Pain-related anxiety predicts non-specific physical complaints in persons with chronic pain

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Abstract

Persons with chronic pain often report a range of physical symptoms beyond their primary pain complaint itself. We predicted that non-specific physical symptom complaints would correlate more strongly with pain-related distress than with general measures of distress, and that they would contribute directly to disability. Results from 210 adults with chronic pain showed that collateral physical complaints are common in persons with chronic pain. Correlational analyses showed that greater reporting of physical complaints was associated with reports of higher pain severity, higher levels of depression, more cognitive, escape/avoidance, fearful appraisal, and physiological symptoms of pain-related anxiety and more physical and psychosocial disability. Regression analyses showed that, with pain-related anxiety variables entered either before or after depression, physiological symptoms of pain-related anxiety significantly predicted physical complaints. In comparison with cognitive and somatic depression symptoms physiological symptoms of pain-related anxiety were the stronger predictor.

Introduction

Persons with chronic pain often report a range of physical symptoms beyond their primary pain complaint itself (e.g. Von Korff et al., 1988). These symptom reports may have a number of implications for the patient. They may initially evoke extensive evaluation and medical tests to find the root cause. When the physical symptom reports involve multiple organ systems and occur in the absence of clear organic pathology the patients may be suspected of suffering with somatization or other somatoform disorders (American Psychiatric Association (APA), 1994). In the absence of clear explanations for their pain these non-specific physical complaints may raise the suspicion of a shared psychological cause of all symptoms including the pain. These psychological causes may be defined vaguely and usually implicate depression or other variants of emotional distress (Sullivan and Katon, 1993).

The experience of chronic pain certainly includes an array of negative emotional responses such as depression (Banks and Kerns, 1996), anxiety (McCracken et al., 1992), and anger (Wade et al., 1990). Depression is probably the most common form of distress experienced by persons with chronic pain occurring in a diagnosable form in 30–54% of clinic samples (Banks and Kerns, 1996). Further, it is well accepted that emotional distress is often associated with reports of pain and other physical symptoms (Kirmayer et al., 1994; Sullivan and Katon, 1993). This association is also clearly shown in the diagnostic criteria for affective and anxiety disorders of the American Psychiatric Association (APA, 1994). The mechanisms linking states of emotional distress with physical symptoms include autonomic arousal, vigilance and misinterpretation (Sullivan and Katon, 1993), or somatic amplification (Barsky and Klerman, 1983).

Relations of pain and emotional distress with non-specific physical complaints in persons with chronic pain remain unclear. These relations may take one of two forms, either: (a) emotionally distressing circumstances produce both the pain and additional physical symptom complaints, or (b) the pain is the primary problem that produces a state of emotional distress and associated increased physical symptom complaints. A review of the literature on chronic pain and depression has led to the conclusion that depression is more commonly a consequence and not a cause of chronic pain (Banks and Kerns, 1996). These results favor the view that non-specific physical complaints often reported by persons with chronic pain are a sign of the distress that is inherent in the experience of chronic pain and not a sign that pain is the product of a psychological problem.

Clearly, collateral physical complaints by persons with chronic pain may influence the diagnostic and treatment decisions made by providers of services in pain treatment centers. If nothing else, they may distract the patient and service provider and consume time and effort during evaluation. In addition, these physical symptoms may directly contribute to patient disability (Millard et al., 1991; Ciccone et al., 1996), emotional distress (Von Korff et al., 1988), and health care utilization (Barsky et al., 1986; Ciccone et al., 1996). These considerations emphasize the importance of understanding these symptoms better so that proper management strategies can be applied.

The purpose of this study was to examine the frequency, predictors, and other associated features of non-specific physical symptom complaints in persons with chronic pain. Based on the hypothesis that these symptoms are evoked by the emotionally distressing circumstances of chronic pain, we predicted that these physical symptoms would correlate with pain-related distress and show stronger correlations with pain-related distress than with general measures of distress. We also predicted that these symptoms would contribute directly to disability.

Section snippets

Method

Participants for this study were 210 patients with chronic pain referred to a university pain clinic. These Ss were consecutive clinic attenders who were at least 18-yr-old, could read and write English, and completed all measures for this study. Table 1 includes demographic characteristics of the sample.

Results

Initial analyses showed that the sample achieved a mean MSPQ score of 13.06 (SD=9.80). Patients endorsed an average of 8.00 (SD=9.80) of the 22 physical symptoms listed on the inventory. Only six patients (2.8%) endorsed none of the items. Table 2 includes a summary of the percentage of patients who endorsed each symptom. Muscle twitching (65.2%), muscles in neck aching (60.8%), and pounding in head (52.0%) were the most frequent complaints. Internal consistency for the scale was high (α=0.88).

Discussion

The results of this study showed that collateral, non-specific, physical symptom complaints are common in persons with chronic pain. Analyses of these complaints suggests that they are manifestations of pain-related distress. We compared distress that is tightly tied to the pain experience (pain-related anxiety) with a form of distress that is in most cases initiated by the pain experience (Banks and Kerns, 1996) but is less tied do the day to day variability of pain (depression). While both

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