Chronic pain is frequently associated with substantial psychosocial distress
Depression and anxiety are common. Catastrophizing is a cognitive disorder that is characterized by negative thinking, such as believing that the pain condition will never get better, and feelings of helplessness. Post-traumatic stress disorder (PTSD) is common among patients with past negative experiences, such as a traumatic injury, physical or psychological abuse. These patients may be candidate for a procedure that could provide pain relief, such as an injection or a nerve ablation.
Will a procedure be helpful or not?
A straightforward thought is that, by treating the pain with a procedure, the associated psychosocial distress will be reduced. For instance, depression may be the result of the ongoing pain; therefore, reducing the pain would reduce the depression. Such an improvement has been shown to occur, for instance after treatment of neck pain resulting from car accidents with a nerve ablation (see here).
On the other hand, distressed patients, compared with patients with stable psychosocial condition, are less likely to improve after a procedure, or may experience shorter-lasting pain relief.
These observations raise a question:
Why should a procedure work less well in patients with psychological disorders?
This question is difficult to answer because we do not understand sufficiently the pathophysiology. It is indeed challenging to study the processes underlying the interactions between psychological disorders and pain perception following a procedure, leaving us with relevant knowledge gaps and insufficient answers.
A crucial point is that procedures rarely abolish the pain. In most cases the pain is reduced but not eliminated, even after nerve ablations. Since some degree of pain will likely remain, the relevant question is how an individual reacts to still having pain. Here is where distress may make a difference. Pain intensity is not determined at a joint or nerve; rather, our brain determines the amount of pain. We know that distressed patients have a highly sensitized “pain system” resulting in overactivity of pain pathways, and consequently high levels of pain. The signal that still arrives from the site of pain to the central nervous system may be sufficient to keep the brain pathways overactive, potentially resulting in persisting high levels of pain. In other words, while the procedure will reduce the amount of signals arriving to the spinal cord, the overactive brain pathways will result in persisting high levels of pain.
Emotions and cognition are essential determinants of the pain experience. Persisting depression and insufficient copying strategies, among others, can substantially contribute to the perception of pain, despite successful reduction of the signals arising from the painful site. Pain is not merely the result of the "amount" of signals arising from a painful area, but of the interaction of such signals with emotion and cognition.
The lower chance of success of procedures raises several questions:
Should pain procedures be recommended at all in patients with psychosocial distress?
If so, does it matter how severe the psychosocial distress is?
Are different psychosocial disorders associated with different outcomes of pain procedures? For instance, is anxiety more concerning than depression, or is the opposite true?
While we do not have evidence-based answers to these questions, I believe that psychosocial distress is a relative, but not an absolute contraindication to procedures.
I proceed this way
I always assess the psychosocial status of patients.
The links between pain and psychosocial disorders are always part of the discussion with distressed patients. This can enormously help them understand that successful pain treatment is unlikely to rely only on blocking a signal arising from a painful area.
I discuss therapeutic options for the psychological disorder.
For patient under psychological treatment, I discuss options that have not been tried. For instance, many patients are treated with antidepressants, but have not addressed catastrophizing, have not tried cognitive-behavioral therapy, or mindfulness-based stress reduction.
I start psychological treatment possibly before offering a procedure, which is particularly important in severely distress patients. This plan is frequently in contract with patient’s expectation. Patients mostly want to proceed as soon as possible to interventional treatment, as they are very hopeful that the procedure will help them. I discuss that treatment of the psychosocial issues will maximize the chance of success of the procedure.
For patients who have exhausted treatment options for they psychological problem, I consider offering the procedure after evaluating the risk / benefit ratio and discussing with the patient the lower chances of success. In selected cases, I offer procedures also to severely distressed patients.
Finally, I do not offer procedures if I believe that this is not in the patient's best interest. This frequently leads to disappointment and occasionally anger (read more here). However, providing responsible care must always be our priority.
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