Psychogenic Pain and Iatrogenic Suicide – Global Summit on Diagnostic Alternatives – Richard Lawhern July 5, 2013
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.
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,
- tension headache,
- fibromyalgia and
- psychogenic pain,
as defined in the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM).
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.
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.”
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.
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.”
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
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.
(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.
Original article: Psychogenic Pain and Iatrogenic Suicide – by Richard Lawhern
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