Pain, 4 (1977) 183-192 Elsevier/North-Holland
183
@
Biomedical
PAIN, DEPRESSION, POPULATION
AND ILLNESS
I. PILOWSKY,
C. RICHARD
Press
CHAPMAN
BEHAVIOR
IN A PAIN CLINIC
and JOHN J. BONICA
(I.P.) Department of Psychiatry, University of Adelaide, Adelaide 5000 (Australia), (C.R.C.) Departments of Anesthesiology, Psychiatry and Behavioral Sciences, Psychology, and Anesthesia Research Center, University of Washington School of Medicine, Seattle, Wash. 98195 and (J.J.B.) Department of Anesthesiology and Anesthesia Research Center, University of Washington School of Medicine, Seattle, Wash. 98195 (U.S.A.) (Accepted
March 7th, 1977)
SUMMARY
The relationship between depression, illness behavior and persistent pain was studied in 100 patients referred to the University of Washington Hospital Pain Clinic. The instruments used were the Illness Behavior Questionnaire (IBQ) and the Levine-Pilowsky Depression Questionnaire (LPD). To delineate those aspects of illness behavior characteristic of the Pain Clinic group, their scores were compared to those attained on the IBQ by a Family Medicine Clinic sample. The Pain Clinic group showed greater conviction of disease and somatic preoccupation than the comparison group. Further, they were reluctant to consider their health problems in psychologic terms, and denied current life problems. The Pain Clinic group’s performance on the LPD indicated a low degree of depressive affect overall and few patients manifesting a depressive syndrome. The association between IBQ and depression scores suggests that the predominant clinical pattern presented by pain clinic patients is best characterized as a form of “abnormal illness behavior”.
INTRODUCTION
Although considerable interest has been shown in the relationship between the behavior of chronic pain patients and depression [14] the precise nature of this association remains unclear. One source of confusion derives from a lack of clarity as to the meaning of the term “depression” when used in this context, since it may refer to either an “affect”, a symptom, or a syndrome. As an affect or feeling state, depression is a universal phenom-
184 enon
does not necessarily have pathological connotations. us a it may constitute one of the signs of a variety of somatic and psychological disorders. As a syndrome, however, it refers to a psychological disturbance characterized chiefly by a persistent depressive mood. Many attempts have been made to classify the depressive syndromes, and this literature has been extensively and lucidly reviewed by Becker [ 11. For all praytical purposes, the current situation may be summarized as follows: Most workers find the “reactive-neurotic” and “endogenous-psychotic” classification dichotomy a useful way to conceptualize depressive illness, especially as the two types respond to different treatments. While these two syndromes may overlap to some degree, it is generally possible to differentiate between them on the basis of certain attributes. The endogenous-psychotic form is typified by the patient who shows delusions of the depressive type (hypochondriacal, paranoid, nihilistic, selfdeprecatory) together with a characteristic constellation of “biological” disturbances, such as loss of appetite, early morning awakening, motor retardation, constipation, and loss of libido. The reactive-neurotic form does not show these features; rather it has a more obvious relationship to environmental precipitants, and is more responsive to the social setting in which the patient finds himself. Insomnia, for example, consists of difficulty in falling asleep rather than in early awakening, and appetite is often increased rather than decreased. A second source of confusion encountered by the investigator studying the relationship between depression and chronic pain behavior concerns the problem of assigning diagnostic or descriptive labels to behavioral patterns characteristically manifested by chronic pain patients. As Pilowsky [7] has noted, classifications such as hypochondriacal, hysterical, psychogenic, and functional are often used interchangeably to describe individuals in the illness role without a clear definition of meaning for each. He has suggested that the patient behavior to which such diagnoses are applied may be usefully conceptualized as abnormal forms of illness behavior. Mechanic and Volkart [4] have defined illness behavior as the ways in which individuals differentially evaluate, and react (or do not react) to sickness. In order to perceive, approach this issue more objectively, Pilowsky and Spence [ll] have behavior questionnaire” (IBQ) which generates an developed the “illness illness behavior profile along 7 factor-analytically derived scales. These scales tap attitudes toward illness, associated affective states, communication of affects, denial, and irritability. The illness behavior framework has been usefully applied to the st,udy of chronic pain patients by Pilowsky and Spence [ 121. Thus far the relevant literature suggests that no systematic attempt has been made to evaluate objectively both the degree and nature of depression in a chronic pain population and to relate this observation to the illness behavior of chronic pain patients. However, an association between abnormal forms of illness behavior (hypochondriacal ideas, persistent pain complaints, somatic preoccupation) and depression has repeatedly emerged in a SPPtOm,
which
185 number of studies based on other patient populations [ 2,6,15]. The purpose of this study is to examine depressive manifestations in a pain clinic population psychometrically, using a questionnaire developed to assess the amount of depression as well as the type of depressive illness [9,10] and to relate these findings to those obtained from the same patients with the IBQ [ll]. METHOD
Subjects The sample consisted of 100 patients, 73 women and 27 men, from the University of Washington Hospital Pain Clinic, who were tested over a 3-month period. All were referred patients with a persistent pain problem refractory to conventional therapy. The ages and durations of pain are presented for both men and women in Table I. Seventeen men and 61 women from the University Hospital Family Medicine Clinic served as a comparison group for the study. The mean age was 37.3 (S.D. = 13.3) for women and 41.5 (S.D. = 18.0) for men. No attempts were made to control medications of either patient group prior to testing. Testing instruments The Levine-PiIowsky depression (LPD) questionnaire [lo], a 57-item inventory, which requires yes-no answers, was administered to the sample of Pain Clinic patients only. The scores of the LPD scale range from 1 to 20; in addition the LPD allows the classification of patients into 3 groups: nonTABLE
I
AGE AND DURATION IC PATIENTS
OF
PAIN
PROBLEMS
FOR
MALE
AND
FEMALE
_ Men
Women
Total
Under 21 21-30 31-40 Al-50 5140 61-70 Over 70
1 12 14 22 17 5 2
2 16 19 29 21 10 3
Duration of pain problem Less than 6 months 6 months-l year l-2 years 2-3 years 3-5 years 5-l 0 years More than 10 years
1 10 11 7 10 9 25
3 11 14 10 18 11 33
Age
PAIN
CLIN-
186 endogenous (neurotic), endogenous (psychotic), and non-depressive syndromes [ 91. The IBQ, comprised of 62 yes-no items that inquire about symptoms and illness related problems {II J, was administered to both Pain Clinic and Family Medicine Clinic patients. This inventory yields a profile of scores on 7 subscales, which have been labeled: (1) general hypochondriasis (GH), (2) disease conviction with somatic preoccupation (DC), (3) psychological vs. somatic perception of illness (P-S), (4) affective inhibition (AI), (5) affective disturbance (AD), (6) denial (D), and (7) irritability (I). Procedure All patients were administered the testing inventories during visits to the Pain Clinic or the Family Medicine Clinic. The Pain Clinic patients completed the IBQ first and the LPD second during a single testing session. In addition to IBQ and LPD scores, the age, sex, marital status, pain duration, pain localization, and the medication usage of every Pain Clinic patient were recorded. Only sex and age data were recorded for Family Medicine patients. RESULTS
Depression in pain patients Scores on the LPD scale and the classification
TABLE
of patients
into reactive-
II
CLASSIFICATION BY SYNDROME AND SCORES ON THE DEPRESSION QUESTIONNAIRE FOR PAIN CLINIC PATIENTS -_.-~~~___ __~ -. ~~-EndogenousNeurotic-reactive Classification psychotic
Men Women Total Mean depression Men x SD.
0 4 4
“_._-_--.__--3 3 6
LEVINE-PILOWSKY
Non-depressive (do not have depressive syndrome)
- ._-24 66 90
scores
-
13.33 3.21
3.00
Women x S.D.
11.00 1.41
13.00 I.73
5.55 2.83
Total x S.D.
11.00 1.41
13.17 2.32
6.58 2.86
5.67
187 TABLE
III
COMPARISON OF CHIATRIC PATIENT Pain
Clinic
MEAN DEPRESSION POPULATIONS
SCORES
FOR
PAIN
PATIENT
PSY-
6.25
patients
Psychiatric patients (grouped Psychotic depression Psychosis with depression Non-depressed psychosis Neurotic depression Psychiatric patients Improved Much improved
AND
by admission
[9]) 14.20 10.80 10.00 12.10
on discharge
Psychiatric patients grouped Not depressed Slightly depressed Moderately depressed Severely depressed
diagnosis
from
Psych,
Hosp.
by psychiatrists’assessment
7.00 7.70 4.70
[IO]
of depressive
affect 5.20 8.70 10.60 12.30
[IO]
neurotic, endogenous-psychotic, and nondepressive subgroups are depicted in Table II according to sex differences. It is clear that only 10% of the patients manifest either a neurotic or a psychotic depressive syndrome, a relatively small proportion of this group. Table II also indicates that there are no noteworthy sex differences in depression scores. The lack of males in the small group of reactive-neurotic patients was possibly due to the relatively small sample of men. In Table III the mean depression scores for all pain patients (X = 6.25, S.D. = 3.45) is compared to mean scores for psychiatric patient populations. It is evident that the pain patients’ mean reflects only very minimal, if any, depression. Thus, while depressed pain patients are a significant minority that require appropriate management, they are a relatively small proportion of the population under investigation. Illness behavior assessment in pain clinic and family medicine patients In order to relate depression to illness behavior in pain patients, it is first necessary to identify the ways in which pain patients differ from other patient groups. Accordingly, data from a Family Medicine Clinic population were compared to those provided by the Pain Clinic patients. Fig. 1 provides a visual comparison of the two groups with the IBQ scale scores plotted as profiles. The differences between the profiles for the two groups were observed to be statistically significant when evaluated by a Hotelling T* multivariate test, TZ = 92.52, F(7,170) = 13.18, P< 0.001. In order to specify which individual scales contributed to the significant differences between the profiles, univariate analyses of covariance were applied to the individual comparisons
&
PAIN CLINIC
PATIENTS
A FAMILY MEDICINE
PATIENTS
I
2
3
GH
DC
P-S
4
5
6
7
Al
AD
0
I
Iw)-
Fig. 1. Comparison medicine patients.
TABLE
of
illness
behavior
questionnaire
profiles
of
pain
clinic
and
family
EACH
SCALE
IV
RESULTS OF UNIVARIATE ANALYSES THE IBQ PROFILE (age and sex as covariates) df = 1, 174
in each
OF
COVARIANCE
FOR
analysis,
Scale
F value for group difference
E’ value for effect of age
F value for effect of sex
1. General hypochondriasis 2. Disease conviction 3. Psychologic vs. somatic perception 4. Affective inhibition 5. Affective disturbance 6. Denial 7. Irritability
n.s. 28.71
n.s. n.s.
n.s. n.s.
* P < 0.05. *** P < 0.001.
52.25 n.s. n.s. 17.87 n.s.
*** ***
***
4.26 n.s. n.s. 17.38 n.s.
*
***
n.s. n.s. n.s. n.s. tl.S.
IN
189 at each of the 7 scales. Age and sex were employed as covariates in each case. Table IV lists the results of these tests. Pain patients showed greater conviction of disease and somatic preoccupation than did the comparison group (scale 2), and they were more reluctant to consider their problems in psychologic terms than were family medicine patients, preferring to focus on somatic distresses (scale 3). They also were significantly more likely to deny life problems not directly related to disease than the comparison group (scale 6). No sex differences were evident at any of the 7 scales, but age correlated significantly (r = -0.25, P < 0.001) with scale 3, indicating that older patients were more likely to perceive their problems as somatic disorders than were younger patients, who were more open to construing their difficulties in psychologic terms. Age also correlated significantly with scale 6 (denial), r = 0.36, P < 0.001. This implies that older patients were more prone to deny life stresses unrelated to illness than were younger patients. Relationship of depression scores to illness behavior While the depression assessed in most pain patients was minimal, a wide range of scores was observed in the group as a whole. It is useful to relate these scores to each of the 7 illness behavior scales provided by the IBQ. Table V lists these scales and the Pearson product moment correlation of depression with each scale. It is clear that general hypochondriasis and depression are positively related, with depressed individuals tending to be more hypochondriacal than other pain patients. Similarly, the more depressed pain patients are more likely to have a stronger conviction of disease and somatic preoccupation when ill than are others. Not surprisingly, scale 5, which reflects dysphoria (both anxiety and depression), correlated highly with depression and the more depressed pain patient is more likely to be irritable. These observations illustrate that certain salient dimensions of illness behavior covary positively with degree of depression in chronic pain patients. TABLE
V
RELATIONSHIP PAIN PATIENTS ___~~ Scale
OF DEPRESSION
SCORES
TO SCALES
Correlation
OF ILLNESS
BEHAVIOR
IN
with depression ~____
1. Genera1 hypochondriasis 2. Disease conviction 3. Psychologic vs. somatic perception of illness 4. Affective inhibition 5. Affective disturbance (dysphoria) 6. Denial 7. Irritability *** P < 0.001.
0.34 *** 0.40 *** 0.15 0.17 0.46 *** -0.17 0.41 ***
~~
~~~~
190 DISCUSSION
(1) Depression
The scores achieved by this group of pain patients on the LPD questionnaire indicate an overall level of depression affect which is, in general, substantially lower than that observed in populations of psychiatrically ill individuals. This finding is certainly in keeping with clinical experience. Thus, while certain Pain Clinic patients clearly demonstrate severe degrees of depression, no depression or a mild depression is most common. Furthermore, the LPD classification procedure reveals that, although an important minority of patients may be identified as endogenous-depressive, the majority fall into the “non-depressive syndrome” category. This finding underscores the importance on one hand of being alert to the presence of endogenous depression in chronic pain patients, and on the other, the danger of assuming that all patients with chronic pain should be treated on the assumption that their condition denotes the presence of this syndrome. This observation does not imply that antidepressants will not help chronic pain patients without endogenous depression, but it suggests that drug effectiveness may be essentially unrelated to the so-called antidepressant effect. (2) Illness behavior
The Pain Clinic patients differed from the Family Medicine Clinic sample in that they achieved significantly higher mean scores on scales 2, 3 and 6, indicating a greater degree of somatic preoccupation with disease conviction, somatic focusing, and a tendency to deny life problems unrelated to their physical problem. As a whole, therefore, the Pain Clinic patients emerge as manifesting abnormal illness behavior similar to that commonly designated “conversion-reaction” or “hypochondriacal reaction”. This finding supports the work of Merskey [ 53 and Pilowsky and Spence [ 131. The relationship between the IBQ scale scores and the LPD depression scores in the Pain Clinic population is interesting. To the extent that depression is present in these patients, it is significantly associated with hypochondriasis, disease conviction, dysphoria, and irritability with others. To a considerable degreee, this constellation resembles “Factor Pattern C” patients, who were described by Grinker and his coworkers [3 ] as follows: “The striking aspect of this patient is the low loading on dismal and hopeless affect in contrast to the active irrational complaining attitudes. This is the picture of the hypochondriac, where attention is diverted to his own body although seemingly rationalized by some observable somatic manifestations. Many of these know of their illness before it is discovered, too late. They seem to benefit, but only temporarily, from support, reassurance, and drugs. Electric shock therapy often worsens the condition.” Similarly, other factor analytic studies by a number of investigators have also generated factors described as “hypochondriacal” [2] or “abnormal preoccupation with physical health” [6]. Friedman’s hypochondriacal type is germane to the present study. This “type” is described as querulous, self-
191 preoccupied, demanding, and irritable, with marked body consciousness and many physical complaints. The repeated emergence of this cluster reflects the fact that patients of this type may be encountered in many settings and labeled in various ways. It has been previously suggested [7] that “abnormal illness behavior” is the maladaptive coping style that such individuals have in common. The present findings suggest particularly that this term may be useful in classifying this group of patients, since illness behavior concepts are more amenable to investigation in operational terms than such notoriously vague and ill defined labels as “hysterical conversion” and “hypochondriasis” [ 121. Since these patients present with a complex array of physical and psychological problems, it is often quite possible for only one aspect of their disturbance to receive attention. The nature of the difficulty, however, makes a total psychological, social, and somatic evaluation mandatory and emphasizes the need for collaborative interdisciplinary efforts in the management of chronic pain [8]. ACKNOWLEDGEMENTS
We thank Dr. Regina Puryear for assisting in the collection of data from family medicine patients and Ms. Yoko Hiraga for her efforts in data collection and analysis. We are also indebted to Dr. Donald Martin for his assistance in data analysis. Supported in part by USPHS Grant GM15991 from the National Institutes of Health and MB00184 from the HEW Health Resources Administrative Grant. REFERENCES 1 Becker, J., Depression: Theory and Research, Winston and Sons, Washington, D.C., 1974. 2 Friedman, AS., Cowitz, B., Cowen, H.W. and Gramick, S., Syndromes and themes of psychiatric depression, Arch. gen. Psychiat., 9 (1963) 504. 3 Grinker, R.R., Miller, J.B., Sabshin, M., Nunn, R. and Nunnally, J.C., The Phenomena of Depressions, Harper and Row, New York, 1961. 4 Mechanic, D. and Volkart, E.H., Illness behavior and medical diagnosis, J. Hlth Hum. Behav., 1 (1960) 86-90. 5 Merskey, H., Psychiatric patients with persistent pain, J. Psychosom. Res., 9 (1965) 299-309. 6 Overall, J.D., Hollister, L.E., Johnson, M. and Pennington, V., Nosology of depression and differential response to drugs, J. Amer. med. Ass., 195 (1966) 946-950. 7 Pilowsky, I., Abnormal illness behavior, Brit. J. med. Psychol., 42 (1969) 347-361. 8 Pilowsky, I., The psychiatrist and the pain clinic, Amer. J. Psychiat., 133 (1976) 752-756. 9 Pilowsky, I., Levine, S. and Boulton, D.M., The classification of depression by numerical taxonomy, Brit. J. Psychiat., 115 (1969) 937-945. 10 Pilowsky, I. and Spalding, D., A method of measuring depression, Brit. J. Psychiat., 121 (1972) 411-416. 11 Pilowsky, I. and Spence, N.D., Patterns of illness behaviour in patients with intractable pain, J. Psychosom. Res., 19 (1975) 279-287.
192 I:! 13 11 I5
Pilowsky, I. and Spc>ncc, N.D., Pain and illnc~ss behavior: a comparatives study. J. Psychosom. KS., 20 (1976) 131 -13.1. Pilowsky, I. and Spence. N.D., Illness behavior syndromes associated with intractable pain, Pain, 2 (1976) 61--71. Traits and Treatments, Academic Press. New York, Sternbach, R.A.. Pain Patients 1974 Watts, C.A.H., Depressive Disorders in the Community, Wright. Bristol. 1966.
183
@
Biomedical
PAIN, DEPRESSION, POPULATION
AND ILLNESS
I. PILOWSKY,
C. RICHARD
Press
CHAPMAN
BEHAVIOR
IN A PAIN CLINIC
and JOHN J. BONICA
(I.P.) Department of Psychiatry, University of Adelaide, Adelaide 5000 (Australia), (C.R.C.) Departments of Anesthesiology, Psychiatry and Behavioral Sciences, Psychology, and Anesthesia Research Center, University of Washington School of Medicine, Seattle, Wash. 98195 and (J.J.B.) Department of Anesthesiology and Anesthesia Research Center, University of Washington School of Medicine, Seattle, Wash. 98195 (U.S.A.) (Accepted
March 7th, 1977)
SUMMARY
The relationship between depression, illness behavior and persistent pain was studied in 100 patients referred to the University of Washington Hospital Pain Clinic. The instruments used were the Illness Behavior Questionnaire (IBQ) and the Levine-Pilowsky Depression Questionnaire (LPD). To delineate those aspects of illness behavior characteristic of the Pain Clinic group, their scores were compared to those attained on the IBQ by a Family Medicine Clinic sample. The Pain Clinic group showed greater conviction of disease and somatic preoccupation than the comparison group. Further, they were reluctant to consider their health problems in psychologic terms, and denied current life problems. The Pain Clinic group’s performance on the LPD indicated a low degree of depressive affect overall and few patients manifesting a depressive syndrome. The association between IBQ and depression scores suggests that the predominant clinical pattern presented by pain clinic patients is best characterized as a form of “abnormal illness behavior”.
INTRODUCTION
Although considerable interest has been shown in the relationship between the behavior of chronic pain patients and depression [14] the precise nature of this association remains unclear. One source of confusion derives from a lack of clarity as to the meaning of the term “depression” when used in this context, since it may refer to either an “affect”, a symptom, or a syndrome. As an affect or feeling state, depression is a universal phenom-
184 enon
does not necessarily have pathological connotations. us a it may constitute one of the signs of a variety of somatic and psychological disorders. As a syndrome, however, it refers to a psychological disturbance characterized chiefly by a persistent depressive mood. Many attempts have been made to classify the depressive syndromes, and this literature has been extensively and lucidly reviewed by Becker [ 11. For all praytical purposes, the current situation may be summarized as follows: Most workers find the “reactive-neurotic” and “endogenous-psychotic” classification dichotomy a useful way to conceptualize depressive illness, especially as the two types respond to different treatments. While these two syndromes may overlap to some degree, it is generally possible to differentiate between them on the basis of certain attributes. The endogenous-psychotic form is typified by the patient who shows delusions of the depressive type (hypochondriacal, paranoid, nihilistic, selfdeprecatory) together with a characteristic constellation of “biological” disturbances, such as loss of appetite, early morning awakening, motor retardation, constipation, and loss of libido. The reactive-neurotic form does not show these features; rather it has a more obvious relationship to environmental precipitants, and is more responsive to the social setting in which the patient finds himself. Insomnia, for example, consists of difficulty in falling asleep rather than in early awakening, and appetite is often increased rather than decreased. A second source of confusion encountered by the investigator studying the relationship between depression and chronic pain behavior concerns the problem of assigning diagnostic or descriptive labels to behavioral patterns characteristically manifested by chronic pain patients. As Pilowsky [7] has noted, classifications such as hypochondriacal, hysterical, psychogenic, and functional are often used interchangeably to describe individuals in the illness role without a clear definition of meaning for each. He has suggested that the patient behavior to which such diagnoses are applied may be usefully conceptualized as abnormal forms of illness behavior. Mechanic and Volkart [4] have defined illness behavior as the ways in which individuals differentially evaluate, and react (or do not react) to sickness. In order to perceive, approach this issue more objectively, Pilowsky and Spence [ll] have behavior questionnaire” (IBQ) which generates an developed the “illness illness behavior profile along 7 factor-analytically derived scales. These scales tap attitudes toward illness, associated affective states, communication of affects, denial, and irritability. The illness behavior framework has been usefully applied to the st,udy of chronic pain patients by Pilowsky and Spence [ 121. Thus far the relevant literature suggests that no systematic attempt has been made to evaluate objectively both the degree and nature of depression in a chronic pain population and to relate this observation to the illness behavior of chronic pain patients. However, an association between abnormal forms of illness behavior (hypochondriacal ideas, persistent pain complaints, somatic preoccupation) and depression has repeatedly emerged in a SPPtOm,
which
185 number of studies based on other patient populations [ 2,6,15]. The purpose of this study is to examine depressive manifestations in a pain clinic population psychometrically, using a questionnaire developed to assess the amount of depression as well as the type of depressive illness [9,10] and to relate these findings to those obtained from the same patients with the IBQ [ll]. METHOD
Subjects The sample consisted of 100 patients, 73 women and 27 men, from the University of Washington Hospital Pain Clinic, who were tested over a 3-month period. All were referred patients with a persistent pain problem refractory to conventional therapy. The ages and durations of pain are presented for both men and women in Table I. Seventeen men and 61 women from the University Hospital Family Medicine Clinic served as a comparison group for the study. The mean age was 37.3 (S.D. = 13.3) for women and 41.5 (S.D. = 18.0) for men. No attempts were made to control medications of either patient group prior to testing. Testing instruments The Levine-PiIowsky depression (LPD) questionnaire [lo], a 57-item inventory, which requires yes-no answers, was administered to the sample of Pain Clinic patients only. The scores of the LPD scale range from 1 to 20; in addition the LPD allows the classification of patients into 3 groups: nonTABLE
I
AGE AND DURATION IC PATIENTS
OF
PAIN
PROBLEMS
FOR
MALE
AND
FEMALE
_ Men
Women
Total
Under 21 21-30 31-40 Al-50 5140 61-70 Over 70
1 12 14 22 17 5 2
2 16 19 29 21 10 3
Duration of pain problem Less than 6 months 6 months-l year l-2 years 2-3 years 3-5 years 5-l 0 years More than 10 years
1 10 11 7 10 9 25
3 11 14 10 18 11 33
Age
PAIN
CLIN-
186 endogenous (neurotic), endogenous (psychotic), and non-depressive syndromes [ 91. The IBQ, comprised of 62 yes-no items that inquire about symptoms and illness related problems {II J, was administered to both Pain Clinic and Family Medicine Clinic patients. This inventory yields a profile of scores on 7 subscales, which have been labeled: (1) general hypochondriasis (GH), (2) disease conviction with somatic preoccupation (DC), (3) psychological vs. somatic perception of illness (P-S), (4) affective inhibition (AI), (5) affective disturbance (AD), (6) denial (D), and (7) irritability (I). Procedure All patients were administered the testing inventories during visits to the Pain Clinic or the Family Medicine Clinic. The Pain Clinic patients completed the IBQ first and the LPD second during a single testing session. In addition to IBQ and LPD scores, the age, sex, marital status, pain duration, pain localization, and the medication usage of every Pain Clinic patient were recorded. Only sex and age data were recorded for Family Medicine patients. RESULTS
Depression in pain patients Scores on the LPD scale and the classification
TABLE
of patients
into reactive-
II
CLASSIFICATION BY SYNDROME AND SCORES ON THE DEPRESSION QUESTIONNAIRE FOR PAIN CLINIC PATIENTS -_.-~~~___ __~ -. ~~-EndogenousNeurotic-reactive Classification psychotic
Men Women Total Mean depression Men x SD.
0 4 4
“_._-_--.__--3 3 6
LEVINE-PILOWSKY
Non-depressive (do not have depressive syndrome)
- ._-24 66 90
scores
-
13.33 3.21
3.00
Women x S.D.
11.00 1.41
13.00 I.73
5.55 2.83
Total x S.D.
11.00 1.41
13.17 2.32
6.58 2.86
5.67
187 TABLE
III
COMPARISON OF CHIATRIC PATIENT Pain
Clinic
MEAN DEPRESSION POPULATIONS
SCORES
FOR
PAIN
PATIENT
PSY-
6.25
patients
Psychiatric patients (grouped Psychotic depression Psychosis with depression Non-depressed psychosis Neurotic depression Psychiatric patients Improved Much improved
AND
by admission
[9]) 14.20 10.80 10.00 12.10
on discharge
Psychiatric patients grouped Not depressed Slightly depressed Moderately depressed Severely depressed
diagnosis
from
Psych,
Hosp.
by psychiatrists’assessment
7.00 7.70 4.70
[IO]
of depressive
affect 5.20 8.70 10.60 12.30
[IO]
neurotic, endogenous-psychotic, and nondepressive subgroups are depicted in Table II according to sex differences. It is clear that only 10% of the patients manifest either a neurotic or a psychotic depressive syndrome, a relatively small proportion of this group. Table II also indicates that there are no noteworthy sex differences in depression scores. The lack of males in the small group of reactive-neurotic patients was possibly due to the relatively small sample of men. In Table III the mean depression scores for all pain patients (X = 6.25, S.D. = 3.45) is compared to mean scores for psychiatric patient populations. It is evident that the pain patients’ mean reflects only very minimal, if any, depression. Thus, while depressed pain patients are a significant minority that require appropriate management, they are a relatively small proportion of the population under investigation. Illness behavior assessment in pain clinic and family medicine patients In order to relate depression to illness behavior in pain patients, it is first necessary to identify the ways in which pain patients differ from other patient groups. Accordingly, data from a Family Medicine Clinic population were compared to those provided by the Pain Clinic patients. Fig. 1 provides a visual comparison of the two groups with the IBQ scale scores plotted as profiles. The differences between the profiles for the two groups were observed to be statistically significant when evaluated by a Hotelling T* multivariate test, TZ = 92.52, F(7,170) = 13.18, P< 0.001. In order to specify which individual scales contributed to the significant differences between the profiles, univariate analyses of covariance were applied to the individual comparisons
&
PAIN CLINIC
PATIENTS
A FAMILY MEDICINE
PATIENTS
I
2
3
GH
DC
P-S
4
5
6
7
Al
AD
0
I
Iw)-
Fig. 1. Comparison medicine patients.
TABLE
of
illness
behavior
questionnaire
profiles
of
pain
clinic
and
family
EACH
SCALE
IV
RESULTS OF UNIVARIATE ANALYSES THE IBQ PROFILE (age and sex as covariates) df = 1, 174
in each
OF
COVARIANCE
FOR
analysis,
Scale
F value for group difference
E’ value for effect of age
F value for effect of sex
1. General hypochondriasis 2. Disease conviction 3. Psychologic vs. somatic perception 4. Affective inhibition 5. Affective disturbance 6. Denial 7. Irritability
n.s. 28.71
n.s. n.s.
n.s. n.s.
* P < 0.05. *** P < 0.001.
52.25 n.s. n.s. 17.87 n.s.
*** ***
***
4.26 n.s. n.s. 17.38 n.s.
*
***
n.s. n.s. n.s. n.s. tl.S.
IN
189 at each of the 7 scales. Age and sex were employed as covariates in each case. Table IV lists the results of these tests. Pain patients showed greater conviction of disease and somatic preoccupation than did the comparison group (scale 2), and they were more reluctant to consider their problems in psychologic terms than were family medicine patients, preferring to focus on somatic distresses (scale 3). They also were significantly more likely to deny life problems not directly related to disease than the comparison group (scale 6). No sex differences were evident at any of the 7 scales, but age correlated significantly (r = -0.25, P < 0.001) with scale 3, indicating that older patients were more likely to perceive their problems as somatic disorders than were younger patients, who were more open to construing their difficulties in psychologic terms. Age also correlated significantly with scale 6 (denial), r = 0.36, P < 0.001. This implies that older patients were more prone to deny life stresses unrelated to illness than were younger patients. Relationship of depression scores to illness behavior While the depression assessed in most pain patients was minimal, a wide range of scores was observed in the group as a whole. It is useful to relate these scores to each of the 7 illness behavior scales provided by the IBQ. Table V lists these scales and the Pearson product moment correlation of depression with each scale. It is clear that general hypochondriasis and depression are positively related, with depressed individuals tending to be more hypochondriacal than other pain patients. Similarly, the more depressed pain patients are more likely to have a stronger conviction of disease and somatic preoccupation when ill than are others. Not surprisingly, scale 5, which reflects dysphoria (both anxiety and depression), correlated highly with depression and the more depressed pain patient is more likely to be irritable. These observations illustrate that certain salient dimensions of illness behavior covary positively with degree of depression in chronic pain patients. TABLE
V
RELATIONSHIP PAIN PATIENTS ___~~ Scale
OF DEPRESSION
SCORES
TO SCALES
Correlation
OF ILLNESS
BEHAVIOR
IN
with depression ~____
1. Genera1 hypochondriasis 2. Disease conviction 3. Psychologic vs. somatic perception of illness 4. Affective inhibition 5. Affective disturbance (dysphoria) 6. Denial 7. Irritability *** P < 0.001.
0.34 *** 0.40 *** 0.15 0.17 0.46 *** -0.17 0.41 ***
~~
~~~~
190 DISCUSSION
(1) Depression
The scores achieved by this group of pain patients on the LPD questionnaire indicate an overall level of depression affect which is, in general, substantially lower than that observed in populations of psychiatrically ill individuals. This finding is certainly in keeping with clinical experience. Thus, while certain Pain Clinic patients clearly demonstrate severe degrees of depression, no depression or a mild depression is most common. Furthermore, the LPD classification procedure reveals that, although an important minority of patients may be identified as endogenous-depressive, the majority fall into the “non-depressive syndrome” category. This finding underscores the importance on one hand of being alert to the presence of endogenous depression in chronic pain patients, and on the other, the danger of assuming that all patients with chronic pain should be treated on the assumption that their condition denotes the presence of this syndrome. This observation does not imply that antidepressants will not help chronic pain patients without endogenous depression, but it suggests that drug effectiveness may be essentially unrelated to the so-called antidepressant effect. (2) Illness behavior
The Pain Clinic patients differed from the Family Medicine Clinic sample in that they achieved significantly higher mean scores on scales 2, 3 and 6, indicating a greater degree of somatic preoccupation with disease conviction, somatic focusing, and a tendency to deny life problems unrelated to their physical problem. As a whole, therefore, the Pain Clinic patients emerge as manifesting abnormal illness behavior similar to that commonly designated “conversion-reaction” or “hypochondriacal reaction”. This finding supports the work of Merskey [ 53 and Pilowsky and Spence [ 131. The relationship between the IBQ scale scores and the LPD depression scores in the Pain Clinic population is interesting. To the extent that depression is present in these patients, it is significantly associated with hypochondriasis, disease conviction, dysphoria, and irritability with others. To a considerable degreee, this constellation resembles “Factor Pattern C” patients, who were described by Grinker and his coworkers [3 ] as follows: “The striking aspect of this patient is the low loading on dismal and hopeless affect in contrast to the active irrational complaining attitudes. This is the picture of the hypochondriac, where attention is diverted to his own body although seemingly rationalized by some observable somatic manifestations. Many of these know of their illness before it is discovered, too late. They seem to benefit, but only temporarily, from support, reassurance, and drugs. Electric shock therapy often worsens the condition.” Similarly, other factor analytic studies by a number of investigators have also generated factors described as “hypochondriacal” [2] or “abnormal preoccupation with physical health” [6]. Friedman’s hypochondriacal type is germane to the present study. This “type” is described as querulous, self-
191 preoccupied, demanding, and irritable, with marked body consciousness and many physical complaints. The repeated emergence of this cluster reflects the fact that patients of this type may be encountered in many settings and labeled in various ways. It has been previously suggested [7] that “abnormal illness behavior” is the maladaptive coping style that such individuals have in common. The present findings suggest particularly that this term may be useful in classifying this group of patients, since illness behavior concepts are more amenable to investigation in operational terms than such notoriously vague and ill defined labels as “hysterical conversion” and “hypochondriasis” [ 121. Since these patients present with a complex array of physical and psychological problems, it is often quite possible for only one aspect of their disturbance to receive attention. The nature of the difficulty, however, makes a total psychological, social, and somatic evaluation mandatory and emphasizes the need for collaborative interdisciplinary efforts in the management of chronic pain [8]. ACKNOWLEDGEMENTS
We thank Dr. Regina Puryear for assisting in the collection of data from family medicine patients and Ms. Yoko Hiraga for her efforts in data collection and analysis. We are also indebted to Dr. Donald Martin for his assistance in data analysis. Supported in part by USPHS Grant GM15991 from the National Institutes of Health and MB00184 from the HEW Health Resources Administrative Grant. REFERENCES 1 Becker, J., Depression: Theory and Research, Winston and Sons, Washington, D.C., 1974. 2 Friedman, AS., Cowitz, B., Cowen, H.W. and Gramick, S., Syndromes and themes of psychiatric depression, Arch. gen. Psychiat., 9 (1963) 504. 3 Grinker, R.R., Miller, J.B., Sabshin, M., Nunn, R. and Nunnally, J.C., The Phenomena of Depressions, Harper and Row, New York, 1961. 4 Mechanic, D. and Volkart, E.H., Illness behavior and medical diagnosis, J. Hlth Hum. Behav., 1 (1960) 86-90. 5 Merskey, H., Psychiatric patients with persistent pain, J. Psychosom. Res., 9 (1965) 299-309. 6 Overall, J.D., Hollister, L.E., Johnson, M. and Pennington, V., Nosology of depression and differential response to drugs, J. Amer. med. Ass., 195 (1966) 946-950. 7 Pilowsky, I., Abnormal illness behavior, Brit. J. med. Psychol., 42 (1969) 347-361. 8 Pilowsky, I., The psychiatrist and the pain clinic, Amer. J. Psychiat., 133 (1976) 752-756. 9 Pilowsky, I., Levine, S. and Boulton, D.M., The classification of depression by numerical taxonomy, Brit. J. Psychiat., 115 (1969) 937-945. 10 Pilowsky, I. and Spalding, D., A method of measuring depression, Brit. J. Psychiat., 121 (1972) 411-416. 11 Pilowsky, I. and Spence, N.D., Patterns of illness behaviour in patients with intractable pain, J. Psychosom. Res., 19 (1975) 279-287.
192 I:! 13 11 I5
Pilowsky, I. and Spc>ncc, N.D., Pain and illnc~ss behavior: a comparatives study. J. Psychosom. KS., 20 (1976) 131 -13.1. Pilowsky, I. and Spence. N.D., Illness behavior syndromes associated with intractable pain, Pain, 2 (1976) 61--71. Traits and Treatments, Academic Press. New York, Sternbach, R.A.. Pain Patients 1974 Watts, C.A.H., Depressive Disorders in the Community, Wright. Bristol. 1966.
