Home Medicine Comparison of patients diagnosed with “complex pain” and “somatoform pain”
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Comparison of patients diagnosed with “complex pain” and “somatoform pain”

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Published/Copyright: October 1, 2017
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Scandinavian Journal of Pain
From the journal Scandinavian Journal of Pain Volume 17 Issue 1

Abstract

Background and aim

Chronic pain conditions can be diagnosed and treated in both somatic and psychiatric settings. It is still a discussed and unanswered question whether the two groups of patients differ. The purpose of this short article is to inform further reflections concerning the classifications of somatoform pain and complex pain.

Method

Sociodemographic and questionnaire data concerning anxiety and depression, perceived injustice, well-being, and levels of psycho-physiological functioning were compared for patients diagnosed with complex pain (somatic diagnosis) at a pain clinic and somatoform pain (psychiatric diagnosis) at a Liaison-psychiatric clinic.

Results

Very little differences were found between patients with complex pain (N = 162) and somatoform conditions (N = 89). Both patient groups were seriously impaired both physically and mentally.

Conclusion

These comparisons lend support to the viewpoint of non-segregation of somatoform and complex pain.

Implications

Pain treatment might be better-managed in common multidisciplinary centers with specialists in both pain treatment and psychiatric aid.

Keywords: Chronic pain; Complex pain; Somatoform; Psychogenic pain; Ideopatic pain; ICD10

1 Introduction

According to ICD10, patients with persistent pain conditions can be diagnosed in two ways, linking the pain to either a somatic or a psychiatric understanding. The idea of two distinct pain types - one somatic, complex (viewed as medically explainable) and one psychogenic, idiopathic (viewed as medically unexplained) - has historical roots [1], but the idea of pain being of different types is no longer a part of modern pain theory and clinical understanding [2,3]. Still, the ICD10 diagnostic system and the present organizational structures in health management concerning chronic pain maintain the idea of the two pain types, and patients with chronic/long lasting pain conditions can be referred to either a somatic or a psychiatric unit. The diagnostic labels are further exported into diagnostic databases, and they may play a major role in patient rehabilitation and social security management.

The purpose of this short report is to shed light on these inconsistencies in understanding and clinical management by empirically comparing the two groups involved: (1) patients with a diagnosis of complex pain treated in a (somatic) outpatient pain clinic. (2) Patients diagnosed with somatoform pain and treated in an outpatient liaison clinic (“unexplained pain”).

2 Methods

2.1 Participants

All participants had been referred for assessment and treatment at either the Cross-disciplinary Pain Center, Rigshospitalet (N = 89) or the Liaison Clinic, Mental Health Center (N = 89). Both are multidisciplinary clinics in Copenhagen, Denmark. Data were collected between January 1 and December 31, 2014, by consecutively collecting data from the patients referred at the clinics. They were all diagnosed by specialist physicians at the units.

From a total participant sample of 358 individuals, two subgroups were made. One subgroup with the diagnosis of “complex nonmalignant pain” (Pain Center sample, N =162; ICD10 code R522E); one group with the diagnosis of “persistent somatoform pain disorder” (Liaison Clinic, N = 89; ICD10 code F45.4).

2.2 Questionnaires

The data collected comprised sociodemographic information (age, gender, marital status, number of children, educational level, relation to job market, and duration of pain symptoms).

Hospital Anxiety and Depression Scale (HADS), which is a 14-item anxiety and depression screening instrument for use in nonpsychiatric patients [4]. HADS has been validated and found reliable for use in the Danish general population [5], as well as in patients with chronic pain [6,7]. Scores on the HADS range from 0 to 21 for both measures, with higher scores indicating greater anxiety and depression. The average Cronbach’s alphas are reported as 0.83 for anxiety and 0.82 for depression [5].

The Injustice Experience Questionnaire (1EQ) assesses the degree to which individuals perceive their present condition as being characterized by injustice. Respondents rate their experiences of 12 different thoughts/emotions/attitudes using a 5-point Likert scale [8]. The final score is the sum of all items, with high values indicating high perceived injustice levels. In the original study, the IEQ had a Cronbach’s alpha of 0.92 and a test-retest reliability of 0.90 [8]. The Danish validated version showed Cronbach’s alpha = 0.90 [9]

The WHO-five well-being scale (WHO-5) is a well-being index that includes five items concerning feelings of positive mood, vitality, and general interest. It is answered using a 5-point Likert scale, with higher scores indicating higher well-being. The scores are added and multiplied by 4, giving a final score ranging from 0 to 100. The Danish language version of this scale has been found valid [9].

The SF-36 is a standardized, well-validated, multi-dimensional questionnaire that measures health, level of function, and wellbeing in eight dimensions [11]. The Danish language version has been validated and found to be reliable [12].The dimension Physical function is measured using 10 items concerning physical disabilities. Role physical is addressed by 4 items regarding present physical limitations. Bodily pain is evaluated based on 2 items about pain and impact of pain. General health is assessed using 5 items concerning self-rated health perception. The scores on these first four dimensions are used to calculate an overall Physical health component. The dimension Vitality is measured with 4 items concerning feelings of energy and tiredness. Social functioning is assessed using 2 items about social limitations. Role emotional is measured using 3 items about daily limitations for emotional reasons. Finally, Mental health is addressed in 5 items concerning present mood and nervousness. The scores for these last four dimensions are used to compute an overall Mental health component. All SF-36 scores range from 0 to 100, with higher scores indicating better function on the specific dimension. Population studies usually show norms of around 50 for the two-component sum scores [13].

Statistical analyses were performed using SPSS 22 Chi Square methods for showing significant differences in the binary (sociodemographic) variables, while independent t-test comparisons were used for the continuous variables. Controlling differences for age, gender and years with pain was done by using a univariate general linear model.

3 Results

3.1 Sociodemographics

Mean age for the “somatic” pain sample was 50.8 (SD12.5, range 21-81); and for the “psychiatric” pain sample was 41.9 (SD 12.0, range 23-72) (Table 1). The age difference was nearly 9 years, and the “somatic” pain sample has had the pain condition more than three years longer, which was depending on the age: When controlled for age, years with pain was no longer significantly different (p = .66).

Table 1

Sociographic data of the diagnostic groups of somatoform pain and complex pain.

Treatment setting Diagnosis Pain clinic (N =162) Complex pain Liaison clinic, pain (N = 89) Somatoform pain
Age 50.8[**] 41.9
Female gender 59% 64%
Years with pain 12.4[(*)] 9.2
Married or with 52% 50%
partner
Children at home (N) 1.0 0.9
Formal education, yes 76% 69%
Currently employed 19%[*] 30%
If employed, working 25.8 29.5
hours/week

The “somatic” pain sample was employed less frequently, and age played a role here too: only one patient was over official retirement age (65 years) in the “psychiatric” sample, while 18 patients were over 65 years in the “somatic” pain sample. However, when these age-retired patients were removed from analysis, the difference was still significant (Pearson chi-square p = .04).

3.2 Questionnaire data

The calculated scores of the questionnaires are shown are shown in Table 2. Only three of the 14 variables show initial significant differences. The “somatic” pain sample functions worse on the SF36 physical function subscale (items concerning physical disability in everyday functioning such as walking). As this could be seen as a result of the older age and gender roles, reanalysis was made controlling for age and gender, and the difference turned marginally non-significant (p = .051).

Table 2

Questionnaire scores from the diagnostic groups of somatoform pain and complex pain.

Treatment setting Main diagnosis Painclinic (N = 162) Complex pain Liaison clinic (N = 89) Somatoform pain
Anxiety, HADS 9.3 10.3
Depression, HADS 8.1 8.6
Perceived 1njustice Scale 27.3 28.4
WHO-5 total 33.8 28.5
SF36 physical function 42.0[(*)] 50.6
SF36 role physical 13.0 13.1
SF36 bodily pain 21.7 24.2
SF36 general health perception 33.9 33.2
SF36 vitality 27.6 23.6
SF36 social functioning 42.6 40.0
SF36 role emotional 42.4 32.2
Sf36 mental health 54.6 49.7
SF 36 physical sum score 27.2[**] 30.6
SF 36 mental sum score 39.9[**] 35.1

Significant differences were seen on the two summarized scores of SF36. These differences were still significant after controlling for age and gender. The score difference showed the “psychiatric” pain sample to score 3.4 points better than the “somatic” pain sample on the physical sum score; and to score 4.8 point worse on the mental sum score.

4 Discussion

The two groups with “somatic” an “psychiatric” pain conditions differed largely in age and in some of the age-related sociodemographic variables, but were nearly identical with respect to the psychiatric symptoms of anxiety and depression; both groups had high scores. The well-being and psycho-physiological function measures also showed nearly identical and high levels of burden in both groups. The only robust differences were seen in the sum- scores of the SF36; the “psychiatric” pain sample were a little better functioning physically and a little worse functioning mentally. Although significant, the actual differences in scores between the groups are low, 3.4 for the physical, 4.8 for the mental sum score.

The size and relevance of the differences of the SF 36-scores can be put in perspective by looking at (a) normative data and (b) reports of minimal clinical relevant differences.

  1. Several country- and area-specific norms for SF 36 have been published, but no specific Danish norms exist. The norms are to some extend context and country specific, but regarding the sum scores, the figures do not deviate much between countries. Using the UK-norms [14], the mean physical sum normal score is 50.1 and the mean mental normal score is 50.2. People selfreporting themselves with long standing illness, score 44.6 as a physical and 48.2 as a mental norm sumscore in the UK-norms for SF 36.

    These norms are far from the mean of the present pain samples (27.2 and 39.9 for the “somatic” sample and 30.6 and 35.1 for the “psychiatric” sample). Both samples display very low levels of psychosocial functioning, and in both samples the physical score show the greatest distance from the norms. This may indicate that the physical limitations of functioning are worse than the mental limitations - also in the “psychiatric” pain sample.

    Even compared to data from people with selfreported “longstanding illness” (the norms mentioned above), the present pain samples score much lower.

  2. Regarding the size of these limitations, published data on minimal clinical relevant differences for the SF 36 can illuminate the size of the limitations. A change of 12% of baseline score of the subscales are set to be clinically relevant by Angst et al. [15]. Auffinger et al. [16] report a change of 5.6 on the physical sum score and 5.1 on the mental sum score to be clinically relevant. The present total pain sample has more than 4 times the minimal clinical difference for the physical scale (21.2 score points (42%)); and two times the difference for the mental scale (12.3 score points (24%)). This may indicate again that the patients are limited especially regarding the physical activities.

Comparing the difference between the “somatic” and the “psychiatric” sample, the significant sum score difference between the samples (3.4 and 4.8) do not reach the level of minimal clinical relevant difference, as levels are mentioned above. Although the difference between the samples is significant, it is small and below clinical relevance, especially compared to the difference to normal functioning for both samples.

Concerning the scales of anxiety and depression, there were no statistical difference between the groups, and both groups scored high for both anxiety and depression. In fact, the mean scores are classified as “borderline case for a clinical diagnosis” (8-10 points) by the official norms [5]. This could possibly indicate that around half of the patients in both diagnostic groups could be diagnosed with an anxiety and depression code - or both.

The well-being scale (WHO 5, range 0-100) reports a norm mean of 68 points, and scoring <35 is set as “high risk for depression or high stress load” [10]. Mean of the present samples was 31.2, possibly indicating around half of the sample to be in serious distress.

The perceived injustice scale, which measures the unpleasant and illness sustaining feelings of being treated wrong and unjust, ranges 0-48 and has a cut off for a “clinical case” set at >30 [8]. Mean score in present pain sample is close: 27.9, again possibly indicating nearly half of the sample to be “clinical cases.”

This study is limited by the low N, especially for the “psychiatric” sample, which was only a part of the patients referred to the Liaison Clinic. On the other hand, all data were collected at the same time and in exactly the same socio-cultural contexts; the clinics involved was situated within 1 km from each other, and with similar procedures for referral.

As conclusion, there seem to be very few differences between patients diagnosed by “complex” and “somatoform” pain, and they might be considered as one and the same group. This point is in full concordance with the long-lasting works of pain specialist Harold Merskey [1,17,18], who fully acknowledge the big overlap between pain and psychiatric distress. He argues that the high emotional distress in pain patients might be partly rooted in certain personality traits and emotional states, but pain is nevertheless the overriding condition that brings the patients to medical attention.

As perspective, all pain patients may be well treated in multidisciplinary centers with possibilities for both specialist in pain medication and psychiatric aid.

The reasons why some patients with pain are referred to a psychiatric clinic and some patients are referred to a pain center are unknown and could be a target for future research. The aim could be developing a more consistent health organizational structure for patients with chronic pain conditions.

Highlights

  • Comparisons between patients with “somatoform” and “complex” pain were made.

  • Very little differences were found between the groups.

  • Both patient groups were seriously impaired both physically and mentally.

  • The diagnostic groups might be considered as one and the same group.

  • Multidisciplinary centers with both pain and psychiatric specialists are suggested.

Knowledge Center for Functional Diseases, Mental Health Center, Nannasgade 28, 2200 Copenhagen N., Denmark. Email:

  1. Ethical issues: Data collection was performed in accordance with the guidelines for the Danish national scientific ethics committee, and the database was approved by the national Danish Data Protection Agency.

  2. Conflicts of interest: There is no conflict of interests.

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Received: 2017-04-11
Revised: 2017-06-15
Accepted: 2017-07-05
Published Online: 2017-10-01
Published in Print: 2017-10-01

© 2017 Scandinavian Association for the Study of Pain

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https://doi.org/10.1016/j.sjpain.2017.07.001
Keywords for this article
Chronic pain; Complex pain; Somatoform; Psychogenic pain; Ideopatic pain; ICD10

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  1. Observational study
  2. Perceived sleep deficit is a strong predictor of RLS in multisite pain – A population based study in middle aged females
  3. Clinical pain research
  4. Prospective, double blind, randomized, controlled trial comparing vapocoolant spray versus placebo spray in adults undergoing intravenous cannulation
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  6. The Functional Barometer — An analysis of a self-assessment questionnaire with ICF-coding regarding functional/activity limitations and quality of life due to pain — Differences in age gender and origin of pain
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  8. Clinical outcome following anterior arthrodesis in patients with presumed sacroiliac joint pain
  9. Observational study
  10. Chronic disruptive pain in emerging adults with and without chronic health conditions and the moderating role of psychiatric disorders: Evidence from a population-based cross-sectional survey in Canada
  11. Educational case report
  12. Management of patients with pain and severe side effects while on intrathecal morphine therapy: A case study
  13. Clinical pain research
  14. Behavioral inhibition, maladaptive pain cognitions, and function in patients with chronic pain
  15. Observational study
  16. Comparison of patients diagnosed with “complex pain” and “somatoform pain”
  17. Original experimental
  18. Patient perspectives on wait times and the impact on their life: A waiting room survey in a chronic pain clinic
  19. Topical review
  20. New evidence for a pain personality? A critical review of the last 120 years of pain and personality
  21. Clinical pain research
  22. A multi-facet pain survey of psychosocial complaints among patients with long-standing non-malignant pain
  23. Clinical pain research
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  27. Clinical pain research
  28. COMBAT study – Computer based assessment and treatment – A clinical trial evaluating impact of a computerized clinical decision support tool on pain in cancer patients
  29. Original experimental
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  33. Original experimental
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  35. Original experimental
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  42. Quantitative sensory tests (QST) are promising tests for clinical relevance of anti–nociceptive effects of new analgesic treatments
  43. Educational case report
  44. Pregabalin as adjunct in a multimodal pain therapy after traumatic foot amputation — A case report of a 4-year-old girl
  45. Editorial comment
  46. Severe side effects from intrathecal morphine for chronic pain after repeated failed spinal operations
  47. Editorial comment
  48. Opioids in chronic pain – Primum non nocere
  49. Editorial comment
  50. Finally a promising analgesic signal in a long-awaited new class of drugs: TRPV1 antagonist mavatrep in patients with osteoarthritis (OA)
  51. Observational study
  52. The relationship between chronic musculoskeletal pain, anxiety and mindfulness: Adjustments to the Fear-Avoidance Model of Chronic Pain
  53. Clinical pain research
  54. Opioid tapering in patients with prescription opioid use disorder: A retrospective study
  55. Editorial comment
  56. Sleep, widespread pain and restless legs — What is the connection?
  57. Editorial comment
  58. Broadening the fear-avoidance model of chronic pain?
  59. Observational study
  60. Identifying characteristics of the most severely impaired chronic pain patients treated at a specialized inpatient pain clinic
  61. Editorial comment
  62. The burden of central anticholinergic drugs increases pain and cognitive dysfunction. More knowledge about drug-interactions needed
  63. Editorial comment
  64. A case-history illustrates importance of knowledge of drug-interactions when pain-patients are prescribed non-pain drugs for co-morbidities
  65. Editorial comment
  66. Why can multimodal, multidisciplinary pain clinics not help all chronic pain patients?
  67. Topical review
  68. Individual variability in clinical effect and tolerability of opioid analgesics – Importance of drug interactions and pharmacogenetics
  69. Editorial comment
  70. A new treatable chronic pain diagnosis? Flank pain caused by entrapment of posterior cutaneous branch of intercostal nerves, lateral ACNES coined LACNES
  71. Clinical pain research
  72. PhKv a toxin isolated from the spider venom induces antinociception by inhibition of cholinesterase activating cholinergic system
  73. Clinical pain research
  74. Lateral Cutaneous Nerve Entrapment Syndrome (LACNES): A previously unrecognized cause of intractable flank pain
  75. Editorial comment
  76. Towards a structured examination of contextual flexibility in persistent pain
  77. Clinical pain research
  78. Context sensitive regulation of pain and emotion: Development and initial validation of a scale for context insensitive avoidance
  79. Editorial comment
  80. Is the search for a “pain personality” of added value to the Fear-Avoidance-Model (FAM) of chronic pain?
  81. Editorial comment
  82. Importance for patients of feeling accepted and understood by physicians before and after multimodal pain rehabilitation
  83. Editorial comment
  84. A glimpse into a neglected population – Emerging adults
  85. Observational study
  86. Assessment and treatment at a pain clinic: A one-year follow-up of patients with chronic pain
  87. Clinical pain research
  88. Randomized, double-blind, placebo-controlled, dose-escalation study: Investigation of the safety, pharmacokinetics, and antihyperalgesic activity of L-4-chlorokynurenine in healthy volunteers
  89. Clinical pain research
  90. Prevalence and characteristics of chronic pain: Experience of Niger
  91. Observational study
  92. The use of rapid onset fentanyl in children and young people for breakthrough cancer pain
  93. Original experimental
  94. Acid-induced experimental muscle pain and hyperalgesia with single and repeated infusion in human forearm
  95. Original experimental
  96. Swearing as a response to pain: A cross-cultural comparison of British and Japanese participants
  97. Clinical pain research
  98. The cognitive impact of chronic low back pain: Positive effect of multidisciplinary pain therapy
  99. Clinical pain research
  100. Central sensitization associated with low fetal hemoglobin levels in adults with sickle cell anemia
  101. Topical review
  102. Targeting cytokines for treatment of neuropathic pain
  103. Original experimental
  104. What constitutes back pain flare? A cross sectional survey of individuals with low back pain
  105. Original experimental
  106. Coping with pain in intimate situations: Applying the avoidance-endurance model to women with vulvovaginal pain
  107. Clinical pain research
  108. Chronic low back pain and the transdiagnostic process: How do cognitive and emotional dysregulations contribute to the intensity of risk factors and pain?
  109. Original experimental
  110. The impact of the Standard American Diet in rats: Effects on behavior, physiology and recovery from inflammatory injury
  111. Educational case report
  112. Erector spinae plane (ESP) block in the management of post thoracotomy pain syndrome: A case series
  113. Original experimental
  114. Hyperbaric oxygenation alleviates chronic constriction injury (CCI)-induced neuropathic pain and inhibits GABAergic neuron apoptosis in the spinal cord
  115. Observational study
  116. Predictors of chronic neuropathic pain after scoliosis surgery in children
  117. Clinical pain research
  118. Hospitalization due to acute exacerbation of chronic pain: An intervention study in a university hospital
  119. Clinical pain research
  120. A novel miniature, wireless neurostimulator in the management of chronic craniofacial pain: Preliminary results from a prospective pilot study
  121. Clinical pain research
  122. Implicit evaluations and physiological threat responses in people with persistent low back pain and fear of bending
  123. Original experimental
  124. Unpredictable pain timings lead to greater pain when people are highly intolerant of uncertainty
  125. Original experimental
  126. Initial validation of the exercise chronic pain acceptance questionnaire
  127. Clinical pain research
  128. Exploring patient experiences of a pain management centre: A qualitative study
  129. Clinical pain research
  130. Narratives of life with long-term low back pain: A follow up interview study
  131. Observational study
  132. Pain catastrophizing, perceived injustice, and pain intensity impair life satisfaction through differential patterns of physical and psychological disruption
  133. Clinical pain research
  134. Chronic pain disrupts ability to work by interfering with social function: A cross-sectional study
  135. Original experimental
  136. Evaluation of external vibratory stimulation as a treatment for chronic scrotal pain in adult men: A single center open label pilot study
  137. Observational study
  138. Impact of analgesics on executive function and memory in the Alzheimer’s Disease Neuroimaging Initiative Database
  139. Clinical pain research
  140. Visualization of painful inflammation in patients with pain after traumatic ankle sprain using [11C]-D-deprenyl PET/CT
  141. Original experimental
  142. Developing a model for measuring fear of pain in Norwegian samples: The Fear of Pain Questionnaire Norway
  143. Topical review
  144. Psychoneuroimmunological approach to gastrointestinal related pain
  145. Letter to the Editor
  146. Do we need an updated definition of pain?
  147. Narrative review
  148. Is acetaminophen safe in pregnancy?
  149. Book Review
  150. Physical Diagnosis of Pain
  151. Book Review
  152. Advances in Anesthesia
  153. Book Review
  154. Atlas of Pain Management Injection Techniques
  155. Book Review
  156. Sedation: A Guide to Patient Management
  157. Book Review
  158. Basics of Anesthesia
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