Psychogenic Pain and Iatrogenic Suicide

As published by Global Summit On Diagnostic Alternatives:

A recent large-sample analysis investigated the association between several named chronic pain conditions and suicide.  This analysis provides suggestive evidence that thousands of patients who have been diagnosed with a psychiatric condition called “psychogenic pain” may have been placed at greater risk of suicide by the diagnostic label itself.  Like much of psychosomatic medicine, the diagnosis lacks medical evidence of validity.

Introduction

Chronic pain — defined as pain which persists for longer than 12 weeks — is endemic in  America [Ref 1, 2].  While chronic pain may be associated with well-known medical disorders (Osteo- or Rheumatoid Arthritis, orthopedic problems of the spine, Cancer), it is also a frequent symptom in complex or relatively rare medical disorders (Fibromyalgia, Lupus, Complex Regional Pain Syndrome — CRPS, Trigeminal Neuralgia, Temporomandibular Joint Disorder)  which can be difficult to diagnose and resistant to treatment  [Ref 3].

Suicide is the tenth most frequent cause of death in the United States [Ref 4] with an annual age-adjusted death rate of 11.8 deaths per hundred thousand.  On the order of 1800 unsuccessful suicide attempts per hundred thousand occur in a given year.  Some published reports have examined the roles which chronic pain may play in suicide [Ref  5].

Noncancer Pain Conditions and Risk of Suicide

A large-scale analysis of patient records in the US Department of Veterans Affairs Healthcare System (VHA) [Ref 6] examined associations between suicide death and several named chronic non-cancer pain diagnoses during a period of three years in a population of over 4.8 million patients.  Seven pain conditions were addressed, including back pain, arthritis separate from back pain, migraines, tension headache, neuropathy, fibromyalgia and psychogenic pain, as defined in the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM).

Among the 4.8 million patient records analyzed,  2,281,059 gave no indications of a pain diagnosis, 1,616,542 had a single pain condition and  965,485  were diagnosed with two or more pain conditions of the seven named.  During the three years analyzed,  4823 VA patients were found to have died by suicide — a gross unadjusted suicide rate of 33 deaths per hundred thousand per year.  This rate is nearly three times higher than in the US population as a whole.   Among these 4823 suicide deaths,  pain condition diagnoses were noted in the records of 2838 patients (a gross mortality rate of 36.6 per hundred thousand per year).

Several aspects of this large patient sample stand out as different from vital statistics  of US residents as a whole.  91.7% of the sample were male and 56.7% of the total sample were age 60 or older  [Ref 6, Table 1].  It is known that older males have a higher than average rate of suicide.  VA patients also tend to be a “sicker” population even after adjusting for effects of age, in that part of the analyzed group were residents of VA Hospitals and some VA patients have served multiple combat tours under high stress and physical hazard.

Among groups of VA chronic pain patients, the highest hazard ratio for suicide  was observed for patients diagnosed with “psychogenic pain”.  Among this group of 15,922 males and 2223 females,  the hazard ratio after controlling for age, sex, and Charlson score was 2.61, compared to VA patients whose records did not indicate a chronic pain condition  [Ref 6, Table 2].

Discussion

Ilgen, et. al., sought to separate the influence of co-morbid clinical psychiatric disorders, versus chronic pain  as contributors to suicide.  Patient records were analyzed to identify psychiatric diagnoses, including several ICD codes for depression, schizophrenia, bipolar disorder, substance abuse disorders, post traumatic stress disorder and other anxiety disorders as defined in the ICD-9-CM.  When potential contributions from other simultaneous psychiatric diagnoses were controlled for in addition to age, sex and Charlson score,  the estimated hazard ratio for psychogenic pain dropped from 2.61 to 1.58.

Charlson score is a weighting factor intended to model the additive effects of multiple independent causes or factors in the likelihood of a given outcome, where such causes are said to be “comorbid” (“occurring together”).  While such models have proven useful in making medical decisions for people with multiple  medical issues, they are more controversial  where psychiatric disorders are concerned.  For instance,  such a high degree of comorbidity is found between major depression and anxiety disorder,  that the majority of patients diagnosed with either will be diagnosed with both.  [Ref 7]

Dr. Ilgen and his colleagues offer the following discussion of the high risk factor for suicide in patients diagnosed with psychogenic pain:

For psychogenic pain in particular, the ambiguity related to the causes and treatments of the condition may be a core part of the relationship between this diagnosis and suicide risk.  It is notable that over 95% of all patients with psychogenic pain also had another pain condition diagnosis.  This likely reflects the overall severity of the pain-related problems in those with psychogenic pain as well as a high degree of uncertainty about the appropriate diagnosis based on clinical presentation.  However psychogenic pain was associated with a significantly increased risk for suicide even in supplementary analyses that controlled for other concomitant pain conditions, suggesting that there is something unique in terms of suicide risk beyond just the likelihood of other pain-related problems.  It is possible that the burden of having a significant pain condition with an ambiguous cause is particularly difficult for patients, thus increasing their hopelessness, frustration, and risk for suicide.  In addition, when treatment providers believe that a patient has pain without a clear cause or that they attribute mostly to a psychiatric problem,  they may be less likely to provide active pain treatment in the form of pharmacological or behavioral interventions.  This under-treatment of pain could also increase the risk of suicide over time. [Ref 6]

An online survey conducted in early 2013 offers significant patient insights into how chronic pain patients may come to receive a diagnosis of “psychogenic pain.”  Conducted by the Ben’s Friends online communities for patients with 33 types of rare disorders (http://www.bensfriends.org),  the survey invited responders to answer 30 questions and provide a narrative of their experiences after being referred by a medical doctor to a mental health practitioner.

While the survey report analyzed  a limited sample of 180 self-nominated patients from an invited community of over 36,000 people around the world,  the patient commentaries are compelling.  They reveal that among patients with rare or complex medical disorders and chronic pain, significant numbers are referred to mental health professionals after a medical doctor is unable to diagnose or effectively treat their chronic pain, fatigue or both.

To quote from the survey report, [Ref 8, 9]

180 survey responses in February 2013 were analyzed, among which the [most numerous] responses came from patients with severely painful conditions: Trigeminal Neuralgia (82), Fibromyalgia (25), Lupus (20), Chiari Malformation (15), and Psoriatic Arthritis (14).

  • 147 responders (81%) were female, 10 male, and 23 made no entry.  Median age was in the mid-40s.  Half had medical complaints for 10 years or more. Many had seen 10 or more doctors and taken years to get a diagnosis.
  • 97 reported being treated without success before mental health referral, and 62 with “some improvement”.  More than half reported that they had no medical diagnosis before referral to mental health.
  • 81 responders reported they did not agree with mental health referral.  91 agreed and 8 made no entry. 32 were told that if they did not go for mental health evaluation, they would not be further treated.  Half of all responders had been “fired” (discharged) at some time by a medical doctor, not necessarily as an outcome of mental health referral.
  • The most common mental health diagnoses were depression (105), anxiety (90), stress (86) and panic attacks (42).  Half of those referred received an average of 3 diagnoses each.
  • 55 responders were told that their physical symptoms were caused totally or in part by a mental condition. “Psychogenic pain” was named as a diagnosis by 22, of whom 17 disagreed with the diagnosis or other information provided by the mental health professional.
  • 68  responders were prescribed medication by a mental health professional. Of these, 60  reported “no change” in their outcomes.   Treatment without improvement occurred in spite of the fact that 26 were assessed to have no mental health disorder, and indications were found of a physical cause for their symptoms in 21.

Responder narratives revealed that mental health referral was often consequential, even when patients were not helped by treatment.  Five reported that insurance limited or refused further payments after mental health evaluation.  Many reported increased distress as a result of being disregarded or invalidated by medical doctors.  A few related that a mental health professional had explicitly stated that their medical issues were “all in your head.”  It was apparent that some responders had been referred or evaluated by physicians who were ill-trained, overly busy, or predisposed to a negative attitude toward women who report chronic pain.  The latter observation aligns with many literature reports that pain symptoms in women are frequently dismissed by medical doctors as “hysterical.”

In the interests of a balanced assessment, it should also be noted that among 180 survey responders, 80 reported having seen a mental health professional for a problem that was separate from their existing medical issues. 51 of these were seen before their medical problems first presented.  In this sub-group, several patient narratives indicated that the mental health professional had played a positive role in treating anxiety or depression separately from medical issues.  Patient outcomes were generally more positive when the patient sought out professional assistance, than when they felt coerced into a mental health evaluation.

A psychiatric diagnosis of “psychogenic pain” may be entered into a patient record by either a medical or psychiatric professional.  MD Primary Care Providers frequently have little or no training in the psychiatric assessment of their patients, and may make such a diagnosis on the basis of less than 10 minutes consultation with the patient [Ref 10].

Compounding this lack of training, the diagnosis itself is controversial.  Like so-called “conversion hysteria”  or “functional neurological symptom disorder (conversion disorder)” in the recently issued 5th edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-5),  a diagnosis of psychogenic pain is founded upon claims by psychiatric professionals that  it is possible for a patient to “convert” emotional distress or depression into medically significant pain or other symptoms of physical distress and disability.   The problems with this model are  that (a) no biological mechanism has been identified by which it occurs, and (b) there is no body of systematically validated observational data to prove that the category of somatoform “disorders” even  exists as a valid medical entity [Ref 11,12].

An Alternative Model for Suicide Risk in Psychogenic Pain Diagnoses

Descriptions of possible factors in elevated suicide risk for psychogenic pain patients [Ref 6, extract above] are supported by the observations of chronic pain patients reporting their experience with psychiatric referral from medical doctors [Ref 9].  However, many patients would venture beyond the carefully limited observations of Dr Ilgen and his colleagues.  It is conceivable that suicide risk computed without adjustment for comorbid psychiatric disorders (depression, anxiety, etc.)  is a more accurate measure than when these disorders are assumed to be independent of psychogenic pain and discounted.  As noted above, over 95% of VHA patients with this diagnosis also have another chronic pain diagnosis.  Such a correlation is very high to occur only by chance.

From a patient-centered perspective, depression may not be independent of a diagnosis of psychogenic pain, but may  instead comprise an outgrowth of the diagnosis itself.   Chronic pain patients referred to mental health professionals frequently report increased personal distress, deeper depression and anxiety attending their having been told in essence that “your pain is all in your head”  by either the referring medical doctor,  the mental health professional, or both.   In agonizing pain, invalidated by their care-givers and severely impacted by limitations imposed by severe pain on daily life,  we should not wonder that such people are depressed.  Nor should professionals jump to the conclusion that the patient’s pain or other complex medical symptoms are “caused by” their past or present mental states.  Even where there is correlation,  correlation is not cause.

It is arguable that the diagnosis of “psychogenic pain” is at best an imprecise and unsupported hold-over from earlier invalidated notions of conversion hysteria propounded by Freud.  At worst, this diagnosis may be seen as a professionalized psychiatric delusional system that actively increases risk of suicide in patients to whom is it falsely applied.

Recommendations

  1. When a patient presents to either medical or mental health practitioners with chronic pain and deep emotional distress,  the least harmful assumption is that the pain has created the distress — not the other way around.
  2. Medical care givers who treat chronic pain patients should concentrate first on stabilizing the patient and validating their appropriate concerns.  While supportive counseling or  therapy may be helpful for both the chronic pain patient and their significant others, such therapy should be integrated with an ongoing investigation of physical  explanations for physical/medical symptoms.
  3. While some psychotropic medications (e.g. tri-cyclic anti-depressants — TCAs) are known to have a cross-action in moderating neuropathic pain, this action has not been proven to operate by reduction of depression itself.  Care should be taken to closely monitor patients treated with TCA medications for drug allergies and other dangerous side effects.

References

  1. American Academy of Pain Medicine “AAPM Facts and Figures on Pain”,  available online at http://www.painmed.org/patientcenter/facts_on_pain.aspx#refer , accessed June 11, 2013.
  2. Peter D. Hart Research Associates, “Americans Talk About Pain – A Survey Among Adults Nation-Wide,” August 2003.  Available online.
  3. Richard A. Lawhern, PhD, “Patients Are Making A Difference”  published online at http://www.livingwithtn.org/page/patients-making-a-difference,  March 2013
  4. Centers for Disease Control and Prevention, Web-based Injury Statistics Query and Reporting System: leading causes of death reports, http://www.cdc.gov/injury/wisquars/leading_causes_death.html, accessed August 1, 2012 (reported in Ref 1).
  5. NK Tang,  C Crane, “Suicidality in Chronic Pain:  a review of the risk factors, prevalence, and psychological links.” Psychol. Med: 2006;36(5):575-586
  6. Mark A. Ilgen, Felicia Kleinberg, Rosalinda V. Ignacio, Amy S.B. Bohnert, Marcia Valentine, John F. McCarthy, Frederick C. Blow, Ira C. Katz, “Noncancer Pain Conditions and Risk of Suicide” , JAMA Psychiatry, published online May 22, 2013, doi 10.1001/jamapsychiatry.2013.908
  7. Wikipedia,  “Comorbidity”  online at http://en.wikipedia.org/wiki/Comorbidity,  accessed June 11, 2011
  8. Allen Frances, MD, “The Medically Ill Speak For Themselves – and don’t want to be labeled as medically ill”, Saving Normal, blog on Psychology Today, April 5, 2013
  9. Richard A. Lawhern, Ph.D.  “In Their Own Words — Patients With Complex Medical Disorders Speak to the APA”,  March 15, 2013,  available online at http://www.livingwithtn.org/forum/topics/in-their-own-words-patients-with-complex-medical-disorders-speak
  10. Allen Frances, MD, Saving Normal,  Harper Collins, New York, 2013, pp 101-103
  11. Frances Creed, Arthur Barsky, “A Systematic Review of the Epidemiology of Somatization Disorder and Hypochondriasis” Journal of Psychosomatic Research 56 (2004)  391-408.
    On existing evidence, somatisation disorder and hypochondriasis cannot be regarded as definite psychiatric disorders. There is some evidence that numerous somatic symptoms or illness worry may be associated with impairment and high health care utilisation in a way that cannot be solely explained by concurrent anxiety and depression, but further research using population-based samples is required.
  12. Mark D Sullivan, “DSM-IV Pain Disorder: a case against the diagnosis”, International Review of Psychiatry (2000), 12, 91-98