1. Psychological Pain as a symptom
Somatic Symptom Disorder(somatization)
Illness Anxiety Disorder(hypochondriass)
Functional Neurological Symptom Disorder(Conversion)
Factitious Disorder
Pain Disorder

2. Pain Disorder(DSM-5) Prevalence:5-12percent
Is associated with affective and anxiety disorders
Chronic pain most frequently associated with depressive disorders
Acute pain most frequently associated with anxiety disorders

3. Pain Disorder
Depressive disorders, alcohol dependence, and chronic pain are more common in relatives of individuals with chronic pain disorder
Increased risk for suicide:
pain associated with severe depression
Pain in terminal illness such as cancer

4. Etiology Psychodynamic factors Behavioral Factors
Interpersonal Factors
Biological Factors

5. Mind
Brain
Body

6. Psychodynamic Factors:
Intrapsychic Conflicts and body language
Alexythymia
Identification

7. Behavioral and interpersonal factors:
Punishment and Reward
Secondary gain
Manipulation of environment

8. Depression and pain commonly occur.
Between 30-60% of individuals with pain report having comorbid depression.2,3,4
Approximately half of patients with depression report pain.1
1) Katona et al. Clin Med. 2005;5:390-5; 2) Bair et al. Arch Intern Med 2003;163:
3) Hassett et al. Curr Pain Headache Rep. 2014;418:36; 4) Arnold et al. J Clin Psychiatry 2006;67:

9. Chronic Pain equivalent of depression
(Masked depression)

10. Complexity: Multiple Symptoms
Most common complaints:
Chronic widespread pain
Fatigue
Sleep disturbance
Poor mood
Cognitive difficulties
Muscle stiffness
Frequently occurring complaints:
Gastrointestinal symptoms
Headache
Genitourinary
Numbness and tingling
Dizziness/loss of balance
Weakness
Skin changes
Clauw DJ. JAMA 2014;311;
Mease et al. Arthritis Rheum 2008;59(7):952-60

11. Complexity: High Rates of Co-Morbidity
Comorbidity with other chronic pain states
42-70% of patients with FM also meet criteria for CFS
32-80% of patients with FM meet criteria for IBS
42% of back pain patients meet criteria for FM
Aaron & Buchwald. Ann Intern Med 2001;134:868–81
Brummett, Goesling, Tsodikov, Meraj, Wasserman, Clauw &Hassett.
Arthritis Rheum 2013;65:
Co-Morbidity with chronic systemic disease
Rheumatoid arthritis, lupus, inflammatory bowel disease
Lee et al. Ann Rheum Dis 2013;72:
Bliddal et al. Best Prac Res Clin Rheumatol 2007;21:
Schlesinger, Hassett et al. Ann Rheum 2009
Psychiatric co-morbidity – mostly anxiety and depression.

12. Neurobiological perspective.
Brain regions associated with physical pain overlap with psychological pain processing:
Sensory discriminative dimension
Somatosensory cortices (S1, S2)
Dorsal posterior insula
Affective emotional dimension
Anterior insula
Prefrontal cortex
Anterior cingulate cortex
Thalamus
Amygdala
Hippocampus
Goesling, Clauw & Hassett. Curr Psychiatry Rep. 2013;15:421

13. Neurobiological perspective.
Neurotransmitters – pain
Serotonin
Norepinephrine
Glutamate
GABA
Neurotransmitters - depression
Serotonin
Norepinephrine
Glutamate
GABA
Similar neurotransmitter anomalies exist.
Both respond to SNRIs, but SSRIs provide little pain relief.
SNRIs might be better thought of as “neuromodulators.”
Pain relief with SNRIs is often independent of changes in depression.
Ablin, Buskila & Clauw. Curr Pain Headache Rep 2009;13:343-9

14. Pain, Depression and Sleep Triad
(anxiety/stress)
Sleep

15. Pain, Depression and Sleep Triad
(anxiety/stress)
Sleep

16. Sleep Hygiene “Sleep and sleep hygiene”
DHHS 64 million Americans have chronic insomnia (> 20%)
Disrupting slow wave sleep over several nights in sedentary middle-aged females (without reducing total sleep efficiency) results in a decreased pain threshold, increased discomfort, and fatigue.
Lentz et al., J Rheumatol 1999, 26(7),
In FM, >75% report sleep disturbances.
Insomnia up to 65%, snoring and arousals up to 78%, RLS up to 41%, excessive daytime sleepiness up to 93%.
FM with sleep studies = obstructive sleep apnea ~ 80%
Abad et al., Sleep Med Rev 2008;12:211-28

17. Non-Pharmacological Interventions

18. Interventions that enhance positive emotions and resilience!
Many positive affective variables

19. Acknowledgments
Dr Alireza Ahmadi