Adults with chronic pain present to healthcare settings primarily with the symptom of persistent or recurrent pain. The overall population reporting chronic pain is large (see Chapter 5, Epidemiology of chronic pain: classical to molecular approaches to understanding the epidemiology of pain). However, we are concerned here with those who report chronic pain but who are also highly distressed and disabled, and who repeatedly present for a wide range of treatments.
Chronic pain patients often complain of disability and enforced inactivity associated with poor sleep patterns and fatigue. Chronic pain and disability may lead to an impoverished social environment and loss of valued work, family, and social roles.6 Particularly distressing can be an unwanted and countertherapeutic reliance upon social care and medical support systems. It is common, for example, for people to continue to seek and receive ineffective treatments over long periods of time.7
The constant demand to react and adapt to pain and its associated disabling consequences also results in emotional problems. Principal among them is the development of a pattern of pain-related fear that is itself distressing, but is also thought to be a factor in the maintenance of chronic disability.8[IV] Typical targets of fear (or fear-provoking stimuli) for chronic pain patients are physical activity and movement, or even the thought of physical activity and movement. Movement is often associated with the catastrophic belief that increased pain and (re)injury will occur.9 These fears may be specific to the patient group, e.g. the fear for chronic low back pain patients that a back-stressing movement, such as lifting, will lead to disk damage.
Chronic pain patients also report low mood and depression, anger, and frustration.10,1112 13[IV] In general medical practice, there is a longstanding concern about the underdiagnosis of depression associated with illness or disability, a situation that is also relevant to chronic pain. There is a less well-recognized risk of overdiagnosis when almost all the widely used diagnostic criteria and self-report questionnaires include somatic symptoms, such as low energy, fatigue, sleep disturbance, and poor libido, which may also be attributable to pain.14 The dominant psychological model is the diathesis and stress model: the diathesis, or vulnerability to depression, consists of previous depression or pre-pain experiences which may heighten the risk of becoming depressed; and the stress consists of pain and its negative impact on the individual's life.10 There is an urgent need for better understanding of the significance of previous depression, and the process of acceptance and adaptation.15,16,17 There may also be depressive content and cognitive processing specific to chronic pain which warrants more careful identification and targeted treatment. As in depression without chronic pain, it may be that the efficacy of antidepressants has been overestimated and cognitive-behavior treatment is appropriate for depression or depressed mood in the context of chronic pain. Severe depression in the context of chronic pain needs immediate attention because of the risk of suicide and because pain treatment cannot proceed until the patient is able to foresee some worthwhile future.18,19[I]
Prolonged pain, disability, and depression will affect everyday cognition. Patients commonly complain of cognitive problems, such as difficulties in concentration and focused attention.20,21 These effects are likely to reduce everyday problem-solving abilities and to affect confidence in attempting social re-entry. Chronic pain patients often present with a range of problems in addition to persistent pain. This complex presentation has often been referred to as a syndrome, as it is largely a collection of associated and interlocking problems.
There is often a danger in this summarizing of a complex clinical presentation that we might unintentionally imply that an underlying vulnerability of psychopathology is the common feature of chronic pain patients. There is no evidence, however, for the claim that all chronic pain patients share a common psychopathol-ogy. Instead, this syndrome of distress can usefully be understood as resulting from a normal response of people to a fundamentally abnormal situation: pain that does not subside. People persevere and sometimes perseverate in ineffective and frustrating attempts to escape from pain and distress.22,23,24[IV]
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