Pain and the relationship with mood and anxiety disorders and psychological symptoms

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Abstract

Objective

The objective of this study was to investigate the association between pain and mood and anxiety disorders, as well as psychological symptoms, in a population-based sample of women.

Methods

This study examined the data collected from 1067 women aged 20–93 years (median 51 years) participating in the Geelong Osteoporosis Study. Mood and anxiety disorders were diagnosed using a clinical interview (SCID-I/NP) and psychological symptomatology was assessed using the General Health Questionnaire. Pain was determined using a Visual Analogue Scale (0–100 mm) and deemed present if score ≥ 40 mm.

Results

Current mood disorders were associated with an increased likelihood of overall (OR = 3.2, 95% CI 2.0–5.1), headache (OR = 2.8, 95% CI 1.6–4.8), back (OR = 4.0, 95% CI 2.5–6.5) and shoulder pain (OR = 2.2, 95% CI 1.2–4.2). In those with current mood disorders, the pain interfered with daily activities (OR = 3.2, 95% CI 1.9–5.5) and was present most of their time awake (OR = 2.5, 95% CI 1.5–4.1). This pattern was similarly observed for those with past mood disorders. Current anxiety disorders were associated with an increased likelihood for overall (OR = 2.2, 95% CI 1.4–3.6), headache (OR = 2.2, 95% CI 1.3–4.0), back (OR = 1.8, 95% CI 1.1–3.0) and shoulder pain (OR = 1.9, 95% CI 1.0–3.5, p = .05). In those with current anxiety disorders, the pain interfered with daily activities (OR = 2.4, 95% CI 1.4–4.1) and was present most of their time awake (OR = 1.9, 95% CI 1.2–3.2). There was no association between pain and past anxiety. Psychological symptomatology was associated with pain at each site (all p < .001).

Conclusions

This study is consistent with studies utilising clinical samples in reporting that mood and anxiety disorders, as well as psychological symptoms, are associated with higher levels of perceived pain.

Introduction

It is becoming increasingly understood that physical symptoms, typically unexplained pain, are common in the presence of clinical depression, and possibly anxiety [1]. The impact these symptoms have on diagnosis and treatment is significant. Prognosis, management and outcomes in the presence of comorbid pain are complicated, leading to greater health care utilisation [2]. Evidence suggests that the presence of pain symptoms can ultimately increase the range of differential diagnoses or even obstruct the diagnosis of a psychological disorder [3].

A review of the literature on pain symptoms in primary care patients presenting with depression revealed that the prevalence of comorbid pain ranged from 15% to as high as 100%, with a mean prevalence of approximately 65% [4]. A relationship between depression and subsequent pain symptoms has been consistently reported within clinical samples, while evidence from population-based studies is not yet as extensive (see reviews [1], [5], [6], [7]). Consistent with a diathesis-stress model, depression has not only been recognised as an antecedent of pain, but a common consequence or outcome [4], [8]. Pain is associated with certain physical conditions, and considered to be both a physical and psychological stressor that can influence one's disposition and mood [1], [6].

In contrast to the literature on depression and pain, it is less clear whether pain symptoms are as common among those with anxiety disorders [9], [10]. Highlighting the importance of considering anxiety disorders, a recent study investigating the prevalence of Axis I disorders and non-specific back pain in the population found that anxiety disorders (20.9%) were more frequently observed in the presence of pain than mood disorders (12.7%) [11]. Moreover, specific anxiety disorders, namely panic disorder, post traumatic stress disorder and agoraphobia, have been previously reported to have a stronger relationship with pain (associated with severe arthritis, rheumatism or a bone or joint disease) than depression [12]. It is thus possible that chronic pain is associated with a spectrum of psychological disorders, rather than having a specific relationship with depression.

At present, the evidence base tends to be dominated by studies utilising selected patient or treatment seeking (primary care) samples, self-report psychological measures, self-report questionnaires to determine the presence or absence of disorders, such as arthritis, over the lifetime as a proxy for pain or having a depression-only focus. For these reasons, we aimed to investigate the association between pain and both clinically diagnosed mood and anxiety disorders, as well as psychological symptoms, in a large, randomly-selected, population-based sample of adult women.

Section snippets

Participants

This study examined the data collected from women participating in the Geelong Osteoporosis Study (GOS), a large population-based study initially developed to investigate the epidemiology of osteoporosis in Australia, but later expanded to examine other diseases including mental health. Originally, 1494 women (aged 20–94 years) were randomly recruited from the electoral rolls for the Barwon Statistical Division (south-eastern Australia) between 1994 and 1997, with a response of 77.1% [13].

Mood disorders and pain

Two hundred and seventeen (20.3%) women were identified with a past mood disorder, and 89 (8.3%) with a current mood disorder. Differences were identified across the groups in regard to age, physical activity level, medication use (number and antidepressant use) and pain symptoms; otherwise the groups were similar (Table 1).

After adjustment for age, current mood disorders were associated with an increased odds of overall pain (OR = 3.2, 95% CI 2.0–5.1, p ≤ .001), headache (OR = 2.8, 95% CI 1.6–4.8, p ≤

Discussion

In this cross-sectional, population-based study in women, we report that past and current mood disorders as well as current anxiety disorders and psychological symptoms were associated with an increased likelihood of overall pain, and head, back and shoulder pain, compared to those with no prior history. There was no association between pain and past anxiety. These associations were independent of sociodemographic characteristics, medical conditions, medication use and other lifestyle factors.

Conflict of interest

Lana Williams has received grant/research support from Eli Lilly, Pfizer, The University of Melbourne, Deakin University and the NHMRC.

Julie Pasco has received speaker fees from Amgen, Eli Lilly and Sanofi-Aventis and funding from the Geelong Region Medical Research Foundation, Barwon Health, Perpetual Trustees, the Dairy Research and Development Corporation, The University of Melbourne, the Ronald Geoffrey Arnott Foundation, ANZ Charitable Trust, the American Society for Bone and Mineral

Acknowledgments

The study was funded by the National Health and Medical Research Council of Australia and supported by an unrestricted educational grant from Eli Lilly.

The funding providers played no role in the design or conduct of the study; collection, management, analysis, and interpretation of the data; or in preparation, review, or approval of the manuscript.

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