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Chronic Pain and Traumatic Brain Injury

Chronic pain conditions are common sequelae of traumatic brain injury (TBI). Unfortunately, the incidence of TBI among personnel deployed for Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) is significant, and there is growing evidence that ongoing pain, particularly headaches, will be a primary concern for these individuals. In a recent paper published in Rehabilitation Psychology, the authors examined empirical data from civilian and veteran populations and clinical experience with OEF/OIF personnel with multiple traumas to provide recommendations for the assessment and treatment of chronic pain among those with TBI. The available data signal the need for the incorporation of early and aggressive pain management strategies into existing treatment models. Challenges to providing effective pain management for OEF/OIF veterans are numerous and include comorbid cognitive, medical, and emotional impairments that complicate readjustment to civilian life. It is likely that the problem of polytrauma pain and associated comorbid conditions such as posttraumatic stress disorder and postconcussive syndrome will require the development of integrated approaches to clinical care which bridge traditional subspecialty divisions.

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"Cruel and Unusual Abuse" Alleged in Prison Lawsuit

A former inmate at an Illinois super-maximum prison is alleging "cruel and unusual" punishment in his lawsuit against the prison and his former psychiatrist, Dr Rakesh Chandra.  In the case being heard before a federal jury, 35-year old Anthony Gay is claiming lingering trauma from the psychiatric treatment that he received from Dr. Chandra at Tamms Correctional Center.  The treatment often involved his being strapped naked to a metal bed frame for up to 32 hours at a time.  Gay is claiming that the abuse that he received is causing him to self-mutilate various parts of his body.  He maintains that he should have been treated with medication and therapy instead of the restrictive treatment that Dr. Chandra ordered.  Dr. Chandra and other staff have testified that Gay's clothing was removed to prevent him from hurting himself and that he often engaged in self-harm to manipulate staff members. 

Gay, who was initially sentenced in 1993 to seven years for robbery, later incurred nineteen other charges for various offenses including assaulting officers and possession of a weapon.  He is eligible for parole in 2095. 

Tamms Correctional Center is a 500-bed maximum security facility designed to house extremely violent and/or disruptive inmates. Opened in 1998, the prison was designed to meet constitutional challenges that have been faced in other jurisdictions, including the Federal Bureau of Prisons.   Inmates are locked down twenty-three hours a day, only move when shackled, and kept segregated from other inmates during recreation.  The use of solitary confinement in dealing with mentally ill prisoners has been cited as a human rights abuse by U.S. legislators such as Senator Dick Durbin.  In a recent meeting, Senator Durbin stated that, ""While in prison, many mentally ill prisoners have limited or no access to mental health services and their conditions deteriorate." 

The case is proceeding.  Governor Pat Quinn has ordered a review of the prison and its controversial restraint policy while state lawmakers are contemplating a prison reform bill.

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Does Knowing About Medical Treatment Affect Outcome?

Any medical treatment has 2 components, the first being the specific effects of the treatment itself, the second, the knowledge that the treatment is being performed (the placebo effect). So far, the placebo effect has been studied by eliminating the specific effects of the therapy through the administration of a dummy treatment. A recent issue of Prevention and Treatment outlines a study comparing the effectiveness of hidden medical treatment (lack of patient knowledge that the treatment was being  given)  and open treatment (full disclosure).   Using multiple patient samples (including Parkinson's disease, post-operation patients)  and a sample of healthy volunteers, all study participants were informed ahead of time that analgesic treatment either would or would not be administered and that they would not be informed as to their treatment status.  All experimental protocols were consistent with the Declaration of Helsinki.  Medications studied included morphine, diazepam, propranolol, and atropine.  Statistical analysis comparing open and hidden administration showed that the hidden administrations of pharmacological and nonpharmacological therapies are less effective than the open ones  across the range of medical populations studied for both pain and anxiety.   In particular, diazepam was found to be totally ineffective when covertly administered.  Overall, treatments appear more effective when they are openly carried out although it remains unclear whether this is de to expectation of treatment outcome or other confounding factors.  Perceived interruption of treatment (whether pain medication, diazepam, or subthalamic stimulation) also produces a more significant worsening of symptoms than a hidden interruption does.  The authors stress the need for a better understanding of the role of psychological factors  in medical treatment.

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Does Pain Increase Suicide Risk?

A study published in the December 2008 issue of the Journal of Pain examines the link between chronic pain and suicidal ideation and behaviour. Using the results from a nationwide US survey, self-report information from 5692 adult respondents was regarding pain conditions, nonpain medical conditions, and suicidal history. Additional information on DSM-IV mood, anxiety, and substance use disorders was obtained assessed using the World Health Organization's Composite International Diagnostic Interview. Antisocial and borderline personality traits were assessed with the International Personality Disorder Examination screening questionnaire. Statistical analysis of the results found the presence of any pain condition was associated with lifetime and suicidal ideation, plan, or attempt in the previous twelve months. After controlling for demographic, medical, and mental health covariates, the presence of any pain condition remained significantly associated with lifetime suicidal ideation and plan. Among pain subtypes, severe or frequent headaches and "other" chronic pain remained significantly associated with lifetime suicidal ideation and plan; "other" chronic pain was also associated with attempt. The researchers concluded that risk for suicidal thoughts and behaviors that may accompany back, neck, and joint pain can be accounted for by comorbid mental health disorders. There may be additional risk accompanying frequent headaches and "other" chronic pain that is secondary to psychosocial processes not captured by the mental disorders assessed.

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Do Socioeconomic Factors Predict Functional Disability in Chronic Pain Cases?

A study published in the November 2008 issue of Disability and Rehabilitation investigates whether socioeconomic status in patients with back pain helped predict functional disability. Using data from a national primary care trial of physical treatments for back pain (UKBEAM trial), 949 chronic pain patients were measured on Townsend scores (measuring economic deprivation), educational levels and work status adjusted for baseline variables. Roland Disability Questionnaire (RDQ) scores (measuring functional disability related to back pain) increased in relation to Townsend scores. Lower levels of educational attainment were also associated with higher RDQ scores. Those 'Not in Work' reported markedly higher levels of RDQ scores which increased over time. There was no evidence that one particular treatment was more suitable for participants of different socioeconomic status. The researchers concluded that the study findings add to existing research suggesting the importance of socioeconomic factors as an influence on health, including resultant disability related to chronic musculoskeletal conditions such as back pain. Work status was particularly dominant in their findings and may suggest that helping patients with back pain back to work where appropriate, is an especially important part of the management process.

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Does Suppressing Anger Affect Pain Sensitivity?

An article in the September 2008 issue of Health Psychology provides evidence linking anger inhibition or suppression and chronic pain severity. Based on ironic process theory, researchers have proposed that attempting to suppress suppress angry thoughts during when experiencing painful stimuli would increase subsequent pain intensity among chronic low back pain (CLBP) patients, due to paradoxically enhanced anger. Although previous research has indicated a link, these studies have focused on correlational data. Using an experimental model, a sample of 58 CLBP patients (N = 58) were assigned to suppression and nonsuppression conditions while performing a computer maze task with a harassing confederate. A structured pain behavior task (SPBT) followed. The subects were tested in terms of self-reported anger, estimated pain severity and observed on the experimental trials. The results showed that patients told to suppress during provocation: (a) reported greater anger following the maze task, reported greater pain intensity during the SPBT, and exhibited more pain behaviors than patients not suppressing; (b) postmaze anger levels significantly affected group differences on pain behaviors. The researchers concluded that attempts by CLBP patients to suppress anger may aggravate pain related to their clinical condition through ironically increased feelings of anger.

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Does Borderline Personality Disorder Affect Pain Sensitivity?

A research study published in the January 2008 issue of the World Journal of Biological Psychiatry compared pain sensitivity in patients with different psychiatric diagnoses under baseline and stress conditions. The study used a sample of 76 female subjects: 16 patients with borderline personality disorder (BPD), 16 patients with posttraumatic stress disorder (PTSD), 20 patients with bulimia nervosa and 24 healthy controls. Using a contact thermal probe, heat and cold pain thresholds were determined under baseline and stress conditions while mental stress was induced with a cognitive task (Paced Auditory Serial Addition Task). The results showed that pain thresholds in patients with BPD were significantly higher compared to healthy controls under baseline conditions. Patients with PTSD and bulimia nervosa did not show significant differences in pain thresholds compared to healthy controls. Under stress conditions, the difference between BPD patients and healthy controls became even more prominent, whereas the results in the other patient groups remained insignificant. The authors conclude that reduced pain sensitivity is a prominent feature of BPD, which may differentiate this disorder from other stress-related psychiatric conditions.

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Measuring Pain

An article published in the May 2008 issue of The Lancet features the results of a nationwide survey examining chronic pain in a representative sample of individuals across the USA. Using random-digit dialling, a stratified sample of 10,700 individuals were contacted and recruited for the study involving the collection of pain diary information for one 24-h period. Subjects were asked to rate pain on a 0-6 anchored scale for three randomly selected 15-min intervals. Activities of those individuals who reported substantial pain were also examined. Of the 3982 individuals who were interviewed (response rate 37%), 28.8% of men and 26.6% of women reported feeling some pain at the sampled times. Subjects with lower income or less education were found to spend a higher proportion of time in pain and reported higher average pain than did those with higher income or more education.  The average pain rating increased with age, although a plateau was found between the ages of about 45 years and 75 years, with little difference between men and women. Life and health satisfaction varied inversely with reported pain. The authors report that the telephone diary technique represents a promising method for assessing the prevalence of chronic pain and the factors that can interfere with successful coping.

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Chronic Pain in Elderly Patients

In the November 2007 issue of the International Journal of Geriatric Psychiatry, an article presents the result of a study examining chronic pain in depressed geriatric inpatients.  By examining the medical charts of patients who were admitted to a geriatric psychiatric unit over a two year period, 148 patients with a depressive disorder were identified. Of these depressed patients, 62% of patients were found to reports problems with chronic pain. Further analysis found that depressed older adults with chronic pain were more likely to report suicidal ideation, be diagnosed with personality disorder, have chronic care needs, and experience less total sleep time compared to depressed older adults without chronic pain. The results match those of previous studies identifying chronic pain as a possible suicide risk factor in the elderly, particularly when depression is involved.  : Chronic pain-common in depressed older adults-may influence clinical features of depression and should be assessed as a possible suicide risk factor. Prospective studies should examine causal relationships and determine the effects of adequate pain treatment on depression course and suicide risk in older adults.

Click here for the abstract   

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Chronic Pain Affects Short-term Memory and Attention

In the May 2007 issue of Anesthesia and Analgesia, a study examining the relationship between chronic pain and performance on neuropsychological measures of short-term memory and attention is presented.  A team of researchers at the University of Alberta administered a series of computerized measures of working (short-term) memory and attention to a sample of chronic pain patients.  Their results indicated that two-thirds of the chronic pain patients tested were found to be impaired on tests of working memory and attention.  Additional factors such as age, education level, disturbed sleep, and pain relief were ruled out as possible confounding factors.  Performance on the cognitive tests was not improved by short-term pain relief using analgesics.   The researchers conclude that chronic pain can directly affect cognitive performance which can, in turn, affect quality of life and level of functioning.    

Click here for the study abstract.