisol is potentially a highly destructive substance because to ensure a high level of glucose it breaks down proteins in muscles and inhibits the ongoing replacement of calcium in bones. Cortisol is the main hormonal product of the hypothalamic-pituitary-adrenal axis in humans. Although increased cortisol secretion is considered an adaptive response of the organism when stressed, prolonged secretion can lead to negative effects such as muscle atrophy, impairment of growth and tissue repair, immune system suppression and depression. Cortisol serves as a good marker for the level of stress an individual may be experiencing and in fact in some research studies failure to suppress cortisol when challenged with dexamethasone has been suggested as a biological marker of depression.
Dr. Robert Gatchel describes a broad conceptual model of the transition from acute to chronic pain. He suggests three stages, based on his research with low back pain that might generalize to all types of pain. Stage One is associated with an emotional reaction such as fear and anxiety, resulting from the perception of pain during this acute phase. Pain is associated with harm and so there is a natural emotional reaction when one experiences pain. If the pain persists past a reasonable period of two to four months, Stage Two is usually entered in which the individual begins to experience a wider array of psychological reactions such as learned helplessness, depression, distress, anger or further somatization. These outcomes result from the chronic nature of pain. The form they take on may well depend on pre-morbid or pre-existing psychosocial characteristics of the individual as well as other phenomena such as socio-economic conditions. That is, for a person with a pre-morbid problem with depression for whom a pattern of chronic pain seriously affects their economic status, depressive symptoms may be exacerbated. Further, a personality disorder may severely hamper a person's ability to cope with the stress of chronic pain. It has even been suggested by researchers that some individuals actually possess a pattern of personality making them extremely vulnerable to respond adversely to pain. Thus, certain pre-disposing psychosocial characteristics as well as phenomena in the environment that differ from one individual to the next may be exacerbated by the stress of attempting to cope with pain. Finally, in Stage Three, an individual accepts or adopts a passive, illness based role in which they begin to lead their lives in such a way as to avoid pain, assuming that there is nothing they can do to change their "miserable existence."
Keep in mind also that for each of these three phenomena, cognitive problems secondary to brain injury, chronic pain secondary to physical injury, emotional disorders secondary to either of the first two or the experience of a traumatic event, complicates treatment. Effective pain treatment requires a resilient mindset, one generally free of helpless, hopeless or anxious thinking. The ability to effectively confront psychological impairments requires physical health. Treating each of these phenomena requires functional cognitive capacity and consistency in the ability to participate in treatment, a phenomena that is often impaired for individuals suffering the adverse neuropsychological consequences of traumatic brain injury.
Important questions remain to be answered as to how mental and cognitive disorders are exacerbated by pain and how a predisposition towards a particular psychiatric disorder affects the experience of pain and the evolution of a chronic disability. We have yet to clearly identify the underlying neuropathways in these phenomena. Finally, we have yet to define who may be the best treatment responder or what phenomena contribute significantly to treatment outcome. It has been demonstrated thus far that early identification and aggressive treatment with an understanding towards pre-accident vulnerability phenomena is effective.
Given the idiosyncratic nature by which pain is experienced, it is likely that helping judges and juries understand the chronically impairing course some individuals with pain may experience, even absent significant comorbid problems, will continue to be difficult. Given the biopsychosocial nature of pain, it often falls on the shoulders of the forensic neuropsychologist to provide an understanding of our current knowledge in the field as well as assist judges and juries to appreciate the potentially significant, disabling effects of chronic pain.
References of Interest
Dersh, J., Polatin, P., & Gatchel, R. (2002). Chronic pain and psychopathology: Research findings and theoretical considerations. Psychosomatic Medicine, 64, 773-786.
Gatchel, R.J., & Dersh, J. (2002). Psychological disorders in chronic pain: Are there cause and effect relationships? In D.C. Turk and R.J. Gatchel (Eds.), Psychological Approaches to Pain Management: A Practitioner's Handbook (2nd Edition). New York, NY: Guilford.
Gureje, O., Simon, G., & Van Korf, M. (2001). A cross national study of the course of persistent pain and primary care. Pain, 92, 195-200.
Kroenke, K., Spitzer, R.L., & Williams, J.B. (1994). Physical symptoms and primary care. Predictors of psychiatric disorders and functional impairment. Archives of Family Medicine, 3, 774-779.
Ray, Q. (2004). How the mind hurts and heals the body. American Psychologist, 59, 29-40.
Watson, D., & Pennebaker, J. (1989). Health complaint stress and distress. Exploring the central role of negative affectivitiy. Psychological Review, 96, 234-254.
