Psychosomatics 40:233-238, June 1999
© 1999 The Academy of Psychosomatic Medine
A Psychiatric Study of Nonorganic Chronic Headache Patients
Ahmed Okasha, M.D.,
Moustafa K. Ismail, M.D.,
Afaf H. Khalil, M.D.,
Refaat El Fiki, M.D.,
Alaa Soliman, M.D., and
Tarek Okasha, M.D.
Received June 24, 1998; revised July 6, 1998; accepted August 28, 1998. From the Institute of Psychiatry, Faculty of Medicine, Ain Shams University, Cairo, Egypt. Address correspondence and reprint requests to Dr. Okasha, 3 Shawarby Street, Kasr El Nil, Cairo, Egypt; e-mail: aokasha{at}internetegypt.com
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ABSTRACT
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Nonorganic chronic headache is a common, challenging presentation in clinical practice. The aim of this study was to investigate the frequency of associated psychiatric psychopathology, personality disorders, or traits. In addition, the study attempted to investigate possible relationships of nonorganic chronic headache with alexithymia, locus of control, and pain perception. Psychiatric pathology, personality traits, and pain profiles were examined in 100 randomized patients with chronic headache lacking an obvious organic basis, and they were compared with 100 subjects, 50 with headache of a known organic cause and 50 seemingly healthy persons, by using structured clinical interviews. Somatoform pain disorder was diagnosed in 43% of the nonorganic and 20% of the organic headache group. Nine percent of the former group had major depression, 16% had dysthymia, and 8% had both. In the organic group, 56% had no psychiatric disorder and 20% had somatoform pain disorder. Seventy-seven percent of the patients in the nonorganic pain group had personality disorders, mostly of the mixed and multiple types, compared with 24% of the organic headache patients. The study sample was more alexithymic than the other groups (in 65% of subjects) and had a culturally influenced locus of control and a pain profile characterized by dramatization, vagueness, lower pain threshold, and lower pain tolerance. The nonorganic chronic headache patients showed a high prevalence of somatoform, depressive, and other forms of psychiatric disorders. The high frequency of personality disorders, mostly the mixed and multiple types, the high alexithymic pattern, and low pain threshold and tolerance in the study group should be taken into consideration in the evaluation and management of nonorganic headache patients.
Key Words: Chronic Pain • Headaches • Pain
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INTRODUCTION
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Chronic pain is a frequent and usually frustrating clinical problem for which there is no adequate solution. The absence of an obvious organic basis produces many dilemmas. Not only is it difficult to confidently rule out organic causes, considering the rarity of pure psychogenic pain,1 but in addition the involved psychobiologic mechanisms are still poorly understood.2 Also, the existence of competing explanations for the psychological aspects of chronic headache suggest that experts do not fully agree about its origin, or therapeutic intervention.3 Finally, these patients are usually resistant to psychological evaluation and interventions.4 Chronic pain has recently become a topic of psychiatric research. Areas such as psychiatric diagnosis,5 personality disorders,6 personality characteristic,7 alexithymia,8 locus of control,9 and pain profile10 are of special interest for research on chronic pain.
In Egypt, pain has been studied in relation to depression.11 In cases of patients with organic pain, depression was always secondary to the onset of pain, whereas in depressive pain, 80% of cases showed simultaneous occurrence of pain and depression. In the remaining 20%, however, depression preceded pain, suggesting a possible causal relationship. Patients in 73.3% of the cases of depressive pain reported that once the pain started, it continued without relief, unless treatment was started.
Headache is one of the most common presentations in this group of patients,12 in whom organic pathology is exceptional and pathogenesis has been primitive.13 The large number of such patients and their disability and demands on all medical resources indicate the need for clearer understanding and more effective clinical policies.14
The aim of this study is to investigate the possibility of underlying psychiatric disorders with chronic headache, correlation with personality disorders and/or specific personality traits, and any association of alexithymia and locus of control with chronic headache pain. The study also sought to identify the pain profile, especially its sensory, emotional, and evaluative components, as well as the tolerance and threshold levels, to gain further understanding of the nonorganic chronic pain problem.
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METHODS
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Subjects
The total study sample consisted of 200 subjects. The first group included one hundred patients (n=100) with chronic headache lacking an obvious organic cause, from hereon referred to as the study group (or Group 1 in the tables). An organic cause was excluded through a thorough neurological examination, electroencephalography, and computerized axial tomography. In some cases, nuclear magnetic resonance imaging was used. The diagnosis was based on the criteria of the International Headache Society in 1988, where these patients fit the nonspecific headache category. The second group were patients with organic headaches (Group 2) (n=50), with benign physical causes. The third group was a seemingly healthy group (Group 3) (n=50) of subjects with no history of persistent pain or psychiatric disorder.
Cases were randomly selected from the outpatient departments of neurology and psychiatry; ENT (ear, nose, and throat); and internal medicine of Ain Shams University Hospitals, Cairo, Egypt. We conducted our study in 1994. The subjects of the fourth control group were nonrelatives of the patients and working hospital personnel. Control cases matched the study group for gender and age. An informed consent was obtained from all groups of patients and control subjects. Emphasis on voluntary participation was ensured.
Procedure
The headache patients, those with a known benign cause and those with no obvious organic pathology (Groups 1 and 2), were assessed with the following measures: 1) a thorough medical evaluation; 2) Structured Clinical Interview (SCID) for DSM-III-R Axis I and II diagnoses. The study used the SCID as an instrument designed to enable a clinically trained interviewer to make DSM-III-R diagnoses. Patients were recorded as either threshold (fulfilling criteria) or subthreshold (the full criteria are not met, but clinically the disorder seems likely). Patients were then assessed with the SCID (Axis-II) (SCID-II, version 1.0), designed by Spitzer et al.15 SCID–II was applied for subthreshold-accentuated personality traits. Both interviews were translated into Arabic through a translation-retranslating process; 3) the Alexithymia Provoked Response Questionnaire;16 4) Rotter's locus of control;17 5) the Visual Analogue Scale (VAS); 6) a structured McGill Pain Questionnaire (MPQ) for pain analysis;18 and 7) a semiobjective (ischemic) method for measuring pain threshold, intensity, and tolerance.19
The healthy control subjects were assessed by Measures 2, 3, and 7 only.
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RESULTS
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Psychopathology
According to the structured clinical interview (SCID–I), 43% of the subjects in the study group had a somatoform pain disorder, 16% had a dysthymic disorder, 9% had a major depressive disorder, and 8% had double depression. In the organic group (Group 2), 56% had no psychiatric disorder and 20% had a somatoform pain disorder (Table 1).
Regarding the presence of a personality disorder, 77% of the patients in Group 1 had a diagnosis of personality disorder, which was significantly high, compared with 24% of the patients in the organic headache group and only 12% of the healthy subjects (P<0.001). The most prevalent personality disorders and pathological personality traits in Group 1 were the anxious (63%), borderline (43%), and obsessive (40%) subtypes. Multiple and mixed panic disorder were recorded in 29% and 26% of the subjects, respectively (Table 1).
Alexithymia
The study group was significantly more alexithymic than the other groups (P<0.001) (Table 2), pointing to the probable role of alexithymia in the psychobiology of chronic pain. Also, a positive significant correlation was found between alexithymia and the somatizing tendency in that group ( 2=42.34, df=2, P<0.001) (Table 3).
Locus of Control
No significant correlation was detected between the different groups and the attribution of reinforcement to external or internal factors (Table 4).
Pain Profile
The patients in the study group were found to exaggerate or dramatize their pain experience. This finding was indicated by the significantly high differences on the MPQ, the paired difference between VAS (subjective clinical pain) and the tourniquet pain ratio (semiobjective experimental matching pain), as well as the lack of difference between the study group and the organic pain group, when pain severity was evaluated by the semiobjective method and compared with the VAS.
Evaluation of the three components of pain experience with the MPQ revealed that the patients in the study group used significantly more words to describe sensory components of their pain, that is, vague description, more emotional words, and reported more severity ascribed to their headaches (Table 5). The presence of a personality disorder correlated positively with the tendency to report severe pain intensity (2=22.38, df=6, P<0.1) and alexithymia (2= 95.1, df=4, P<0.05).
Regarding pain threshold and tolerance, the subjects in the study group had a significantly lower pain tolerance than the other two groups (Table 6).
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DISCUSSION
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The high frequency of depression in chronic pain patients, as revealed in our study, has been supported by earlier research. Ziegler et al.20 found that higher frequency of headaches was strongly associated with a higher self-rating of depression among both men and women with severe headaches in a community sample.20 According to Reich et al., the prevalence of depression among headache patients varies between 22% and 78%.6
Compared with the control subjects, the headache subjects showed higher levels of anxiety, depression, and anger/hostility and significantly greater levels of suppressed anger,21 and Kaiser diagnosed depression in 86% of 28 patients between the ages of 13 and 18 who had chronic daily headaches.22 Furthermore, it was argued that recurrent headache sufferers reported higher levels of depression and physical symptoms than comparison subjects, irrespective of whether they had or had not sought treatment for their headache problems.23 The severity of depression seems to correlate significantly with the degree of disability perceived as a result of the headache.24,25 Suppression of anger among the patients appeared to be a moderating variable that intensified the experience of depression.
The clinical overlap of pain and depression is readily understandable. Both nociceptive and affective pathways coincide anatomically.26 Norepinephrine and serotonin, the two neurotransmitters most implicated in the pathophysiology of mood disorders, are also involved in the gate-control mechanism of pain,27,28 and antidepressants were found to be effective in the treatment of chronic pain patients.28
Breslau and Davis suggested that migraine, major depression, and anxiety disorders might share common predispositions.29 However, considering chronic pain as a variant of depression or masked depression, in the absence of the criteria of a depressive disorder, is a nosological confusion. For better assessment of depressive disorders in chronic pain population, scales should eliminate symptoms that do not differentiate depressed patients from others with chronic pain (e.g., insomnia, fatigue, etc). Also it might be too difficult to distinguish primary and secondary depression in chronic pain patients, as the temporal relationship between pain and depression is not reliable and may be influenced by the inaccurate recall of events.30
Research on psychological factors in head pain has generally focused upon personality traits and psychopathology. Personality seems to color the psychobiology of pain experience; however, controlled studies have generally failed to reveal consistent psychological profiles of such patients. The percentage of personality disorders among chronic pain patients in this study (77%) is higher than that recorded in other studies—for example, 37% by Reich et al.6 and 40% by Large.5 However, in both studies the authors did not use a structured interview. Among personality disorders in the study group, multiple and mixed (26%) were the most prevalent types, which is similar to other findings reported by Large,5 Alnaes and Torgersen,31 Zimmerman and Coryell,32 Nurnberg et al.,33 and Okasha et al.34 It is likely that personality is directly involved in the psychobiology of chronic pain through certain psychophysiologic (mainly autonomic) mechanisms, which may give the condition both its stability and resistance to treatment.
The role of illness beliefs offers another method of elucidating perceptions, attitudes, and convictions toward a somatic complaint.
Our study findings are also suggestive of a role for a psychopathological background in the development of somatoform pain disorder and/or chronic pain state. Passchier et al.35 showed that subjects with at least weekly headaches had more life events and higher inadequacy, social inadequacy, rigidity, and injuredness than the subjects with less frequent headaches. The high rate of personality disorders as well as the subthreshold accentuated (pathological) personality traits in the study group may explain the clinical observation of the treatment resistance, chronic course, and poor prognosis seen in somatoform pain disorder. The primary abnormality in chronic pain patients may be the behavior of complaining that can be understood not as an illness or a syndrome but as a set of behaviors arising from an interaction between personality characteristics and life situations. On the other hand, the experience of chronic pain may in itself contribute to personality changes. Love and Peck argue that patients in chronic pain have to adopt a considerably different life-style, and apparent personality change may, in several cases, be secondary to the pain experience itself and not be due to any premorbid personality disorder.36
The study group was significantly (P<0.001) more alexithymic than the other groups, pointing to a probable role for alexithymia in the psychobiology of chronic pain. Wise et al. investigated 100 patients evaluated for head pain at a neurology clinic by using the Illness Behavior Questionnaire, the illness effects questionnaires, and the Toronto Alexithymia Scale, and the researchers found that patients with head pain are psychologically distressed but often possess alexithymic characteristics that make insightful associations difficult.37
Physicians tend to mistake the physical symptoms of these patients for undetected organic pathology, which results in overinvestigation and overtreatment and frequently adds iatrogenic complications to the patient's disorder. Also, since alexithymic patients are usually not overtly psychiatrically ill, their physicians regard them as psychologically sound, and these patients are referred for psychiatric consultation rather late or not at all. These two observations present a vital task for the consultation-liaison psychiatrists, which is to help their fellow physicians appreciate the full set of problems these patients face.
Evaluation of the three components of the pain experience with MPQ revealed that nonorganic headache patients used significantly more words to describe sensory components of their pain and reported more severity ascribed to their headaches. However, it should not be concluded that these significant differences could distinguish/differentiate organic from nonorganic cases, because the patients in the organic group diagnosed as having somatoform pain disorder gave the same characteristics as the nonorganic pain group. Mechanic38 used the concept of "abnormal illness behavior" to describe the pain experience in these patients. However, this term does not necessitate that these patients are actually not suffering from pain or that they are feigning symptoms.
Pain experience was shown to be a complex psychobiological phenomenon, which, in addition to sociocultural influences, bears on the shaping of illness behavior in chronic pain states.39 The reported effect of attention on the pain experience reported by Melzack40 may explain the results of Table 6, where clinical distraction of attention raised the magnitude of the minimal stimulus required for pain experience. The nonorganic headache patients had a significantly lower pain tolerance, which is in line with the findings of Peters et al.,10 who found that lower pain tolerance might be psychological, that is, a set of behavior that resulted from reinforced behavior to complain, derived from an interaction between personality characteristics and life situations.
Many other divergent influences, such as psychological needs and social and iatrogenic factors, interact with the mentioned mechanisms to complicate the understanding of chronic pain states.
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CONCLUSION
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The nosological confusion of chronic pain as due to psychogenic-organic dichotomy should be abandoned. Chronic pain (or somatoform) disorder is more understandable as a psychobiological disorder, not as a metaphor. It is the art of the evaluating psychiatrist to identify the components of the patient's state and choose the appropriate interventions. Early detection, management, and probably prevention of chronic pain problems depends on a multidisciplinary team of specialists. Among them is the consultation-liaison psychiatrist, who should share and exchange his/her diagnostic skills with other members of the treatment team to avoid errors of commission and omission that occur in treating chronic pain patients.
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REFERENCES
|
-
Tyrer SP: Psychiatric assessment of chronic pain. Br J Psychiatry 1992; 160:733–741[Free Full Text]
-
Peatfield R: Headache. New York, Springer-Verlag, 1986
-
Chapman CR: Introduction, in The Management of Pain, Vol 2, 2nd Edition, edited by Bonica JJ. Philadelphia, PA, Lea and Febiger, 1990, pp. 284–286
-
Turner JA, Romano JM: Psychological evaluation of pain, in The Management of Pain, Vol 2, 2nd Edition, edited by Bonica JJ. Philadelphia, PA, Lea and Febiger, 1990, pp. 595–659
-
Large RC: DSM-III diagnosis in chronic pain—confusion or clarity? J Nerv Ment Dis 1986; 174:295–303
-
Reich J, Tupin JP, Abromovitz SI: Psychiatric diagnosis of chronic pain patients. Am J Psychiatry 1983; 140:1459–1498
-
Fishbain DA, Goldberg M, Meagher BR: Male and female chronic pain patients categorized by DSM-III psychiatric diagnostic criteria. Pain 1986; 26:181–197[Medline]
-
Catchlove RFH, Cohen K, Braha RED, et al: Incidence and implications of alexithymia in chronic pain patients. J Nerv Ment Dis 1985: 173:264–268
-
McCready C, Turner J: Locus of control, repression, sensitization, and psychological disorder in chronic pain patients. Clinical Psychology 1984; 80:897–901
-
Peters ML, Schmidt AJM, Van Den Hout MS: Chronic low back pain reaction to repeated acute pain stimulation. Pain 1989; 39:69–76[Medline]
-
Okasha A, Sadek A, Al-Sherbini O, et al: Psychometric study of the interrelationship between complaint of pain and depressive illnesses. Egyptian Journal of Psychiatry 1982; 5:257–269
-
Gureje O, Obikoys B: Somatization in primary care pattern and correlates in a clinic in Nigeria. Acta Psychiatr Scand 1992: 86:223–227
-
Peatfield R: Headache. Recent advances in clinical neurology. Headache 1992; 8:1–25
-
Mayou R: Medically unexplained physical symptoms: do not over investigate. BMJ 1991; 303:534–535
-
Spitzer RL, William JB, Gibbon AM: Structured Clinical Interview of DSM-III-R (SCID-I and II, Version l.0). Washington, DC, American Psychiatric Press, 1990
-
Krystal JH, Giller L, Cicchetti DV: Assessment of alexithymia in posttraumatic stress disorder and somatic illness: introduction of a reliable measure. Psychol Med 1986; 48:84–94
-
Rotter JB: Generalized expectancies for internal versus external control of reinforcement. Psychological Monographs General and Applied 1966; 80:1–27
-
Chapman CR, Syrjala KL: Measurement of pain, in The Management of Pain, Vol 2, 2nd Edition, edited by Bonica JJ. Philadelphia, PA, Lea and Febiger, 1990, pp. 80–94
-
Howells JG: Modern Perspectives in Psychiatric Aspects of Surgery. London, UK, The Macmillan Press Ltd, 1978, p. 113
-
Ziegler DK, Rhodes RJ, Hassanein RS: Association of psychological measurements of anxiety and depression with headache history in a non-clinic population. Research and Clinical Studies on Headache 1978; 6:123–135
-
Hatch JP, Schoenfeld LS, Boutros NN, et al: Anger and hostility in tension type headache. Headache 1991; 31:302–304[Medline]
-
Kaiser RS: Depression in adolescent headache patients. Headache 1992; 32:340–344[Medline]
-
Rokicki LA, Holroyd KA: Factors influencing treatment seeking behavior in problem headache sufferers. Headache 1994; 34:429–434[Medline]
-
Tschannen TA, Duckro PN, Margolis RB, et al: The relationship of anger, depression, and perceived disability among headache patients. Headache 1992; 32:501–503[Medline]
-
Jason B, Celentano ScD, Stewart W, et al: Personality and emotional disorder in a community sample of migraine headache sufferers. Am J Psychiatry 1990; 147:303–308[Abstract/Free Full Text]
-
Basbaum AL, Fields HL: Endogenous pain control mechanisms review and hypothesis. Ann Neurol 1978; 4:451–462[Medline]
-
Yaksh TL: The effect of intrathecally administered opioid and adrenergic agents on spinal function, in Spinal Afferent Processing, edited by Yaksh TL. New York, Plenum, 1986, pp. 505–539
-
Lindsay PG, Olsen RB: Maprotiline in pain and depression. J Clin Psychiatry 1985; 46:226–228[Medline]
-
Breslau N, Davis GC: Migraine, major depression and panic disorder: a prospective epidemiologic study of young adults. Caphalalgia 1992; 12:85–90
-
Ward NG: Pain and depression, in The Management of Pain, Vol 2, 2nd Edition, edited by Bonica JJ. Philadelphia, PA, Lea and Febiger, 1990, pp. 310–319
-
Alnaes R, Torgerson S: The relationship between DSM-III symptom disorder (Axis I) and personality disorder (Axis II) in an out-patient population. Acta Psychiatr Scand 1990; 87:485–492
-
Zimmerman M, Coryell W: Diagnosing personality disorder in the community. Arch Gen Psychiatry 1990; 47:527–531[Abstract/Free Full Text]
-
Nurnberg HG, Raskin M, Levine PE, et al: The co-morbidity of borderline personality disorder and other DSM-III-R Axis II personality disorder. Am J Psychiatry 1991; 1448:1371–1377
-
Okasha A, Omar A, Lotaief F, et al: Comorbidity of Axis I and Axis II diagnosis of Egyptian patients with neurotic disorders. Compr Psychiatry 1996; 37:95–101[Medline]
-
Passchier J, Schouten J, van der Donk J, et al: The association of frequent headaches with personality and life events. Headache 1991; 31:116–121[Medline]
-
Love AW, Peck CL: The MMPI and psychological factors in chronic low back pain: a review. Pain 1978; 28:1–12
-
Wise TN, Mann LS, Jani N, et al: Illness beliefs and alexithymia in headache patients. Headache 1994; 34:362–365[Medline]
-
Mechanic D: The concept of illness behavior culture, situation and personal predisposition. Psychol Med 1986; 16:1–7[Medline]
-
Sternbach RA: Psychophysiologic pain syndromes, in The Management of Pain, Vol 2, 2nd Edition, edited by Bonica JJ. Philadelphia, PA, Lea and Febiger, 1990, pp. 287–291
-
Melzack R: The Puzzle of Pain, 3rd Edition. London, UK, Penguin, 1977
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ABSTRACT
INTRODUCTION
