161
Pain, 40 (1990) 161-170 Elsevier
PAIN 01529
Psychological defence mechanisms in patients with pain Elisabeth Tauschke a, Harold Merskey avband Edward Helmes b uDep.ofResearch, London Psychiatric Hospital, London, Ont. {Canada), and
’ Dept. of Psychiatry, University of Western Ontario,
Landon, Ont. (Canada) (Received
25 April 1989, revision received 28 July 1989, accepted
17 August
1989)
There is a long standing position that pain, and especially chronic pain, may arise from psychological mechanisms of SUrn~ defenee. We have compared a group of chronic pain patients with a sample of psychiatric patients attending for reasons other than pain. The pain group had less evidence of poor care in childhood (measured by the Parental Bonding Instrument) and tended to use more mature psychological defence mechanisms (assessed with the Defense Mechanisms Inventory), compared with the other group. The pain group also had fewer current psychiatric diagnoses but more evidence of anxiety and depression on the Hospital Anxiety and Depression Scale. We conclude that in general the patients with chronic pain had more normal childhoods and more mature defences than the psychiatric control group. They showed an increase in the diagnosis of depression, attributable to reactive factors. In the sample of patients with pain the majority of the psycholo~cal change cannot be attributed to the operation of primitive psychological defences. Key words: Chronic
pain;
Psychological
mechanisms;
Defence
Psychiatric diagnosis and psychological explanations The relationship between psychological factors and pain is a continuing matter of interest. Freud saw pain as the result of a conversion neurosis, serving as a compromise between the fulfilling of a forbidden wish and its punishment [15]. He offered both a diagnosis (conversion hysteria) and a dynamic explanation of its production. The literature has regularly followed this pattern. Most authors have attempted first to define the psychiatric diagnoses with which pain is associated and then to identify the mental mechanisms which may generate pain as a bodily symptom [30]. The
Correspondence to: H. Merskey, D.M., Department of Research, London Psychiatric Hospital, 850 Highbury Avenue, P.O. Box 2532, London, Ont. N6A 4H1, Canada. 03043959/90/$03.50
0 1990 Elsevier Science Publishers
majority have described pain as a conversion neurosis, a hypochondriacal reaction or a form of depression [28,23,40]. One of the first systematic studies on a series of patients came from Engel [12,13] who diagnosed most of his cases as hysteria or h~~hond~asis. He described characteristic features in patients suffering chronic pain: a history of suffering, defeat, neglect and abuse in their childhood that resulted in the prominence of guilt and a strong aggressive drive that is not fulfilled; the experience of pain taking the place of emotion, a location of pain determined by unconscious identification with a love object; and the development of pain upon loss or threatened loss. Engel’s portrayal of the ‘pain-prone’ patient had a strong influence on subsequent research. Merskey [25] found that resentment was much commoner in patients with pain than in those without. The communicative function of pain was
B.V. (Biomedical
Division)
162
also evident in patients with lower intelhgence and education, but Spear [44] found no increased association with either hostility or covert aggression in patients with pain. Thus the description of patients by Engel was only confirmed in part. There is very little other work which is methodologically satisfactory and which would support Engel’s concept [e.g.. see 4,481. The second prominent diagnosis in research on pain and psychological factors is depression [40]. Of all psychological patterns, depression seems to have the strongest association with pain, yet the nature of a causal relationship between chronic pain and depression remains unsettled. Again methodological difficulties prevent definite conclusions. Pain is the most common complaint in medicine [3] and apart from substance abuse, depression and anxiety are the most common psychiatric disorders in the general population [31]. Their prevalence contributes to the strong link found between them and pain and makes the matter difficult to disentangle. In the theories of Freud and Engel, for both depression and pain, the concept of aggression directed inwards is a key psychodynamic explanation. However, Von Knorring [.50] pointed out that systematic studies on this theory have been contradictory for depression. It is more so for pain. Hypotheses on the relationship between pain and depression vary from regarding pain as an equivalent of a depressive disorder j6] or as a masked depression 121,221, to proposing that they are psycholo~cally independent but share common physiological or biological mechanisms [52]. Some claim the same psychological factors for the development of pain and depression [51,52]. When a physical explanation for pain has not been found, a psychological cause is often proposed for the pain without supporting psychological evidence [27]. However, research which focussed on the effects of a chronic painful illness on the life and personality of the patient suggested that depression was mainly a consequence of the painful condition [45,55]. Benjamin et al. [4] found that distinguis~ng between painful conditions caused by physical lesions and others did not seem to show whether psychological factors, especially
depression, were primary or secondary to pain. 1n their sample, patients without a physical lesion showed significantly lower ratings for severity 01 psychological problems than patients with physical lesions and the authors concluded that pain patients cannot be divided into a simple dichotomy of those with physical or mental illness. Two recent studies investigating children suffering from migraine found a negative and stressful impact of a painful condition on the personality and mood of the children [ 1.91. The family background has been said to affect the relationship between depression and pain. As we have noted above, Engel [13] suggested similar psychodynamic mechanisms for pain and depression. His description of the family background of pain patients resembles that of many depressed patients. But although it is widely held that the family plays an important role in the health of its members, the exact relationship with pain is far from being resolved. Pilowsky et al. [38] showed that childho~~d hospitalization could contribute both to depressive illness and to intractable pain in adults. Preschool admission to hospital had occurred more often in depressed patients than in a rheumatology group. Later childhood admission was more common in :I pain clinic group. There have been two extensive reviews on the association between pain and families - the families of origin as well as the family in which the patient is currently living [36,48]. Although Payne and Norfleet find some hints supporting Engel’s theory, they state that empirical evidence is lacking. Turk and his colleagues in their more recent review came to the conclusion that for almost all related questions there has been much interesting hypothesizing but very little empirical study and support. Many of the difficulties arose from the problem that all studies were retrospective, and the transformation of a correlation into a causal relationship has been mostly a matter of interpretation. Further, few studies made adequate allowance, or indeed any allowance, for the influence of selection in patients with pain f26J. Crook and Tunks [8] provide a notable exception in the examination of patients from pain clinics and the community, but adequate control studies
163
of families are few in number or slight in quantity. Merskey et al. [29] found that pain patients did not seem to have significantly different childhood experiences from patients in general practice, whether their pain was mostly physical in origin or whether there was no obvious physical explanation of the pain experience. However, general practice populations are themselves selected and there is some modest evidence that patients with pain and no lesions have more difficult parents than patients with lesions [28].
Defence mechanisms
Defence mechanisms are unconscious mechanisms that are supposed to protect against external and internal stressors [14]. They might be a help in clarifying some of the confusions between psycholo~cal factors, especially childhood experience and depression, and the experience of pain. For example, it might be postulated that pain associated with lesions will manifest different defence mechanisms from pain without lesions. In a related study, we found that the choice of defences is influenced by the relationship between parents and children [46]. It seems that good parental care increases the use of more mature defences. We found that maternal care has the strongest influence in reducing defences of aggression and hostility whereas paternal care supports defences that produce socially acceptable behaviour. So far as we know, there have been two reports to meetings [10,22] and only two published articles investigating defence mechanisms in pain patients [34,35]. All these studies have used the Defense Mechanisms Inventory (DMI) [17,19]. The DMI is a paper and pencil test that measures the relative strength of 5 defensive clusters. The test comprises 10 stories describing conflict situations, including issues relating to conflicts around authority, competition, ind~endence and sex. The subjects are asked to state their most likely actual behaviour, what they would most like to do, their thoughts and their feelings in response to each circumstance which the stories describe. Thus 4 responses are required with respect to each story. For each of
these responses, the subjects have a choice of 5 answers in accordance with the 5 defensive scales. These are defined by Gleser and Ihilevich as follows: Turning Against the Self (TAS), Turning Against the Object (TAO, including identification with the aggressor and displacement), PROjection (PRO), REVersal (REV, including negation, denial, reaction formation and repression), and PRINcipalization (PRIN, including intellectualization, isolation and rationalization). The test has an unusual feature in that the description of one type of behaviour, wish, thought or feeling, reduces the score for other such categories that can be attributed to the subject. In other words it is an ipsative measure: the total score for any set of responses remains the same. Only the relative strength of defence mechanisms within individuals can be measured with accuracy [2]. The DMI usually takes 30-45 min to complete. Each answer in each modality (what the subject would be likely to do, what he would prefer to do, what thoughts or feelings he would have) has a score of 0,l or 2. The sum of the 4 scores is added for each defence. The theoretical range of scores for any defence summed through the 10 questions is from 0 to 80. The reliability and validity of the test have been investigated in many studies [19]_ Internal consistency estimates range from 0.57 to 0.83 for the separate scores, apart from a reliability of 0.21 for Turning Against the Self in a homogeneous set of normal females. Test-retest reliability in studies by 3 authors on 4 samples averaged 0.62-0.82 for the 5 scales separately [19]. In studies of validity, independent raters have found satisfactory correspondence for items keyed to Turning Against the Self, Reversal and Principalization (more than 60% agreement) [5,19]. Additional validation includes a correspondence between observed responses to threats and the DMI categories, correspondence between the concept and the results of a principal components analysis, weak but significant empirical relationships with perceptual styles, some relationships with hemispheric localization, and a relationship between Turning Against Others and Projection on the one hand, and norepinephrine production after surgical operations.
164
Studies in pain patients Passchier and his colleagues examined 59 patients suffering from migraine, 32 patients suffering from tension headache and 26 control subjects. The participants were recruited by advertisements and were investigated with a test battery incIuding a non-validated Dutch version of the Defense Mechanisms Inventory ]17]. The results showed no significant differences between the groups with regard to inadequacy. debilitating anxiety, facilitating anxiety, impulsiveness, obsessive-compulsive behaviour and defence mechanisms. Migraine patients and tension headache patients each showed elevated achievement motivation, while rigidity was mainly present in the latter group. In their second study, however, Passchier et al. [34] found that their students with migraine scored higher on Turning Against the Self and lower on Projection and Turning Against the Object than their control group of students without migraine. Mendelson [24] found Reversal to be used relatively more often in his pain patients than in the control group of I~levich and Gleser, whilst in 3 different pain populations Egle et al. [ll] mainly found a preferential deployment of Turning Against the Object, Turning Against the Self and Projection compared to a student control group. The values for Reversal and Principalization were clearly lower than for the control group. These few studies with defence mechanisms have produced conflicting results with respect to pain. In this study we investigated the relationship between childhood experience, depression and defence mechanisms in a sample of chronic pain patients, and compared them to a series of psychiatric patients without major complaints of pain.
Patients and method Two groups of patients, described further below, were asked to complete a set of forms as follows. Patients with chronic pain were asked to complete a form seeking details of their pain, and also a set of psychological test forms. Patients without chronic pain but with psychiatric illness
were asked to complete the same set t,f psycholitgical test forms. These were: the Defense Mechanisms Inventory (DMI) [ 17,191, which was described above; a revised version of the Parental Bonding Instrument (PBI) [l&33]; and the Hospital Anxiety and Depression Scale (HAD) 1561. The PBI is a reliable and valid questionnaire il~strument for measuring the quahty of parent,,’ child relationships [32]. In reviewing the literature. Parker [32] suggests 2 major components in the parental contribution to the bonding between parent and child: care versus indifference or rejection, and overprotection versus encouragement 01 independence. The PBI comprises 25 questions for each parent, using a Likert-type format. It is scored for care and overprotection for each parent. WC offer a detailed discussion of the interaction btitween the DMI and the PBI in our related paper [46]. The scales of the PBI have shown relationships with other psy~hologi~a1 measures in ii number of studies including some on patients with pain 1291. The HAD is a 14-item questionnaire which measures anxiety and depression and is especially designed for patients suffering from a physical disorder because it avoids symptoms like insomnia, pain or anorexia that might result from physical illness as well as from a mood disorder. It has good reliability and validity [41,42]. The patients reflect consecutive samples of convenience and are highly selected. They comprise chronic pain patients referred to one of us (H.M.): patients without pain referred to H.M. for psychiatric advice; and patients from the open clinic at this psychiatric hospital. Almost all of the pain patients had been through a series of other referrals to neuroiogists, orthopaedic surgeons, neurosurgeons, or anaesthetists’ nerve block clinics. The other patients seen by H.M. must also he assumed to be selected. The patients attending the open clinic were often in social and financial difficulties and had reduced contact with their regular general practitioners. From May 1988 to November 198X 65 chronic pain patients received forms and 60 returned them. Forty-nine other psychiatric patients were given forms by H.M. and 31 returned them. In the hospital open out-patient clinic 70 sets of forms
165
were distributed and 34 returned. Thus the return rate for the pain patients was 92%; that for H.M.‘s other psychiatric patients 61%, and that for the patients from the hospital open out-patient clinic 48%. Evidently the pain patients returned the highest proportion of forms, perhaps reflecting their greater interest in the package which for them also included many details of their bodily complaints. The patients with pain, group P, have been compared with the remainder, group R.
Results One hundred and twenty-five forms which were returned by 14 November 1988 were reviewed. Eleven patients were excluded from the study, either because of their difficulties with the English language (N = 2) or because they responded very incompletely to the measures (N = 9). We have analysed the same forms as in our other study [46]. One hundred and fourteen sets of tests were evaluated. Two of the patients excluded had been referred for chronic pain, so that there were 58 pain patients (group P) and 56 other patients (group R). The average age for the pain population was 45.3 years, and for the other population it was 41.3 years. In both groups there were 20 male patients, in the pain group 38 females, in the other group 36 female patients. This sex distribution is in accordance with what is often found in psychiatric clinics. For all tests, internal correlations were in the expected direction, as shown elsewhere [46]. The results for the pain patients are generally nearer to those of a general population than those of the group R. A comparison of the clinical diagnoses reveals that pain patients have no current psychiatric diagnosis significantly more often than the patients of group R (Table I). Table II shows that both groups are more anxious than the general population, but they are similar to each other. Both groups also show signs of depression, but pain patients are significantly more depressed than the others. However, the latter have a number of other diagnoses such as personality disorder and schizophrenia.
TABLE
I
DIAGNOSES
Group P
Group R
21 30 15
13 27 8
1
0
1
0
1 11 1 0 0 0 1 0 0 1 0 0
6 5 2 4 1 1 10 1 2 1 6 6
No psychiatric disorder Affective disorder/anxiety Major affective disorder Major affective disorder + phobia Major affective disorder + hypochondriasis Bipolar disorder Atypical affective disorder Chronic anxiety Dysthymic personality disorder Obsessional personality disorder Hypochondriasis Personality disorder Schizoid Dependent Histrionic Other Schizophrenia
Group
P
Psychiatric diagnosis No psychiatric diagnosis
31 27
Comparisons
exact test.
with Fisher’s
Group
P
R
43 13
ns < 0.03
Some findings with regard to parental care are shown in Tables III and IV. Within our own samples, groups P and R have equivalent proportions of males and females. We have therefore combined the male and female scores on the PBI
TABLE
II
HOSPITAL ANXIETY MEAN SCORES Pain (P) patients patients (N = 56).
Anxiety Depression
AND DEPRESSION
(N = 58) compared
Pain P
Psychiatric R
10.1 9.7
10.5 7.4
SCALE (HAD):
to remainder
(R)
of
P
Normal values: i 7; suspected anxiety and depression: definite anxiety and depression: > 10. ns = no significance at P i 0.05, 2-tailed test.
7-10;
PARENTAL
BONDING
Pain (P) patients patients.
INSTRUMENT
compared
to remainder
Pain P
Psychiatric R
i-4
5x
56
Maternal care Paternal care Mat. overprotection Pat. overprotection
23.1 22.2 13.2 11.9
20.0 15.8 14.5 14.3
ol psychiatric
(R)
P
ns 0.002 ns us
to compare both groups (Table III). Whilst maternal care is not significantly different for the two groups (despite the trend for more care in the P group), paternal care was markedly better in the pain group overall (P = 0.002). Table IV shows the differences between our own groups and a general practice sample studied by Parker [32,33]. A modified Bonferroni procedure was used to correct for the two multiple comparisons with the same group of general prac-
TABLE
ttce patients. The scores in females indicate relatively good parental care in Parker’s sample when compared with our patients in both groups, ours having lower care scores. In males with pain. parental care is the same as that found in general practice. The R group (i.e., our general psychiatric sample) had significantly lower scores for care. ~~ve~rotection is not evident in our pain group compared with general practice patients. hut our psychiatric group (group R) shows significant cvidence of overprotection among the women. As with the PBI, we are able to combine the results of males and females on the DMl because of equivalent proportions. They appear to establish different patterns of defence between the groups (Table V). Pain patients seem to use Turning Against the Self to a lesser extent and Reversal to a greater extent than our group R sample. Calculating Reversal and Principali~ati~~n together, as Juni [ZO] suggested, shows it higher significant difference and suggests that the difference may be more general. Although only 7 comparisons were made in this table, it seemed appropriate to apply a Bonferroni procedure, and
IV
PARENTAL. Comparison
BONDING
INSTRUMENT
of pain (P) and remainder
of psychiatric
(R) patients
to Parker’s
general
practice
(G) sample ._
Group
Pain I’
Psychiatric R
Parker’s general practice G -
Ft?~Wf~ N Mat. care Pat. care Mat. overprotection Pat. overprotection
3x 20.9 20.17 14.37 12.55
36 19.43 16.75 14.x5 15.63
279 27.1 24.3 12.9 12.7
IMill external aggression (comparable with Turning Against the Object) than their control group. This corresponds with the findings by Merskey [25] of ittcreased external resentment in pain patients. but not much guilt, although Spear [44] found no increase in covert or overt hostility in pain patients. Our pain patients show the highest tendency of all the groups which we have compared with them to use the defences included in Reversal. This result is in accordance with Mendelson [24] who found Reversal in his pain patients to be higher than in the normal population of Gleser and Ihilevich. One possible explanation, ;1s noted above, is the higher age of our population. Passchier et al. [35] found no differences in the DMI between pain populations and a control group. that was comparable with respect to age. Furthermore. other studies have shown that reversal seems to be an important defence mechanism in coping with a chronic illness. Reversal is negatively correlated with preoperative fear. days in bed after operation and demands for pain medication [54]. Women relying most on Reversal and Principalization showed lower premenstrual discomfort [ 1gf
169
than those using Turning Against the Object and Projection. Reversal seems to be a successful defence in terms of perception of health and survival after myocardial infarction [37]. As well Reversal has been found to defend most successfully against anxiety [7,17,37,38]. Our study indicates that depression in pain patients can be seen as an effect of pain on the mood of the patients. Their preference for using Reversal compared to the control sample of Gleser and I~le~ch can partly be attributed to their significantly higher age and is consistent with other studies on age and the DMI. Vaillant [46] found a shift from more immature to more mature defences with age. As we have concluded in a related paper, Reversal and P~ncipalization are the most mature defences in the DMI in terms of Vaillant’s ranking. Our results support the view that the defences employed by our pain patients are not more disturbed than those of a general population and indeed, less disturbed than that of patients who attend a psychiatric clinic. Their use of defence mechanisms is more comparable to a normal population than to a psychiatric population.
Elisabeth Tauschke was supported by a research fellowship from the FAZIT-Stiftung, Federal Republic of Germany. We thank Dr. Viera Barta and the staff of the Mental Health Clinic at London Psychiatric Hospital, who selected and diagnosed the patients in the clinic series and Ms. Mai Why, who provided extensive bibliographical help.
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4 Benjamin, S., Barnes, D.. Berger, S., Clarke, 1. and Jeacock, J., The relationship of chronic pain, mental illness and organic disorder, Pain, 32 (1988) 185-195. 5 Blacha, M.D. and Fancher, R.E., A content validity study of the Defense Mechanisms Inventory, J. Pers. Assess., 41 (1977) 402-404. 6 Blumer, D. and Heilbronn, M., Chronic pain as a variant of depressive disorder: the pain-prone disorder, J. Nerv. Ment. Dis., 170 (1982) 381-414. 7 Clum, G.A. and Glum, J., Choice of defence mechanisms and their relationship to mood level. Psychol. Rep., 32 (1973) 334-349. 8 Crook. J. and Tunks, E., Defining the ‘chronic pain syndrome’: an epidemiological method. In: H.L. Fields, R. Dubner and F. Cervero-(Eds.), Advances in Pain Research and Therapy, Vol. 9, Raven Press, New York, 1985, pp. 871-877. 9 Cunningham, S.J., McGrath, P-J., Ferguson, H.B., Humphreys, P., D’Astous, J., Latter, J., Goodman. J.T. and Firestone, P., Personality and beha~o~al characteristics in pediatric migraine, Headache, 27 (1987) 16-20. 10 Donovan, D.M., Hague, W.H. and O’Leary, M.R.. Perceptual differentiation and defence mechanisms in alcoholics, J. Stud. Alcohol, 387 (1975) 456-470. 11 Egle, U.T., Schwab, R., Rudolf, M.L., Schaefer, M.. Bassler, M. and Hoffmann. S.O., Illness behaviour and defence mechanisms of patients with psychogenic pain, rheumatoid arthritis and fibrositis syndrome, Presented at Vth World Cong. Pain, Hamburg, Aug. 1987. 12 Engel, G.E., Primary atypical facial neuralgia. A hysterical conversion symptom, Psychosom. Med., 13 (1951) 375-396. pain and the pain-prone patient. 13 Engel, G.E.. ‘Psychogenic’ Am. J. Med., 26 (1959) 899-918. 14 Freud, A., Das Ich und die Abwch~echanismen, Kindler. Munich, 1956. 15 Freud, S., Studien ueber Hysterie. In: 1. Band (Ed.). Gesammelte Werke, Imago, London. 1952. 16 Gamsa, A., A note on a modification of the Parental Bonding Instrument, AI. J. Med. Psychol., 60 (1987) 291-294. 17 Gieser, G.C. and Ihiievich, D., An objective instrument for measuring defense mechanisms, J. Cons. Clin. Psychol., 33 (1969) 51-60. 18 Greenberg, R.P. and Fisher, S., Menstrual discomfort, psychological defences and feminine identification J. Pers. Assess., 48 (1984) 634-648. 19 Ihilevich, D. and Gleser. G.C.. Defence Mechanisms: their Classification Correlates and Measurement with the Defense Mechanisms Inventory, DMI Associates, Owosso, MI, 1986. 20 Juni, S., The composite measure of the Defense Mechanisms Inventory, J. Pers. Assess.. 44 (1982) 484-486. 21 Lesse, S., Atypical facial pain of psychogenic origin: a masked depressive symptom. In: S. Lesse (Ed.), Masked Depression, Jason Aronson Inc., New York, 1974, pp. 302-317. 22 Lopez-Ibor, T.J., Masked depression. Br. J. Psychiat.. 120 (1972) 245-258.
170 23 Magni. G., On the relationship between chrome pain and depression when there is no organic lesion, Pain 31 (1987) l--21. 24 Mendelson, G., The use of psychological defence mechanisms by chronic pain patients, Presented at IVth World Cong. Pain. Seattle, WA. 1984. 25 Merskey, H., Psychiatric patients with persistent pain. J. Psychosom. Res.. 9 (1965) 299-309. 26 Merskey. H., The role of the psychiatrist in the investigation and treatment of pain. In: J.J. Bonica (Ed.), Pain. Raven Press, New York, 1980, pp. 249-260. 27 Merskey, H., Regional pain is rarely hysterical. Arch. Neurol., 45 (1988) 915-918. 28 Merskey. H. and Boyd. D.B., Emotional adjustment and chronic pain. Pain, 5 (1978) 1733178. 29 Merskey, H., Lau, C.L., Russell. ES.. Brooke, R.I.. James. M., Lappano, S.. Nielson. J. and Tilsworth. R.H.. Screening for psychiatric morbidity. The pattern of psychological illness and premorbid characteristics on four chronic pain populations, Pain, 30 (1987) 141-157. 30 Merskey, H. and Spear, F.G., Pain: Psychological and Psychiatric Aspects, Bailliere, Tindall and Cassell. London, 1967. 31 Myers, J.K., Weissnam, M.M., Tischler. G.L., Holzer, C.H., Leaf, P.J.. Orvaschel, H., Anthony. J.C., Boyd, J.H., Burke, J.D., Kramer, M. and Stoltzman, R., Six months of prevalence of psychiatric disorders in three communities: 1980 to 1982, Arch. Gen. Psychiat.. 41 (1984) 959-967. 32 Parker, G., Parental Overprotection. Grune and Stratton, New York, 1983. 33 Parker, G., Tupling, H. and Brown, L.B., A Parental Bonding Instrument, Br. J. Med. Psycho]., 52 (1979) l-10. 34 Passchier, J., Goudswaard, P., Orlebeke. J.F. and Verhage, F., Migraine and defence mechanisms: psychological relationship in young females, Sot. Sci. Med., 26 (1988) 343-350. 35 Passchier. J., Van der Hylm-Hylkema. H. and Orlebeke, J.F., Personality and headache type: a controlled study. Headache, 24 (1984) 140-145. 36 Payne. B. and Norfleet, M.A., Chronic pain and the family: a review, Pain, 26 (1986) l-22. 37 Peglar, M. and Borgen, F.H., The defence mechanisms of coronary patients, J. Clin. Psycho]., 40 (1984) 6699679. 38 Pilowsky, I., Bassett, D.L., Begg, M.W. and Thomas, P.G., Childhood hospitalization and chronic intractable pain in adults: a controlled retrospective study, Int. J. Psychiat. Med., 12 (1982) 75-84. 39 Rohsenow. D.J., Erickson, R.C. and O’Leary. M.R., The Defense Mechanisms Inventory and alcoholics, Int. J. Addict.. 13 (1978) 403-414.
40 Romano, J.M. and Turner, J.A., Chrome pain and depression: does the evidence support a relationship?. Psycho1 Bull., 97 (1985) 18-34. 41 Snaith, R.P., The Hospital Anxiety and Depression Scale. Br. J. Psychiat., 154 (1988) 424-439. 42 Snaith. R.P. and Taylor, C.M.. Irritability: definition, a\srssment and associated factors. Br. J. Psychiat.. 147 (1985) 127-136. 43 Spear, F.G., A Study of Pain as a Symptom in Psychiatric Illness, M.D. Thesis, University of Bristol, England. 44 Spear, F.G., Pain in psychiatric patients, J. Psychosom. Res.. 11 (1967) 1877193. 45 Sternbach. R.A., Pain Patients: Traits and ‘Treatment. Academic Press. New York, 1974. 46 Tauschke, E., Merskey. H. and Helmes, E., A systematic inquiry into recollections of childhood experience and their relationship to adult defence mechanisms. Submitted for publication, 1989. 47 Turk, D. and Flor, H.. Etiological theories and treatments for chronic back pain. II. Psychological models and interventions, Pain, 19 (1984) 2099233. 48 Turk, D.. Flor, H. and Rudy. T.E., Pain and families. 1. Etiology, maintenance and psychosocial impact, Pain, 30 (1987) 3.-27. 49 Vaillant, G., Natural history of male psychological health. V. The relation of choice of ego mechanisms of defence to adult adJustment, Arch. Gen. Psychiat., 33 (1976) 535-545. 50 Von Knorring, L.. Pertis. C., Eisemann, I.. Eriksson, U. and Perris, H., Pain as a symptom in depressive disorders. 11. Relationship to personality traits as assessed by means of KSP, Pain. 17 (1983) 377-3X4. 51 Violon, A., The onset of facial pain, Psychother. Psychoborn.. 34 (1980) ll- 16. 52 Walker, E.. Katon, W., Harrop-Griffiths, J.. Helm. L., Russo. J. and Hickok. L.R., Relationship of chronic pain to psychiatric diagnoses and childhood sexual abuse, Am. J. Psychiat., 145 (1988) 75-80. 53 Ward, N.G.. Bloom, V.L. and Friedel, R.O., The effectiveness of tricyclic antidepressants in the treatment of coexisting pain and depression Pain, 7 (1979) 331-341. 54 Wilson, J.F., Recovery from surgery and scores on the Defence Mechanism Inventory, J. Pers. Assess., 46 (1982) 312-319. 55 Woodforde, J.M. and Merskey, H., Personality traits of patients with chronic pain. J. Psychosom. Res.. 16 (1972) 1677172. 56 Zigmond, A.S. and Snaith R.P., The Hospital Anxiety and Depression Scale, Acta Psychiat. Stand., 67 (1983) 361-370.
Pain, 40 (1990) 161-170 Elsevier
PAIN 01529
Psychological defence mechanisms in patients with pain Elisabeth Tauschke a, Harold Merskey avband Edward Helmes b uDep.ofResearch, London Psychiatric Hospital, London, Ont. {Canada), and
’ Dept. of Psychiatry, University of Western Ontario,
Landon, Ont. (Canada) (Received
25 April 1989, revision received 28 July 1989, accepted
17 August
1989)
There is a long standing position that pain, and especially chronic pain, may arise from psychological mechanisms of SUrn~ defenee. We have compared a group of chronic pain patients with a sample of psychiatric patients attending for reasons other than pain. The pain group had less evidence of poor care in childhood (measured by the Parental Bonding Instrument) and tended to use more mature psychological defence mechanisms (assessed with the Defense Mechanisms Inventory), compared with the other group. The pain group also had fewer current psychiatric diagnoses but more evidence of anxiety and depression on the Hospital Anxiety and Depression Scale. We conclude that in general the patients with chronic pain had more normal childhoods and more mature defences than the psychiatric control group. They showed an increase in the diagnosis of depression, attributable to reactive factors. In the sample of patients with pain the majority of the psycholo~cal change cannot be attributed to the operation of primitive psychological defences. Key words: Chronic
pain;
Psychological
mechanisms;
Defence
Psychiatric diagnosis and psychological explanations The relationship between psychological factors and pain is a continuing matter of interest. Freud saw pain as the result of a conversion neurosis, serving as a compromise between the fulfilling of a forbidden wish and its punishment [15]. He offered both a diagnosis (conversion hysteria) and a dynamic explanation of its production. The literature has regularly followed this pattern. Most authors have attempted first to define the psychiatric diagnoses with which pain is associated and then to identify the mental mechanisms which may generate pain as a bodily symptom [30]. The
Correspondence to: H. Merskey, D.M., Department of Research, London Psychiatric Hospital, 850 Highbury Avenue, P.O. Box 2532, London, Ont. N6A 4H1, Canada. 03043959/90/$03.50
0 1990 Elsevier Science Publishers
majority have described pain as a conversion neurosis, a hypochondriacal reaction or a form of depression [28,23,40]. One of the first systematic studies on a series of patients came from Engel [12,13] who diagnosed most of his cases as hysteria or h~~hond~asis. He described characteristic features in patients suffering chronic pain: a history of suffering, defeat, neglect and abuse in their childhood that resulted in the prominence of guilt and a strong aggressive drive that is not fulfilled; the experience of pain taking the place of emotion, a location of pain determined by unconscious identification with a love object; and the development of pain upon loss or threatened loss. Engel’s portrayal of the ‘pain-prone’ patient had a strong influence on subsequent research. Merskey [25] found that resentment was much commoner in patients with pain than in those without. The communicative function of pain was
B.V. (Biomedical
Division)
162
also evident in patients with lower intelhgence and education, but Spear [44] found no increased association with either hostility or covert aggression in patients with pain. Thus the description of patients by Engel was only confirmed in part. There is very little other work which is methodologically satisfactory and which would support Engel’s concept [e.g.. see 4,481. The second prominent diagnosis in research on pain and psychological factors is depression [40]. Of all psychological patterns, depression seems to have the strongest association with pain, yet the nature of a causal relationship between chronic pain and depression remains unsettled. Again methodological difficulties prevent definite conclusions. Pain is the most common complaint in medicine [3] and apart from substance abuse, depression and anxiety are the most common psychiatric disorders in the general population [31]. Their prevalence contributes to the strong link found between them and pain and makes the matter difficult to disentangle. In the theories of Freud and Engel, for both depression and pain, the concept of aggression directed inwards is a key psychodynamic explanation. However, Von Knorring [.50] pointed out that systematic studies on this theory have been contradictory for depression. It is more so for pain. Hypotheses on the relationship between pain and depression vary from regarding pain as an equivalent of a depressive disorder j6] or as a masked depression 121,221, to proposing that they are psycholo~cally independent but share common physiological or biological mechanisms [52]. Some claim the same psychological factors for the development of pain and depression [51,52]. When a physical explanation for pain has not been found, a psychological cause is often proposed for the pain without supporting psychological evidence [27]. However, research which focussed on the effects of a chronic painful illness on the life and personality of the patient suggested that depression was mainly a consequence of the painful condition [45,55]. Benjamin et al. [4] found that distinguis~ng between painful conditions caused by physical lesions and others did not seem to show whether psychological factors, especially
depression, were primary or secondary to pain. 1n their sample, patients without a physical lesion showed significantly lower ratings for severity 01 psychological problems than patients with physical lesions and the authors concluded that pain patients cannot be divided into a simple dichotomy of those with physical or mental illness. Two recent studies investigating children suffering from migraine found a negative and stressful impact of a painful condition on the personality and mood of the children [ 1.91. The family background has been said to affect the relationship between depression and pain. As we have noted above, Engel [13] suggested similar psychodynamic mechanisms for pain and depression. His description of the family background of pain patients resembles that of many depressed patients. But although it is widely held that the family plays an important role in the health of its members, the exact relationship with pain is far from being resolved. Pilowsky et al. [38] showed that childho~~d hospitalization could contribute both to depressive illness and to intractable pain in adults. Preschool admission to hospital had occurred more often in depressed patients than in a rheumatology group. Later childhood admission was more common in :I pain clinic group. There have been two extensive reviews on the association between pain and families - the families of origin as well as the family in which the patient is currently living [36,48]. Although Payne and Norfleet find some hints supporting Engel’s theory, they state that empirical evidence is lacking. Turk and his colleagues in their more recent review came to the conclusion that for almost all related questions there has been much interesting hypothesizing but very little empirical study and support. Many of the difficulties arose from the problem that all studies were retrospective, and the transformation of a correlation into a causal relationship has been mostly a matter of interpretation. Further, few studies made adequate allowance, or indeed any allowance, for the influence of selection in patients with pain f26J. Crook and Tunks [8] provide a notable exception in the examination of patients from pain clinics and the community, but adequate control studies
163
of families are few in number or slight in quantity. Merskey et al. [29] found that pain patients did not seem to have significantly different childhood experiences from patients in general practice, whether their pain was mostly physical in origin or whether there was no obvious physical explanation of the pain experience. However, general practice populations are themselves selected and there is some modest evidence that patients with pain and no lesions have more difficult parents than patients with lesions [28].
Defence mechanisms
Defence mechanisms are unconscious mechanisms that are supposed to protect against external and internal stressors [14]. They might be a help in clarifying some of the confusions between psycholo~cal factors, especially childhood experience and depression, and the experience of pain. For example, it might be postulated that pain associated with lesions will manifest different defence mechanisms from pain without lesions. In a related study, we found that the choice of defences is influenced by the relationship between parents and children [46]. It seems that good parental care increases the use of more mature defences. We found that maternal care has the strongest influence in reducing defences of aggression and hostility whereas paternal care supports defences that produce socially acceptable behaviour. So far as we know, there have been two reports to meetings [10,22] and only two published articles investigating defence mechanisms in pain patients [34,35]. All these studies have used the Defense Mechanisms Inventory (DMI) [17,19]. The DMI is a paper and pencil test that measures the relative strength of 5 defensive clusters. The test comprises 10 stories describing conflict situations, including issues relating to conflicts around authority, competition, ind~endence and sex. The subjects are asked to state their most likely actual behaviour, what they would most like to do, their thoughts and their feelings in response to each circumstance which the stories describe. Thus 4 responses are required with respect to each story. For each of
these responses, the subjects have a choice of 5 answers in accordance with the 5 defensive scales. These are defined by Gleser and Ihilevich as follows: Turning Against the Self (TAS), Turning Against the Object (TAO, including identification with the aggressor and displacement), PROjection (PRO), REVersal (REV, including negation, denial, reaction formation and repression), and PRINcipalization (PRIN, including intellectualization, isolation and rationalization). The test has an unusual feature in that the description of one type of behaviour, wish, thought or feeling, reduces the score for other such categories that can be attributed to the subject. In other words it is an ipsative measure: the total score for any set of responses remains the same. Only the relative strength of defence mechanisms within individuals can be measured with accuracy [2]. The DMI usually takes 30-45 min to complete. Each answer in each modality (what the subject would be likely to do, what he would prefer to do, what thoughts or feelings he would have) has a score of 0,l or 2. The sum of the 4 scores is added for each defence. The theoretical range of scores for any defence summed through the 10 questions is from 0 to 80. The reliability and validity of the test have been investigated in many studies [19]_ Internal consistency estimates range from 0.57 to 0.83 for the separate scores, apart from a reliability of 0.21 for Turning Against the Self in a homogeneous set of normal females. Test-retest reliability in studies by 3 authors on 4 samples averaged 0.62-0.82 for the 5 scales separately [19]. In studies of validity, independent raters have found satisfactory correspondence for items keyed to Turning Against the Self, Reversal and Principalization (more than 60% agreement) [5,19]. Additional validation includes a correspondence between observed responses to threats and the DMI categories, correspondence between the concept and the results of a principal components analysis, weak but significant empirical relationships with perceptual styles, some relationships with hemispheric localization, and a relationship between Turning Against Others and Projection on the one hand, and norepinephrine production after surgical operations.
164
Studies in pain patients Passchier and his colleagues examined 59 patients suffering from migraine, 32 patients suffering from tension headache and 26 control subjects. The participants were recruited by advertisements and were investigated with a test battery incIuding a non-validated Dutch version of the Defense Mechanisms Inventory ]17]. The results showed no significant differences between the groups with regard to inadequacy. debilitating anxiety, facilitating anxiety, impulsiveness, obsessive-compulsive behaviour and defence mechanisms. Migraine patients and tension headache patients each showed elevated achievement motivation, while rigidity was mainly present in the latter group. In their second study, however, Passchier et al. [34] found that their students with migraine scored higher on Turning Against the Self and lower on Projection and Turning Against the Object than their control group of students without migraine. Mendelson [24] found Reversal to be used relatively more often in his pain patients than in the control group of I~levich and Gleser, whilst in 3 different pain populations Egle et al. [ll] mainly found a preferential deployment of Turning Against the Object, Turning Against the Self and Projection compared to a student control group. The values for Reversal and Principalization were clearly lower than for the control group. These few studies with defence mechanisms have produced conflicting results with respect to pain. In this study we investigated the relationship between childhood experience, depression and defence mechanisms in a sample of chronic pain patients, and compared them to a series of psychiatric patients without major complaints of pain.
Patients and method Two groups of patients, described further below, were asked to complete a set of forms as follows. Patients with chronic pain were asked to complete a form seeking details of their pain, and also a set of psychological test forms. Patients without chronic pain but with psychiatric illness
were asked to complete the same set t,f psycholitgical test forms. These were: the Defense Mechanisms Inventory (DMI) [ 17,191, which was described above; a revised version of the Parental Bonding Instrument (PBI) [l&33]; and the Hospital Anxiety and Depression Scale (HAD) 1561. The PBI is a reliable and valid questionnaire il~strument for measuring the quahty of parent,,’ child relationships [32]. In reviewing the literature. Parker [32] suggests 2 major components in the parental contribution to the bonding between parent and child: care versus indifference or rejection, and overprotection versus encouragement 01 independence. The PBI comprises 25 questions for each parent, using a Likert-type format. It is scored for care and overprotection for each parent. WC offer a detailed discussion of the interaction btitween the DMI and the PBI in our related paper [46]. The scales of the PBI have shown relationships with other psy~hologi~a1 measures in ii number of studies including some on patients with pain 1291. The HAD is a 14-item questionnaire which measures anxiety and depression and is especially designed for patients suffering from a physical disorder because it avoids symptoms like insomnia, pain or anorexia that might result from physical illness as well as from a mood disorder. It has good reliability and validity [41,42]. The patients reflect consecutive samples of convenience and are highly selected. They comprise chronic pain patients referred to one of us (H.M.): patients without pain referred to H.M. for psychiatric advice; and patients from the open clinic at this psychiatric hospital. Almost all of the pain patients had been through a series of other referrals to neuroiogists, orthopaedic surgeons, neurosurgeons, or anaesthetists’ nerve block clinics. The other patients seen by H.M. must also he assumed to be selected. The patients attending the open clinic were often in social and financial difficulties and had reduced contact with their regular general practitioners. From May 1988 to November 198X 65 chronic pain patients received forms and 60 returned them. Forty-nine other psychiatric patients were given forms by H.M. and 31 returned them. In the hospital open out-patient clinic 70 sets of forms
165
were distributed and 34 returned. Thus the return rate for the pain patients was 92%; that for H.M.‘s other psychiatric patients 61%, and that for the patients from the hospital open out-patient clinic 48%. Evidently the pain patients returned the highest proportion of forms, perhaps reflecting their greater interest in the package which for them also included many details of their bodily complaints. The patients with pain, group P, have been compared with the remainder, group R.
Results One hundred and twenty-five forms which were returned by 14 November 1988 were reviewed. Eleven patients were excluded from the study, either because of their difficulties with the English language (N = 2) or because they responded very incompletely to the measures (N = 9). We have analysed the same forms as in our other study [46]. One hundred and fourteen sets of tests were evaluated. Two of the patients excluded had been referred for chronic pain, so that there were 58 pain patients (group P) and 56 other patients (group R). The average age for the pain population was 45.3 years, and for the other population it was 41.3 years. In both groups there were 20 male patients, in the pain group 38 females, in the other group 36 female patients. This sex distribution is in accordance with what is often found in psychiatric clinics. For all tests, internal correlations were in the expected direction, as shown elsewhere [46]. The results for the pain patients are generally nearer to those of a general population than those of the group R. A comparison of the clinical diagnoses reveals that pain patients have no current psychiatric diagnosis significantly more often than the patients of group R (Table I). Table II shows that both groups are more anxious than the general population, but they are similar to each other. Both groups also show signs of depression, but pain patients are significantly more depressed than the others. However, the latter have a number of other diagnoses such as personality disorder and schizophrenia.
TABLE
I
DIAGNOSES
Group P
Group R
21 30 15
13 27 8
1
0
1
0
1 11 1 0 0 0 1 0 0 1 0 0
6 5 2 4 1 1 10 1 2 1 6 6
No psychiatric disorder Affective disorder/anxiety Major affective disorder Major affective disorder + phobia Major affective disorder + hypochondriasis Bipolar disorder Atypical affective disorder Chronic anxiety Dysthymic personality disorder Obsessional personality disorder Hypochondriasis Personality disorder Schizoid Dependent Histrionic Other Schizophrenia
Group
P
Psychiatric diagnosis No psychiatric diagnosis
31 27
Comparisons
exact test.
with Fisher’s
Group
P
R
43 13
ns < 0.03
Some findings with regard to parental care are shown in Tables III and IV. Within our own samples, groups P and R have equivalent proportions of males and females. We have therefore combined the male and female scores on the PBI
TABLE
II
HOSPITAL ANXIETY MEAN SCORES Pain (P) patients patients (N = 56).
Anxiety Depression
AND DEPRESSION
(N = 58) compared
Pain P
Psychiatric R
10.1 9.7
10.5 7.4
SCALE (HAD):
to remainder
(R)
of
P
Normal values: i 7; suspected anxiety and depression: definite anxiety and depression: > 10. ns = no significance at P i 0.05, 2-tailed test.
7-10;
PARENTAL
BONDING
Pain (P) patients patients.
INSTRUMENT
compared
to remainder
Pain P
Psychiatric R
i-4
5x
56
Maternal care Paternal care Mat. overprotection Pat. overprotection
23.1 22.2 13.2 11.9
20.0 15.8 14.5 14.3
ol psychiatric
(R)
P
ns 0.002 ns us
to compare both groups (Table III). Whilst maternal care is not significantly different for the two groups (despite the trend for more care in the P group), paternal care was markedly better in the pain group overall (P = 0.002). Table IV shows the differences between our own groups and a general practice sample studied by Parker [32,33]. A modified Bonferroni procedure was used to correct for the two multiple comparisons with the same group of general prac-
TABLE
ttce patients. The scores in females indicate relatively good parental care in Parker’s sample when compared with our patients in both groups, ours having lower care scores. In males with pain. parental care is the same as that found in general practice. The R group (i.e., our general psychiatric sample) had significantly lower scores for care. ~~ve~rotection is not evident in our pain group compared with general practice patients. hut our psychiatric group (group R) shows significant cvidence of overprotection among the women. As with the PBI, we are able to combine the results of males and females on the DMl because of equivalent proportions. They appear to establish different patterns of defence between the groups (Table V). Pain patients seem to use Turning Against the Self to a lesser extent and Reversal to a greater extent than our group R sample. Calculating Reversal and Principali~ati~~n together, as Juni [ZO] suggested, shows it higher significant difference and suggests that the difference may be more general. Although only 7 comparisons were made in this table, it seemed appropriate to apply a Bonferroni procedure, and
IV
PARENTAL. Comparison
BONDING
INSTRUMENT
of pain (P) and remainder
of psychiatric
(R) patients
to Parker’s
general
practice
(G) sample ._
Group
Pain I’
Psychiatric R
Parker’s general practice G -
Ft?~Wf~ N Mat. care Pat. care Mat. overprotection Pat. overprotection
3x 20.9 20.17 14.37 12.55
36 19.43 16.75 14.x5 15.63
279 27.1 24.3 12.9 12.7
IMill external aggression (comparable with Turning Against the Object) than their control group. This corresponds with the findings by Merskey [25] of ittcreased external resentment in pain patients. but not much guilt, although Spear [44] found no increase in covert or overt hostility in pain patients. Our pain patients show the highest tendency of all the groups which we have compared with them to use the defences included in Reversal. This result is in accordance with Mendelson [24] who found Reversal in his pain patients to be higher than in the normal population of Gleser and Ihilevich. One possible explanation, ;1s noted above, is the higher age of our population. Passchier et al. [35] found no differences in the DMI between pain populations and a control group. that was comparable with respect to age. Furthermore. other studies have shown that reversal seems to be an important defence mechanism in coping with a chronic illness. Reversal is negatively correlated with preoperative fear. days in bed after operation and demands for pain medication [54]. Women relying most on Reversal and Principalization showed lower premenstrual discomfort [ 1gf
169
than those using Turning Against the Object and Projection. Reversal seems to be a successful defence in terms of perception of health and survival after myocardial infarction [37]. As well Reversal has been found to defend most successfully against anxiety [7,17,37,38]. Our study indicates that depression in pain patients can be seen as an effect of pain on the mood of the patients. Their preference for using Reversal compared to the control sample of Gleser and I~le~ch can partly be attributed to their significantly higher age and is consistent with other studies on age and the DMI. Vaillant [46] found a shift from more immature to more mature defences with age. As we have concluded in a related paper, Reversal and P~ncipalization are the most mature defences in the DMI in terms of Vaillant’s ranking. Our results support the view that the defences employed by our pain patients are not more disturbed than those of a general population and indeed, less disturbed than that of patients who attend a psychiatric clinic. Their use of defence mechanisms is more comparable to a normal population than to a psychiatric population.
Elisabeth Tauschke was supported by a research fellowship from the FAZIT-Stiftung, Federal Republic of Germany. We thank Dr. Viera Barta and the staff of the Mental Health Clinic at London Psychiatric Hospital, who selected and diagnosed the patients in the clinic series and Ms. Mai Why, who provided extensive bibliographical help.
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