Chronic, Noncancer Pain Boosts Suicide Risk – Fran Lowry – May 28, 2013
Though a bit older, this study found that pain is an important predictor of suicide risk – especially when it is diagnosed as “psychogenic pain”.
Previous research suggests that individuals with pain may be at increased risk for suicidal thoughts and behaviors, but it is likely that “not all pain is created equal” in terms of its association with suicide, and that the association between pain and suicide could vary, depending on the type of pain patients experience, Dr. Ilgen said.
The study was published online May 22, 2013 in JAMA Psychiatry. In the current study, the investigators sought to understand the degree to which specific pain conditions related to suicide risk.
The investigators also wanted to understand whether pain remained an important predictor of suicide, even after controlling for other mental health conditions that are associated with both pain and suicide risk.
The team looked at treatment records of all patients (n = 4,863,036) who were seen in the Veterans Health Administration system in fiscal year 2005 and who were alive at the start of fiscal year 2006.
They then examined the association between baseline clinical diagnoses of the following pain-related conditions:
- back pain,
- headache or tension headache,
- fibromyalgia, and
- psychogenic pain,
as well as the extent to which each of these conditions predicted risk for suicide in fiscal years 2006 to 2008
Arthritis was the most common diagnosis, occurring in 2,076,514 patients (42.7%), followed by back pain, in 1,111,187 (22.8%).
Psychogenic pain was the least frequent diagnosis, occurring 18,145 patients (0.4%). Suicide occurred in 4823 (0.01%) in the subsequent fiscal years.
After controlling for demographic and other factors, including age, sex, and Charlson score, the researchers found that except for arthritis and neuropathy, each pain condition was associated with an elevated risk for suicide.
- Psychogenic pain was associated with the greatest risk for suicide death (hazard ratio [HR], 2.61; 95% confidence interval [CI], 1.82 – 3.74).
The torment is worst when you are not believed, so it’s no wonder that “psychogenic” pain has the greatest suicide risk.
- Back pain was associated with a 33% increased risk for suicide death (HR, 1.33; 95% CI, 1.22 – 1.45),
- migraine with a 68% increased risk (HR, 1.68; 95% CI, 1.28 – 2.20),
- headache or tension headache with a 38% increased risk (HR, 1.38; 95% CI, 1.17 – 1.64), and
- fibromyalgia with a 45% increased risk (HR, 1.45; 95% CI, 1.16 – 1.81).
“Psychogenic pain is listed within the ICD-9 [International Classification of Diseases, Ninth Revision] coding system and characterizes pain that is caused by psychological instead of purely physical factors,” Dr. Ilgen explained.
“This is a diagnosis that is used relatively infrequently within the VA, and there is considerable disagreement among pain and mental health professionals about the validity and utility of this diagnosis,” he said.
Because of the type of data that were analyzed in this study, it is impossible to tell what treatment providers were thinking when they used the diagnosis of psychogenic pain, Dr. Ilgen added.
“Still, this diagnosis had the strongest association with suicide of any of the pain disorders that we examined.
It is my guess that a diagnosis of psychogenic pain is given to patients with pain that is poorly understood and that may be particularly difficult to treat.
In other words, the diagnosis of psychogenic pain is a cop-out, a junk diagnosis for pain that doctors don’t understand and believe to be mostly “in your head”.
When this subjective diagnosis is added to a patient’s medical record, all subsequent medical personnel see it and continue believing this patient does not have “real pain”.
Once this medical mindset is established there’s no escape for the patient, who can never prove it wrong because a subjective diagnosis, which is not based on verifiable facts but rather an opinion, cannot be refuted.
Also, there is the possibility that patients with this diagnosis are particularly frustrated with their care and hopeless about the resolution of their pain condition.
This is not much different from claiming your pain is caused by some “sin”. You know it’s not true but can never disprove it and, as long as doctors are pursuing that line of inquiry, they cannot possibly find the real problem.
I do not interpret our findings to indicate that ‘psychogenic pain,’ as it is defined in the ICD-9, is directly causing suicide, rather, that there is something about being diagnosed with this condition that is associated with a particularly poor prognosis.”
The poor prognosis is because the doctor has medically given up on this patient.
Sufferers are often stigmatized, because both medical professionals and the general public tend to think that pain from psychological source is not “real”. However, specialists consider that it is no less actual or hurtful than pain from other sources.
No matter how often they state that “it is no less actual or hurtful than pain from other sources”, there is still a huge difference between a diagnosis of a physical issue causing pain versus any involvement of a “mental issue”.
Diagnosing the source of pain as “in the mind” will affect all subsequent medical care. No one will continue investigating physical (and treatable) causes of your pain because they assume it’s a psychological problem.
This is a relief for doctors facing patients with chronic pain, which often has no clear physical cause, because it relieves them of the duty to keep medically treating physical pain they don’t understand.
It also means that they aren’t obligated to prescribe the strong pain relief opioids provide since opioids cannot treat psychological problems.
Until I was diagnosed with EDS, many doctors did not believe my pain was “real” because they could not find a physical cause. Luckily, I was not labeled with “psychogenic pain” because that would have stopped all efforts to treat it or continue seeking the very real physical cause.
I suspect that when patients with psychogenic pain insist on pursuing a more “real” and physical explanation for their pain, doctors simply assume this is part of their “psychogenic pain syndrome”. This kind of dismissal by doctors would certainly make a patient feel hopeless about ever getting help.
My eventual EDS diagnosis proved all those doctors were wrong.
There is much documentation of how EDS can lead to many different kinds of pain – none of them “psychogenic”.