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Pain and cancer
Journalof Psychosomatic Research,Vol. 14, pp. 365 to 370. PergamonPress,1970. Printedin NorthernIreland
PAIN AND CANCER* JOHN M.
WOODFORDE
(Received
and
JENNIFER
19 January
R.
FIELDING
1970)
PAIN, destruction or loss of body parts, and death are the expected associates of cancer. In practice these pessimistic forbodings are not necessarily realised. In particular the incidence of severe, intractable pain is low contrary to the expectations of both the patients and their doctors. The pervasive sense of inevitability undoubtedly leads to the prescribing by doctors of addiction producing narcotics and it has been our observation that this hopelessness and helplessness may contribute to the complaint of pain by the patients. The diagnosis of the cause of pain usually is seen as manifestly clear in patients with demonstrated tissue damage due to the neoplastic disease and the usually difficult question of whether there are ‘psychogenic’ components to the pain is easily pushed aside. Yet it is clear that patients with neoplastic disease, like any other disease, often have complaints which have major emotional determinants. Furthermore, while all doctors agree that it is natural to have an emotional reaction following the diagnosis of neoplastic disease and its treatment, there are some who would prefer to agree with the patients who state or imply that the emotional effects are necessarily secondary to The tendency in clinical practice is to the pain, rather than involved in its causation. accept the ‘psychogenic-organic’ dichotomy too easily. Previous papers [l, 21 have described the evaluation and management of patients with intractable pain referred for consultation at a Pain Clinic. We, like many others [3-61 have sought more information about the patient’s complaint of pain. This present paper reports some investigations into the pain of patients with cancer. METHOD
The Cornell Index was introduced to this clinic in an attempt to provide, in a simple fashion, some more information about the emotional state of the patient. Weider ei al. [7,8] have described this test and its uses as an adjunct to the interview and as an instrument which “would statistically differentiate persons with serious personal and psychosomatic disturbances from the rest of the population”. As a practical point it was hoped that, by having more information about the patient’s personality, it would be possible to predict those patients who would respond best to the recommended treatment. Querido [9] has shown that assessment of personality and social factors allowed prediction of the results of treatment in a general hospital. The first hypothesis in the present study was that patients referred to the Pain Clinic for treatment of intractable pain have more personality disturbance than those who have not been referred. The second hypothesis in this investigation is that patients with the greatest personality disturbance respond less well to pain relieving procedures. Form N2 of the Cornell Index was used. This is a very simple pencil and paper test. It has 101 questions on two sides of a page. The patient has to answer “yes” or “no” to these questions which are phrased in informal English and can be understood by all those people who can read simple English. It can be completed usually within 15 min. Each patient attending the Pain Clinic was invited to complete the questionnaire in the waiting room of the Outpatient Department. He was then interviewed by the members of the clinic. The recommended treatment usually was performed by a member of the Pain Clinic and varied from nerve block, cordotomy, antidepressants, and/or alteration of analgesics. The results were assessed at a subsequent visit to the clinic or by contact with the referring doctor. The result of treatment was assessed on a three point scale as (1) “complete” or “satisfactory” relief; (2) “slight” or “fair” or “some” relief; and (3) “unchanged” or “worse”. It was occasionally * St. Vincent’s Hospital, Sydney, N.S.W. Australia 2010. 1
365
366
J. M.
WOODFORDE
and J. R.
FIELDING
difficult to make distinctions as the pain often varied from time to time and as to the informant. In the final analysis the distinction was between two categories only, “improved” or “unimproved”. The largest source of referral to the Pain Clinic was the Radiotherapy and Tumor Clinic of this hospital. And, although these patients formed a very small percentage of the population of the Radiotherapy and Tumour Clinic, it was decided to seek a sample of unreferred patients against which to compare the scores on the Index. The sample of “unreferred” patients sought in the Radiotherapy and Tumour Clinic was matched with those referred to the Pain Clinic. This was done for age, diagnostic categories, and with the stipulation that they have active disease. It is of interest that there was a greater resistance to completing the questionnaire at the Radiotherapy and Tumour Clinic than at the Pain Clinic. RESULTS During the period of one year of investigation 80 patients attended the Pain Clinic; Of these 80 patients, 54 were undergoing, or had undergone, treatment in the Radiotherapy and Tumour Clinic of this hospital. It is this latter group which is the subject for investigation regarding response to procedures for pain relief. It is a percentage similar to that previously reported [l]. Of this group of 54 Pain Clinic patients two patients refused or were too ill to complete the Index. A further five patients could not be assessed regarding their response to treatment. The reasons for this were that they either refused to accept the recommendation regarding management, that they died before treatment or later assessment, or were otherwise lost to follow-up. This left 47 patients who had both completed the Index and were available for assessment of their response to treatment. TABLE
l.-AGE
Age
DISTRIBUTION OF THE PATIENTS
Pain clinic (%)
80-89 70-79 2 6&69 18 50-59 13 4@49 8 30-39 3 20-29 2 n = 52
Unreferred (%)
I1 34 25 15 6 4
1: 12 13 10 4 4 n = 55
2: 22 24 18 7 7
There was twice as many men (35) as women (17) in our group of Pain Clinic patients referred from the Tumour Clinic. This fact is largely related to the sex incidence of the particular site of the neoplasms. The average age was 55.6 yr with a wide distribution from 25 to 80 yr but 86 per cent of patients fell within the range 40-79 (Table 1). TABLE?!-SITE
DISTRIBUTION OF THE PRIMARY MALIGNANCY
Organs involved
Pain clinic
Head and Neck Lung Breast Bowel Genitourinary Other
19 5 3 6 12 7
Unreferred 13 7 18 1 11 5
The diagnosis was malignant disease of some type. In the largest group the primary site (Table 2) was the head and neck on 19 occasions-lip, tongue, floor of the mouth, salivary glands, pharynx, palate, oesophagus and larynx, and in the skin of the head. On a further 12 occasions the primary lesion was in the genitourinary system-kidney, prostate, bladder, testes and cord, ovary, uterus. The next largest group (6) was those with primary lesions in the rectum and colon. Lesions in the bronchi occurred on five occasions. There was a smaller number of primary lesions in the breast (3) limbs (3 sarcomas). The site of pain was the head and neck on 19 occasions, the chest 11 times, the shoulder and upper limbs 9 times, the abdomen 4 times and the pelvis and lower limbs on 12 occasions. There was no
367
Pain and cancer
pattern of lateralisation of the site of pain. The pain was located on the left side by 20 patients, the right by 18 patients and a further 16 patients did not indicate whether the pain was localised to one particular side. The total scores on the Index of the patients seen in the Pain Clinic were compared with their response to treatment. The scores were fairly symmetrically distributed about the median of 18 and ranged from a score of 1 to a score of 48 (Table 3). TABLE 3.-DISTRIBUTION OFCORNELL MEDICALINDEX SCORES AND THE RESPONSE TO TREATMENT OF PAIN
Index score 23+ IS-22 13-17 O-12
Response to treatment of pain Slight None Good 9 5 6 5 25
1 2 3 5 11
6 0 0 5 11
Different methods of “cut-off levels” of score are used with this test. An Index score of 13 or more is reported [S] to include the majority of those with severe personality disturbance and a number of ostensibly healthy persons. A smaller percentage of serious personality disturbances but few ostensibly healthy persons are included when a cut-off level of 23 is used. In this investigation an intermediate “cut-off level” of 18 was chosen for statistical purposes. There was no significant correlation between the score on the Cornell Index and the response to treatment (x* = 0.15; p = 0.70). The second sample of patients given the Index were those who were under treatment in the Radiotherapy and Tumour Clinic but who had not been referred to the Pain Clinic i.e., the “unreferred” sample. There were 55 patients in this sample. The average age was 55.6 yr with 84 per cent lying between the age of 40 and 79. There were 25 men and 30 women, The sex distribution was more equal than in the group of patients referred to the Pain Clinic. Comparison of the mean scores on the Index between the two samples of patients indicates some differences (Table 4). The Pain Clinic sample has a mean total score of 18.81 which is significantly greater than the 12.66 of the unreferred patients, i.e., in the direction of more personality disturbance. TABLE~.--COMPARISON
Total score Fear and Inadequacy Depression Nervousness and Anxiety Neurocirculatory Startle Reactions Psychosomatic Symptoms Hypochondriasis
and Asthenia
Gastrointestinal Sensitivity and Suspiciousness Psychopathy
OF CORNELL
MEDICAL
INDEX SCORES
Pain clinic
Unreferred
T
18.81 3.17 1.64 I.80 1.27 1.19 2.62
12.66 3.05 0.64 1.47 1.38 1.4 1.55
2.764 0.2276 3.392 1.166 0.4919 0.664 2.381
2.21
1.41
2.335
3.19 0.38 1.32
1.47 0.65 1.33
3.946 1.586 0.031
PO.l 0.05 >O.l >O.l <0.02 >O.Ol <0.05 >0.02 to.001 >O.l >O.l
Furthermore, it can be seen in the analysis of the scores that there are significant differences in the symptom complexes between the Pain Clinic sample and the “unreferred” sample. The patients referred to the Pain Clinic scored higher in the areas of Depression, Psychosomatic symptoms, Gastrointestinal symptoms, Hypochondriasis and Asthenia. The occurrence of depression among patients with pain referred to this clinic has been commented upon previously [1, 21. It is possible that there would be differences in the Index scores between the men and women in each group both in the total scores and in the areas of the different symptom complexes. However it can be seen (Table 5) that in neither the Pain Clinic sample or the “unreferred” sample is there any significant difference in the mean scores between the sexes. The difference between the groups were not attributable to sex difference between the two groups.
J. M.
368
TABLE 5.-COMPARISON
WOODFORDE BETWEEN
and J. R.
SEXESOF
Pain clinic Females Males Total score Depression Other Psychosomatic Symptoms Hypochondriasis and Asthenia Gastrointestinal
FIELDING
CORNELL MEDICAL
f
19.66 1.77 2.91
17.06 1.35 2.00
0.8019 0.7936 1.751
2.2
2.23
3.31
2.94
INDEX SCORES
Unreferred Males Females
t
13.6 0.64 1.4
11.87 0.73 1.6
0.5091 0.3243 0.3922
0.061
1.44
1.50
0.013
0.4944
1.52
1.43
0.016
DISCUSSION
The use of the Cornell Medical Index (C.M.I.) has confirmed our clinical impression that the group of “referred” cancer patients with intractable pain has more personality disturbance (higher mean total scores) than the “unreferred” group of cancer patients. The personality disturbance which distinguished the group of “referred” patients was in the areas of depression, psychosomatic symptoms, gastrointestinal symptoms, hypochondriasis and asthenia. However there was no correlation between scores on the C.M.I. and the response to treatment within the group of referred patients. Therefore the use of the test as a screening tool at the Pain Clinic would be of little use with cancer patients similar to those in this group. We had considered that personality features would be one factor significantly related to the complaint of pain, as would be the fear of helplessness of the patient and damage to the body image. It is worthwhile to look at each of these considerations and some of the relationships between them. A wide range of emotional reactions can occur to cancer [lo] or be associated with the complaint of pain [11,12] but the occurrance of depression in our “referred” group was not unexpected. Yet the relationship of the depression to the intractable pain in the patients is not simply explained. The pain could be part of the depressive syndrome or it could be secondary to the pain resulting from the progression of the cancer. Of course, the latter too has its significance emotionally as well as due to local pressure on peripheral nerves. The widespread occurrence of moderately severe depression presenting with physical symptoms, such as pain, is recognised frequently by psychiatrists but less often by other doctors [13]. Bradley [14] has drawn attention to the depression of patients presenting with persistent localised pain and this association has been observed in our experience at the Pain Clinic in the treatment of patients with postherpetic neuralgia [2]. The latter have some characteristics in common with cancer patients: the pain is persistent to the point of making both doctor and patient feel helpless, and there is a marked disturbance of body image. The pain is generally relieved by the use of antidepressant medication. Cancer differs from most other conditions by the nature of its being a progressive disease. This progression depends on many factors including emotional factors and hormonal changes. West [lo] has drawn attention to psycho!ogical defences which are utilised in cancer patients and how these may affect host resistance and result in success or failure of therapy for the disease. It is an important observation in this regard that many of the cancer patients with intractable pain referred to the Pain
Pain and cancer
369
Clinic have subsequently died within a few months. It seems likely that the pain, depression and the progress of the disease are all indicative of the patient’s helplessness to cope with the disease, the damage of his body and the threat of life on both the biochemical and the emotional level. Childlike helplessness was a factor in the relationship between pain and depression recently discussed by Joffe and Sandler [15] who suggested that the depressive reaction is a “response to a state of pain, a response that reflects helplessness, capitulation, and resignation in the face of pain”. They introduced the notion of a painful discrepancy in the self representation, in effect, a loss of self-image causing psychic pain which may result in depression or may be displaced to the idea of bodily pain. In those cases where there is pain and depression they regarded these as mixed clinical states in which no stable defensive solution has been reached. Another aspect of the complaint of pain is its communication function. The pattern of communication between the doctor and the patient with cancer has been reviewed by Abrams [16]. She points to the changes in the communications from phase to phase of the disease. Many of the patients in the present study were in the phase of advancing disease (metastasis, etc.) when it is obvious to both the doctor and the patient that treatment has been unsuccessful in halting the disease. Abrams reminds us of the change from the optimism of the earlier treatment phase which gives way in this next phase to anxiety, euphemism and evasion, and dependency on the doctor with fears of abandonment. Abrams report that patients rarely talk about the diagnosis at this stage but they wish to talk about questions related to bodily symptoms, diet, activity, etc. The complaint of pain can be an assurance of getting help in a euphemistic fashion without acknowledging the disease itself, It is evident that the recognition and appropriate treatment of the depression and the implied requests for help will afford a great deal of relief to cancer patients who complain of pain. SUMMARY The Cornell Medical Index was used to provide more information regarding the personality disturbance of cancer patients referred to a Pain Clinic. There was no significant correlation between the scores of the Cornell Medical Index and the response to procedures for pain relief of a sample of 54 patients with persistent pain referred from the Radiotherapy and Tumor Clinics. There were significant differences between the scores of this referred sample and a sample of 55 patients at the Radiotherapy and Tumor Clinics who had not been referred. These differences indicate that the sample of patients referred to the Pain Clinic had more personality disturbance and that there were significant differences in the areas of Depression, Gastrointestinal symptoms, Hypochondriasis and Asthenia, and Psychosomatic symptoms. The relationship between the complaint of pain and the emotional state of the patient as a reaction to cancer has been discussed. REFERENCES 1. MCEWAN B. W., DE WILDE F. W., DWYER B., W~~DFORDE J. M., BLEASEL K. and CONNOLLEY T. J. The pain clinic; a clinic for the management of intractable pain. Med. J. Aust. 1, 676 (1965). 2. W~~DFORDE J. M., DWYER B., MCEWAN B. W., DE WILDB F. W., BLEASEL K., CONXOLLEYT. J. and Ho C. Y. Treatment of post-herpetic neuralgia. Med. J. Aust. 2, 869 (1965). 3. KOLB L. C. The Painful Phantom. Psychology, Physiology and Treatment. Charles C. Thomas, Springfield, Illinois (1954).
310 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16.
J. M. W~~DFORDE and J. R. FOLDING SZASZT. S., Pain and Pleasure. A studv of Bodily Feelings. Tavistock, London (1957). ENGEL G. L. Psychogenic pain and the pain prone pat&t. Am. J. Med. 26, 899 (1959). MERSKEYH. and SPEARF. G. The concevt of vain. J. Psvchosom. Res. 2, 59 (1967). WEIDERA., BRODMANK., MI~TELMANNB:, WE~HSLERD .‘and WOLFFH. G. The Cornell Index. Psychosom. Med. 8,411 (1946). WEIDER A., WOLFF H. G., BRODMANK., MI~~ELMANNB. and WECHSLERD. Cornell Index Manual. Aust. Council of Educational Research. Melbourne (1948). QUERIDOA. Forecast and Follow-up. An investigation into the clinical, social, and mental factors determining the results of hospital treatment. Br. J. Preu. Sot. Med. 13, 33 (1959). WEST, P. M. Psychologic factors and host resistance to cancer, In Year Book of Cancer (Edited by CLARK R. I. and CLIMLEYR. W.), p. 542. (19561957). WALTERSA. Psychogenic regional pain alias hysterical pain. Brain 84, 1 (1961). MERSKEYH. The characteristics of persistent pain in psychological illness. J. Psychosom. Res. 9, 291 (1965). W~-rrs C. A. H. The mild endogenous depression. Br. Med. J. 1,4 (1957). BRADLEYJ. J. Severe localised pain associated with the depressive syndrome. Br. J. Psychiat. 109, 741 (1963). JOFFEW. G. and SANDLERJ. On the concept of pain with special reference to depression and psychogenic pain. J. Psychosom. Res. 2, 69 (1967). ABRAMSR. D. The patient with cancer-his changing pattern of communication. New Et@. J. Med. 274, 317 (1966).
PAIN AND CANCER* JOHN M.
WOODFORDE
(Received
and
JENNIFER
19 January
R.
FIELDING
1970)
PAIN, destruction or loss of body parts, and death are the expected associates of cancer. In practice these pessimistic forbodings are not necessarily realised. In particular the incidence of severe, intractable pain is low contrary to the expectations of both the patients and their doctors. The pervasive sense of inevitability undoubtedly leads to the prescribing by doctors of addiction producing narcotics and it has been our observation that this hopelessness and helplessness may contribute to the complaint of pain by the patients. The diagnosis of the cause of pain usually is seen as manifestly clear in patients with demonstrated tissue damage due to the neoplastic disease and the usually difficult question of whether there are ‘psychogenic’ components to the pain is easily pushed aside. Yet it is clear that patients with neoplastic disease, like any other disease, often have complaints which have major emotional determinants. Furthermore, while all doctors agree that it is natural to have an emotional reaction following the diagnosis of neoplastic disease and its treatment, there are some who would prefer to agree with the patients who state or imply that the emotional effects are necessarily secondary to The tendency in clinical practice is to the pain, rather than involved in its causation. accept the ‘psychogenic-organic’ dichotomy too easily. Previous papers [l, 21 have described the evaluation and management of patients with intractable pain referred for consultation at a Pain Clinic. We, like many others [3-61 have sought more information about the patient’s complaint of pain. This present paper reports some investigations into the pain of patients with cancer. METHOD
The Cornell Index was introduced to this clinic in an attempt to provide, in a simple fashion, some more information about the emotional state of the patient. Weider ei al. [7,8] have described this test and its uses as an adjunct to the interview and as an instrument which “would statistically differentiate persons with serious personal and psychosomatic disturbances from the rest of the population”. As a practical point it was hoped that, by having more information about the patient’s personality, it would be possible to predict those patients who would respond best to the recommended treatment. Querido [9] has shown that assessment of personality and social factors allowed prediction of the results of treatment in a general hospital. The first hypothesis in the present study was that patients referred to the Pain Clinic for treatment of intractable pain have more personality disturbance than those who have not been referred. The second hypothesis in this investigation is that patients with the greatest personality disturbance respond less well to pain relieving procedures. Form N2 of the Cornell Index was used. This is a very simple pencil and paper test. It has 101 questions on two sides of a page. The patient has to answer “yes” or “no” to these questions which are phrased in informal English and can be understood by all those people who can read simple English. It can be completed usually within 15 min. Each patient attending the Pain Clinic was invited to complete the questionnaire in the waiting room of the Outpatient Department. He was then interviewed by the members of the clinic. The recommended treatment usually was performed by a member of the Pain Clinic and varied from nerve block, cordotomy, antidepressants, and/or alteration of analgesics. The results were assessed at a subsequent visit to the clinic or by contact with the referring doctor. The result of treatment was assessed on a three point scale as (1) “complete” or “satisfactory” relief; (2) “slight” or “fair” or “some” relief; and (3) “unchanged” or “worse”. It was occasionally * St. Vincent’s Hospital, Sydney, N.S.W. Australia 2010. 1
365
366
J. M.
WOODFORDE
and J. R.
FIELDING
difficult to make distinctions as the pain often varied from time to time and as to the informant. In the final analysis the distinction was between two categories only, “improved” or “unimproved”. The largest source of referral to the Pain Clinic was the Radiotherapy and Tumor Clinic of this hospital. And, although these patients formed a very small percentage of the population of the Radiotherapy and Tumour Clinic, it was decided to seek a sample of unreferred patients against which to compare the scores on the Index. The sample of “unreferred” patients sought in the Radiotherapy and Tumour Clinic was matched with those referred to the Pain Clinic. This was done for age, diagnostic categories, and with the stipulation that they have active disease. It is of interest that there was a greater resistance to completing the questionnaire at the Radiotherapy and Tumour Clinic than at the Pain Clinic. RESULTS During the period of one year of investigation 80 patients attended the Pain Clinic; Of these 80 patients, 54 were undergoing, or had undergone, treatment in the Radiotherapy and Tumour Clinic of this hospital. It is this latter group which is the subject for investigation regarding response to procedures for pain relief. It is a percentage similar to that previously reported [l]. Of this group of 54 Pain Clinic patients two patients refused or were too ill to complete the Index. A further five patients could not be assessed regarding their response to treatment. The reasons for this were that they either refused to accept the recommendation regarding management, that they died before treatment or later assessment, or were otherwise lost to follow-up. This left 47 patients who had both completed the Index and were available for assessment of their response to treatment. TABLE
l.-AGE
Age
DISTRIBUTION OF THE PATIENTS
Pain clinic (%)
80-89 70-79 2 6&69 18 50-59 13 4@49 8 30-39 3 20-29 2 n = 52
Unreferred (%)
I1 34 25 15 6 4
1: 12 13 10 4 4 n = 55
2: 22 24 18 7 7
There was twice as many men (35) as women (17) in our group of Pain Clinic patients referred from the Tumour Clinic. This fact is largely related to the sex incidence of the particular site of the neoplasms. The average age was 55.6 yr with a wide distribution from 25 to 80 yr but 86 per cent of patients fell within the range 40-79 (Table 1). TABLE?!-SITE
DISTRIBUTION OF THE PRIMARY MALIGNANCY
Organs involved
Pain clinic
Head and Neck Lung Breast Bowel Genitourinary Other
19 5 3 6 12 7
Unreferred 13 7 18 1 11 5
The diagnosis was malignant disease of some type. In the largest group the primary site (Table 2) was the head and neck on 19 occasions-lip, tongue, floor of the mouth, salivary glands, pharynx, palate, oesophagus and larynx, and in the skin of the head. On a further 12 occasions the primary lesion was in the genitourinary system-kidney, prostate, bladder, testes and cord, ovary, uterus. The next largest group (6) was those with primary lesions in the rectum and colon. Lesions in the bronchi occurred on five occasions. There was a smaller number of primary lesions in the breast (3) limbs (3 sarcomas). The site of pain was the head and neck on 19 occasions, the chest 11 times, the shoulder and upper limbs 9 times, the abdomen 4 times and the pelvis and lower limbs on 12 occasions. There was no
367
Pain and cancer
pattern of lateralisation of the site of pain. The pain was located on the left side by 20 patients, the right by 18 patients and a further 16 patients did not indicate whether the pain was localised to one particular side. The total scores on the Index of the patients seen in the Pain Clinic were compared with their response to treatment. The scores were fairly symmetrically distributed about the median of 18 and ranged from a score of 1 to a score of 48 (Table 3). TABLE 3.-DISTRIBUTION OFCORNELL MEDICALINDEX SCORES AND THE RESPONSE TO TREATMENT OF PAIN
Index score 23+ IS-22 13-17 O-12
Response to treatment of pain Slight None Good 9 5 6 5 25
1 2 3 5 11
6 0 0 5 11
Different methods of “cut-off levels” of score are used with this test. An Index score of 13 or more is reported [S] to include the majority of those with severe personality disturbance and a number of ostensibly healthy persons. A smaller percentage of serious personality disturbances but few ostensibly healthy persons are included when a cut-off level of 23 is used. In this investigation an intermediate “cut-off level” of 18 was chosen for statistical purposes. There was no significant correlation between the score on the Cornell Index and the response to treatment (x* = 0.15; p = 0.70). The second sample of patients given the Index were those who were under treatment in the Radiotherapy and Tumour Clinic but who had not been referred to the Pain Clinic i.e., the “unreferred” sample. There were 55 patients in this sample. The average age was 55.6 yr with 84 per cent lying between the age of 40 and 79. There were 25 men and 30 women, The sex distribution was more equal than in the group of patients referred to the Pain Clinic. Comparison of the mean scores on the Index between the two samples of patients indicates some differences (Table 4). The Pain Clinic sample has a mean total score of 18.81 which is significantly greater than the 12.66 of the unreferred patients, i.e., in the direction of more personality disturbance. TABLE~.--COMPARISON
Total score Fear and Inadequacy Depression Nervousness and Anxiety Neurocirculatory Startle Reactions Psychosomatic Symptoms Hypochondriasis
and Asthenia
Gastrointestinal Sensitivity and Suspiciousness Psychopathy
OF CORNELL
MEDICAL
INDEX SCORES
Pain clinic
Unreferred
T
18.81 3.17 1.64 I.80 1.27 1.19 2.62
12.66 3.05 0.64 1.47 1.38 1.4 1.55
2.764 0.2276 3.392 1.166 0.4919 0.664 2.381
2.21
1.41
2.335
3.19 0.38 1.32
1.47 0.65 1.33
3.946 1.586 0.031
P
Furthermore, it can be seen in the analysis of the scores that there are significant differences in the symptom complexes between the Pain Clinic sample and the “unreferred” sample. The patients referred to the Pain Clinic scored higher in the areas of Depression, Psychosomatic symptoms, Gastrointestinal symptoms, Hypochondriasis and Asthenia. The occurrence of depression among patients with pain referred to this clinic has been commented upon previously [1, 21. It is possible that there would be differences in the Index scores between the men and women in each group both in the total scores and in the areas of the different symptom complexes. However it can be seen (Table 5) that in neither the Pain Clinic sample or the “unreferred” sample is there any significant difference in the mean scores between the sexes. The difference between the groups were not attributable to sex difference between the two groups.
J. M.
368
TABLE 5.-COMPARISON
WOODFORDE BETWEEN
and J. R.
SEXESOF
Pain clinic Females Males Total score Depression Other Psychosomatic Symptoms Hypochondriasis and Asthenia Gastrointestinal
FIELDING
CORNELL MEDICAL
f
19.66 1.77 2.91
17.06 1.35 2.00
0.8019 0.7936 1.751
2.2
2.23
3.31
2.94
INDEX SCORES
Unreferred Males Females
t
13.6 0.64 1.4
11.87 0.73 1.6
0.5091 0.3243 0.3922
0.061
1.44
1.50
0.013
0.4944
1.52
1.43
0.016
DISCUSSION
The use of the Cornell Medical Index (C.M.I.) has confirmed our clinical impression that the group of “referred” cancer patients with intractable pain has more personality disturbance (higher mean total scores) than the “unreferred” group of cancer patients. The personality disturbance which distinguished the group of “referred” patients was in the areas of depression, psychosomatic symptoms, gastrointestinal symptoms, hypochondriasis and asthenia. However there was no correlation between scores on the C.M.I. and the response to treatment within the group of referred patients. Therefore the use of the test as a screening tool at the Pain Clinic would be of little use with cancer patients similar to those in this group. We had considered that personality features would be one factor significantly related to the complaint of pain, as would be the fear of helplessness of the patient and damage to the body image. It is worthwhile to look at each of these considerations and some of the relationships between them. A wide range of emotional reactions can occur to cancer [lo] or be associated with the complaint of pain [11,12] but the occurrance of depression in our “referred” group was not unexpected. Yet the relationship of the depression to the intractable pain in the patients is not simply explained. The pain could be part of the depressive syndrome or it could be secondary to the pain resulting from the progression of the cancer. Of course, the latter too has its significance emotionally as well as due to local pressure on peripheral nerves. The widespread occurrence of moderately severe depression presenting with physical symptoms, such as pain, is recognised frequently by psychiatrists but less often by other doctors [13]. Bradley [14] has drawn attention to the depression of patients presenting with persistent localised pain and this association has been observed in our experience at the Pain Clinic in the treatment of patients with postherpetic neuralgia [2]. The latter have some characteristics in common with cancer patients: the pain is persistent to the point of making both doctor and patient feel helpless, and there is a marked disturbance of body image. The pain is generally relieved by the use of antidepressant medication. Cancer differs from most other conditions by the nature of its being a progressive disease. This progression depends on many factors including emotional factors and hormonal changes. West [lo] has drawn attention to psycho!ogical defences which are utilised in cancer patients and how these may affect host resistance and result in success or failure of therapy for the disease. It is an important observation in this regard that many of the cancer patients with intractable pain referred to the Pain
Pain and cancer
369
Clinic have subsequently died within a few months. It seems likely that the pain, depression and the progress of the disease are all indicative of the patient’s helplessness to cope with the disease, the damage of his body and the threat of life on both the biochemical and the emotional level. Childlike helplessness was a factor in the relationship between pain and depression recently discussed by Joffe and Sandler [15] who suggested that the depressive reaction is a “response to a state of pain, a response that reflects helplessness, capitulation, and resignation in the face of pain”. They introduced the notion of a painful discrepancy in the self representation, in effect, a loss of self-image causing psychic pain which may result in depression or may be displaced to the idea of bodily pain. In those cases where there is pain and depression they regarded these as mixed clinical states in which no stable defensive solution has been reached. Another aspect of the complaint of pain is its communication function. The pattern of communication between the doctor and the patient with cancer has been reviewed by Abrams [16]. She points to the changes in the communications from phase to phase of the disease. Many of the patients in the present study were in the phase of advancing disease (metastasis, etc.) when it is obvious to both the doctor and the patient that treatment has been unsuccessful in halting the disease. Abrams reminds us of the change from the optimism of the earlier treatment phase which gives way in this next phase to anxiety, euphemism and evasion, and dependency on the doctor with fears of abandonment. Abrams report that patients rarely talk about the diagnosis at this stage but they wish to talk about questions related to bodily symptoms, diet, activity, etc. The complaint of pain can be an assurance of getting help in a euphemistic fashion without acknowledging the disease itself, It is evident that the recognition and appropriate treatment of the depression and the implied requests for help will afford a great deal of relief to cancer patients who complain of pain. SUMMARY The Cornell Medical Index was used to provide more information regarding the personality disturbance of cancer patients referred to a Pain Clinic. There was no significant correlation between the scores of the Cornell Medical Index and the response to procedures for pain relief of a sample of 54 patients with persistent pain referred from the Radiotherapy and Tumor Clinics. There were significant differences between the scores of this referred sample and a sample of 55 patients at the Radiotherapy and Tumor Clinics who had not been referred. These differences indicate that the sample of patients referred to the Pain Clinic had more personality disturbance and that there were significant differences in the areas of Depression, Gastrointestinal symptoms, Hypochondriasis and Asthenia, and Psychosomatic symptoms. The relationship between the complaint of pain and the emotional state of the patient as a reaction to cancer has been discussed. REFERENCES 1. MCEWAN B. W., DE WILDE F. W., DWYER B., W~~DFORDE J. M., BLEASEL K. and CONNOLLEY T. J. The pain clinic; a clinic for the management of intractable pain. Med. J. Aust. 1, 676 (1965). 2. W~~DFORDE J. M., DWYER B., MCEWAN B. W., DE WILDB F. W., BLEASEL K., CONXOLLEYT. J. and Ho C. Y. Treatment of post-herpetic neuralgia. Med. J. Aust. 2, 869 (1965). 3. KOLB L. C. The Painful Phantom. Psychology, Physiology and Treatment. Charles C. Thomas, Springfield, Illinois (1954).
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