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Illness behaviour syndromes associated with intractable pain
61 Pain, 2 (1976) 61-71 @ Elsevier/North-Holland,
Amsterdam
ILLNESS BEHAVIOUR INTRACTABLE PAIN I. PILOWSKY Department
(Accepted
- Printed
SYNDROMES
in The Netherlands
ASSOCIATED
WITH
and N.D. SPENCE of Psychiatry,
November
University
of Adelaide,
Adelaide
(Australia)
7th, 1975)
SUMMARY
One hundred patients, referred for the management of intractable pain, (IBQ). Responses were completed a 52-item Illness Behaviour Questionnaire scored on 7 scales: general hypochondria&, disease conviction, psychological versus somatic perception of illness, affective inhibition, affective disturbance, denial, and irritability. IBQ scale profiles were subjected to numerical analysis and 6 taxonomic clusters were identified. Patients in groups 1-3 were characterized by a relatively non-neurotic, reality-oriented attitude to illness, as indicated by low scores on the first three scales. Patients in groups 4-6 manifested greater evidence of ‘abnormal illness behaviour’, and presented syndromes resembling ‘hysteria’, ‘conversion reaction’, and ‘hypochondriasis’ respectively.
INTRODUCTION
An individual’s experience of pain is a complex event determined by many cognitive, affective, interpersonal and cultural factors [ 261. The interaction of these variables, which acts to disrupt any simple one-to-one relationship between degree of pathological damage and severity of pain, is exemplified in the clinical presentation of patients whose complaints of pain persist in the absence of adequate somatic pathology. Clinicians and researchers have noted that patients referred with intractable pain tend to show evidence of affective or personality disorders, including depression [ 1,4-6,13,23,24,26,29,30] , hysteria and conversion [2,4,5,7,13,15,20,23,24,26,29,30], anxiety [4,6,13,15,23,29], hypochondriasis [ 2,24,26,30] , resentment and frustration [ 4-6,8,24,28] , and sometimes psychosis [ 5,291. The first 3 diagnoses appear to have the highest inciReprint requests to Professor I. Pilowsky, Hospital, Adelaide 5000, Australia.
Department
of Psychiatry,
Royal
Adelaide
62 dence. Merskey [ 131, for example, reported their percentage rates as 20, 42, and 33 respectively in a sample of psychiatric patients with persistent pain. The aetiology of intractable pain, however, is invariably multifactorially determined, and hence the diagnostic formulations offered to explain it are not mutually exclusive [29]. In the same individual, for example, pain may function as a form of punishment in response to guilt, it may serve a conversion function by neutralizing unpleasant affects and allowing denial or avoidance of conflicts, and it may occur in conjunction with physiological arousal characterised in particular by chronic muscular overactivit,y [21]. A single patient may thus display several different manifestations of psychological maladjustment, all of which can contribute to the persistence of the pain experience, Pilowsky [17] has discussed this nosological problem and suggests that Mechanic’s [12] concept of illness behaviour might provide a more suitable framework in which to examine the behaviour of patients who complain of pain in the absence of adequate pathology. The term ‘illness behaviour’ refers to the ways in which symptoms may be differentially perceived, evaluated and acted (or not acted) upon by different kinds of persons. In this sense, patients wit,h intractable pain may be described as displaying ‘abnormal’ or ‘maladaptive’ illness behaviour in so far as their behaviour deviates from that regarded as appropriate to the degree of somatic pathology observed, and is not modified by suitable explanation and reassurance provided by a doctor [18]. A questionnaire designed to measure these aspects of ‘abnormal’ illness behaviour has been developed by Pilowsky and Spence [19]. It deals with the patient’s attitudes and feelings about his illness, his perception of the reactions of significant others in the environment (including his doctors) to himself and his illness, and the patient’s own view of his current psychosocial situation. The aim of the present study was to employ a form of numerical classification [lo] to sort patients with intractable pain into taxonomic groups on the basis of their responses to this illness behaviour questionnaire, and to consider the clinical relevance of the group characteristics thus obtained. METHOD
The 52-item IBQ was administered to 100 unselected patients referred to either the pain clinic (90 subjects) or the psychiatric service (10 subjects) of a large metropolitan hospital for the management of intractable pain. The sample comprised 48 men and 52 women with a mean age of 49.1 years (S.D. 14.9). The commonest site of pain was in the back, followed by the head and the abdomen. The average length of time that patients had experienced pain was 7.4 years and ranged from 6 weeks to 60 years. There was no significant relationship between age and duration of pain (r = 0.12). Twenty per cent of patients were judged to have definite organic pathology associated with their pain, and 27% reported marked impairment of customary func-
I
Minor 55
Mild 42
Organic pathology
Impairment
21
Head
yr
yr
Moderate 31
Moderate 25
Ches; 8
31-40 18
6 mths-1 11
OF 100 PATIENTS
mths.
Site of pain
<6 12
21-30 11
of
Age
illness
Length
CHARACTERISTICS
TABLE
yr yr
Marked 27
Major 20
Upper 8
41-50 26
l-2 18
limbs
yr
WITH INTRACTABLE
Back 27
51-60 23
2-5 28
yr
PAIN
yr
yr
yr
Abdominal 12
61-70 14
5-10 10
Lower 11
71+ yr 8
lo-20 11
limbs
yr
yr
More than one area 13
>20 10
64 TABLE
II
SUB-SCALES Responses
DERIVED indicated
FROM
each
THE
received
IBQ
a score
of +I.
___ -._ _.__~
Question
Response scored __
Scale
1 (General
hypochondriasis).
tells you that you are looking better, do 9. If you feel ill and someone you become annoyed? to pain than other people? 20. Are you more sensitive 21. Are you afraid of illness? that you worry about your health more than most 24. Do you think people? of other people’s good health? 29. Do you find that you get jealous about your health which you can’t 30. Do you ever get silly thoughts get out of your mind no matter how hard you try? take your illness? 32. Are you upset by the way people fall ill? 37. Do you often think that you might suddenly is brought to your attention (through the radio, tele38. If a disease vision, newspapers or someone you know) do you worry about getting it yourself? Scale
2 (Disease
11. 16. 44. 46. Scale 22. 36. Scale 12. 18. 47.
3 (Psychological
versus
somatic
perception
Do you Do you Do you
Yes
Yes
Yes
Yes Yes No YC,S
No YPS
Yes
No Yes
No
inhibition).
Can you express your personal feelings easily to other people? When you are angry, do you tend to bottle up your feelings? 5 (Affective
Yes:
of illness).
Do you ever think of your illness as a punishment for something you have done wrong in the past? Are you bothered by many pains and aches? Do you think there is something the matter with your mind? Is your bad health the biggest difficulty of your life? 4 (Affective
Yes Yes
conviction)
2. Do you think there is something seriously wrong with your body? 3. Does your illness interfere with your life a great deal? 7. If the doctor told you he could find nothing wrong with you, would you believe him? 10. Do you find that you are often aware of various things happening in your body? 35. Are you sleeping well? 41, Do you find that you are bothered by many different symptoms? Scale
Yes Yes Yes
No Yes
disturbance).
have trouble with your nerves? find that you get anxious easily? find that you get sad easily?
Yes Yes Yes
65 TABLE
II (continued) Response scored
Question
Scale 6 (Den,al
of problems).
27. Except for your illness, do you have any problems 31. Do you have any financial problems? 43. Do you have any family problems?
No No No
in your life?
Scale 7 (IrritabiIity). 4. Are you easy to get on with when you are ill? 17. Does your illness affect the way you get on with your friends a great deal? 51. Do you find that you get angry easily?
Age
No family
or Yes Yes
<40 yr
tioning due to pain. Table I provides a more detailed outline of the characteristics of the patient population. Responses to the IBQ (plus info~ation concerning the patient’s age, sex, and length of pain) were factor analysed using the method of principal component analysis and rotated to orthogonal structure [14]. Seven factors accounting for 63.3% of the variance were extracted. These were labelled general hypochondriasis, disease conviction with somatic preoccupation, psychological versus somatic perception of illness, affective inhibition, affective disturbance, denial, and irritability [ 19 J . Items with loadings greater than 0.40 on these factors were used to construct 7 sub-scales. Scoring was arbitrarily weighted in the direction of ‘abnormal’ or ‘maladaptive’ illness behaviour, such that a value of one was allotted to each ‘abnormal’ response. The items and responses comprising each scale are shown in Table II. The score on a particular scale is thus regarded as an index of the patient’s relative position on the dimension of illness behaviour reflected by the factor. High scores suggest maladaptive ways of perceiving, evaluating, or acting in relation to one’s state of health. In this manner every patient was assigned a score on each of the 7 subscales and 100 illness behaviour profiles were subjected to numerical analysis. The Sokal or average group method of sorting was used to cluster patients on the basis of the sauared Euclidean ‘distance’ between their scores
RESULTS
The results of the numerical analysis showed 6 principal clusters of, patients. The mean scale profile for each group was calculated (Table III) and a
III
PROFILES
a Significant
P < 0.001.
26.2 a
-
KruskalWallis H*
0.52 0.50 0.78 1.00 0.63 6.36
1
o-9
29 18 9 25 8 11
n
Range
1 2 3 4 5 6
~..
Groups
6 GROUPS
10.6
o-4
O-6
62.3 a
0.31 0.61 0.67 0.07 1.25 0.55
3
38.6 a ____
_.~.
o-4
0.31 0.67 3.22 1.68 2.75 2.55
7
a
_
56.5 54.4 34.7 48.5 33.4 45.6
age (yrs) ~_I
Mean
-... _~~_ ~~_
NIJMERICAL
53.3 a 42.6 ---.____
o-3
o-3
o-2
33.0a
2.46 2.83 2.89 2.31 0.38 1.73
6
0.35 2.06 1.78 1.10 2.50 2.18
5
0.52 0.94 1.00 1 .oo 0.63 1.18
4
BY
for each group. ^._-
IDENTIFIED
of pain have been included
FOR
1.97 2.44 1.44 4.38 4.00 4.72
2
Details of age, sex and duration ~..__ -
MEAN SUB-SCALE BEHAVIOUR
TABLE
-.-
48 55 55 56 50 45
_._-
Per cent females
_-.
ANALYSIS
7 DIMENSIONS
10.3 6.4 6.3 7.5 4.7 4.1
Mean duration of illness ( yrs)
ON
OF
ILLNESS
67 Kruskal-Wallis one-way analysis of variance was applied to each dimension to test whether group membership influenced scale score. On all scales except the third (psychological versus somatic perception of illness) it was found that membership had a highly significant effect (P < 0.001). In this population of patients with intractable pain all individuals emphasize a somatic as opposed to a psychological perception of their pain so that scale 3 cannot be used to discriminate between them. Differences on the remaining scales, however, indicate significant group variation. Description of groups Group 1. The first group is characterised by low scores on nearly all scales. Despite the fact that their pain has persisted on average for over 10 years, patients in this group tend not to report feeling sad, anxious (scale 5) or irritable (scale 7). They describe themselves as being able to adequately express their personal feelings, even negative ones, to other people (scale 6). These patients perceive their pain as definitely somatic in origin (scale 3) though they tend to minimize its seriousness (scale 2), and show little phobic concern about illness (scale 1). Overall, group 1 patients present as underreacting to their pain. Neither their pain nor any other aspect of their life is reported as being problematic. Their pattern of responses suggests that these individuals depend heavily on denial as a means of coping. Group 2. The profile of patients in group 2 is similar to that of the first group in that they also tend to deny the existence of problems in their lives (scale 6). They do, however, admit that they are often sad or anxious (scale 5) which suggests their use of denial may be less effective than is the case in group 1 (scale 2). It is significant that they also report some difficulty in expressing angry feelings (scale 4), a trait often associated with the genesis of depressive feelings. It is of interest in this regard that Sternbach et al. [26] have found that MMPI results commonly indicate depressed affect in patients with chronic pain, but that these individuals show little insight and explain their depression as a result of their illness. A similar use of somatization as a coping style may be characteristic of patients in group 2. Group 3. The outstanding feature of the third group is that patients score highly on scale 7. Accordingly, they describe themselves as being easily angered, report that they are in pain and find that their illness interferes with the way they relate to those close to them. These patients do not show a generally hypochondriacal attitude to illness (scales 1 and 2). They tend to deny the presence of current life difficulties (scale 6) and regard illness as their major problem (scale 3). Group 4. Patients in group 4 are characterized by somatic preoccupation and a resistance to reassurance (scale 2). They complain that their pain disturbs their sleep and their daily activities, and that they are troubled by many symptoms. These individuals regard their bad health as the biggest problem of their life (scale 3) and, although they describe themselves as being somewhat affectively inhibited (scale 4), report few other difficulties (scale 6). Given that they are convinced of the seriousness of their illness,
68
they display little anxiety, sadness (scale 5) or irritation (scale 7). The overall attitude of patients in group 4 might be interpreted as one of affective equilibrium. Despite the fact that they have found it necessary to seek help for its relief and they emphasize how serious their pain is, when given the opportunity, they describe their reaction to it in a relatively mild and resigned way, Group 5. In marked contrast to group 4, patients in the fifth group report numerous difficulties in their lives. While they similarly perceive their pain as serious and intrusive and are preoccupied with their symptoms (scale 2), unlike patients in group 4 they show a strong tendency to be depressed and anxious (scale 5) and also appear to be irritable (scale 7). Moreover, the latter is likely to be overtly expressed since these patients are not affectively inhibited (scale 4). Patients in group 5 also report many financial and family problems (scale 6). For patients in group 6 it seems that pain is part of a general state of psychological decompensation. Group 6. The final group of patients with intractable pain is characterised by an anxious hypochondriacal concern about their health (scale 1). It is interesting that these particular individuals are the only ones tending to obtain high scores on this factor. They are thus likely to be afraid of illness and to ruminate about their symptoms. They regard themselves as more sensitive to pain than other people and fear that they might suddenly fall ill. This phobic preoccupation is accompanied by a feeling of being different to other people and not being properly understood by them. The sense of alienation which these patients report is probably accentuated by their marked inability to communicate their misgivings to others (scale 4). Some evidence of resentment is indicated in their irritability with others (scale 7). Patients in group 6, like those of the fifth group, tend to report affective disturbance (scale 5) and certain domestic difficulties (scale 6). However, whereas group 5 patients readily presented themselves in a dependent role, patients in the sixth group seem less willing to explicitly communicate their needs to either doctor or family. DISCUSSION
In this particular sample of patients, the method of numerical taxonomy has identified six groupings, each characterised by a pattern of illness behaviour that is clinically familiar although not necessarily fitting into a particular diagnostic category. In the case of group 1 the leading feature is the apparent capacity for effective use of denial. Where this occurs in the presence of a life-threatening condition, such a defensive strategy may prove of considerable adaptive value 191. However, such patients may, as a consequence, communicate all affective states in terms of the pain experience. Referral of these patients to a pain clinic may be due to non-response of the pain to treatment, but in assessing this, it is crucial to establish whether the patient’s tendency to deny
69
has extended to the under-utilization of prescribed analgesic medication. Group 2 patients correspond to those who also use denial, but in a less effective way. They are often labelled as suffering from a depressive illness but do not respond particularly well to antidepressants. In some cases, the dysphoric state is clearly an unresolved reaction to loss. Such patients may minimize their feelings of sadness and anger, but persist in pain complaints in a manner which puzzles those caring for them. In some instances, the repeated presentation of pain complaints to a doctor may in fact serve as a ‘hostility equivalent’ in patients unable to express the angry feelings which are part of their loss experience. Group 3 patients are characterised by the irritability and interpersonal friction they experience, and the denial of problems other than their state of physical health. It is important to establish with these patients to what degree their inability to relate constitutes a change in usual functioning. If irritability seems uncharacteristic then the possibility of a recent loss experience should be considered, as well as the development of a chronic brain syndrome. Group 4 patients show a behavioural pattern which may be described as ‘somatic preoccupation’ [ 161, but although convinced of the presence of illness, they can rarely be described as psychotic. It is in such patients that the term ‘abnormal illness behaviour’ is a particularly useful first approximation to achieving a final diagnosis, the difficulties of which have been well discussed by Ziegler et al. [31] . What seems clear, however, is that these patients cling to the sick role in order to achieve psychological equilibrium. In the sense that unpleasant affects are thus neutralized, the condition resembles a conversion reaction. From the management point of view, the defensive nature of the illness behaviour must be recognized since a direct onslaught upon the patient’s sick role status must inevitably disrupt therapeutic contact, and intensify the use of the defensive strategy already chosen. Group 5 patients seem to correspond most closely to those described by Lipsett [ 111 as ‘masochistic depressives’. He refers to the hostile dependent relationships they establish and draws attention to an aspect of management which our own clinical experience would tend to confirm. He suggests that, in managing these patients, a pessimistic approach is often more effective than an optimistic one, and notes the lessening of the depressive features when such a stance is adopted. Group 6 patients present a pattern sometimes seen in sensitive personalities who find themselves enmeshed in the compensation process. Under such circumstances they may feel alienated from all in authority in a way which grossly impairs their capacity to interact productively with doctors or lawyers and, furthermore, renders them exquisitely aware of the imperfections which both the medical and legal systems (like all others) inevitably possess. In these patients, the negative counter-transference may be particularly troublesome, and needs to be constantly monitored. In such cases, rapid resolution of the litigation process, where possible, is of advantage, but because of the patient’s attitude not always possible.
70 CONCLUSION
The patterns which have emerged suggest that in terms of illness behaviour, two broad categories may be discerned. The first, encompassing groups 1-3, is characterised by a relatively non-neurotic, reality-oriented attitude to illness as indicated by low scores on the first 3 scales, i.e., general hypochondriasis, disease conviction and somatic vs. psychological perception of illness. In the case of these groups the pain experience seems part of what might be regarded as an adaptive reaction to stress [28] , but one in which it has been so prominent a feature of the clinical presentation as to obscure other aspects of the stress response, with consequent referral to a pain clinic. The second category, which includes groups 4-6, relates more clearly to the syndrome of ‘abnormal illness behaviour’ [19]. Here the pain syndrome does seem interwoven with, and perhaps symptomatic of, a personality disorder or an essentially maladaptive response to psychological stress. These are the syndromes often labelled ‘hysteria’, ‘conversion reaction’ and ‘hypochondriasis’. REFERENCES 1 Bradley, J.J., Severe localized pain associated with the depressive syndrome. Brit. J. Psychiat., 109 (1963) 741-745. 2 Button, A.D., An enquiry into the psychological effects of ACTH administration, Ph.D. Thesis, Stanford University, 1953. 3 Capon, I., Numerical classification program, Computing Centre Library, University of Adelaide, 1971. 4 Ellman, P., Savage, D.A., Wittkower, E. and Rodger, T.F., Fibrositis: a biographical study of fifty civilian and military cases, Ann. Rheum. Dis., 3 (1942) 56-76. 5 Engel, G.L., Psychogenic pain and the pain prone patient, Amer. J. Med., 26 (1959) 899-918. 6 Gidro-Frank, L. and Gordon, T., Reproductive performance of women with pelvic pain of long duration, Fertil. and Steril., 7 (1956) 440-447. 7 Guze, S.B. and Perley, M.J., Observations on the natural history of hysteria, Amer. J. Psychiat., 119 (1963) 960-965. 8 Holmes, T.H. and Wolff, H.G., Life situations, emotions and backache, Res. Pub]. Ass. Res. nerv. ment. Dis., 24 (1949) 750-772. 9 Kubler-Ross, E., On Death and Dying, Collier Macmillan, London, 1969. 10 Lance, G.N. and Williams, W.T., A genera1 theory of classificatory sorting strategies. I. Hierarchical systems, Comput. J., 9 (1967) 373-380. 11 Lipsett, D.R., Integration clinic. In N.E. Zinberg (Ed.), Psychiatry and Medical Practice in a General Hospital, International University Press, New York, 1964, pp. 231249. 12 Mechanic, D., The concept of illness behaviour, J. chron. Dis., 15 (1962) 189-194. 13 Merskey, H., The characteristics of persistent pain in psychological illness, J. Psychosom. Res., 9 (1965) 291-298. 14 Nie, N.H., Bent, D.H. and Hull, C.H., Statistical Package for the Social Sciences, McGraw Hill, New York, 1956. 15 Paul, L., Psychosomatic aspects of low back pain: a review of recent articles, Psychosom. Med., 12 (1950) 116-124. 16 Pilowsky, I., Dimensions of hypochondriasis, Brit. J. Psychiat., 113 (1967) 89-93. 17 Pilowsky, I., Abnormal illness behaviour, Brit. J. med. Psycho]., 42 (1969) 347-351.
71 18 Pilowsky, I., The diagnosis of abnormal illness behaviour, Aust. N.Z. J. Psychiat., 5 (1971) 136-138. 19 Pilowsky, I. and Spence, N.D., Patterns of illness behaviour in patients with intractable pain, J. Psychosom. Res., 19 (1975) 279-287. 20 Purtell, J.J., Robins, E. and Cohen, M.E., Observations on clinical aspects of hysteria: a quantitative study, J, Amer. med. Ass., 146 (1951) 902-909. 21 Rangell, L., Psychiatric aspects of pain, Psychosom. Med., 15 (1953) 22-37. 22 Siegel, S., Nonparametric Statistics for the Social Sciences, McGraw Hill, New York, 1956. 23 Spear, F.G., A study of pain as a symptom in psychiatric illness, M.D. Thesis, University of Bristol, 1964. 24 Smith, D.F., Pilling, L.F., Pearson, J.S., Rushton, J.G., Goldstein, N.P. and Gibilisco, J.A., A psychiatric study of atypical facial pain, Canad. med. Ass. J., 100 (1969) 286-291. 25 Sternbach, R.A., Pain: A Psychophysiological Analysis, Academic Press, New York, 1969. 26 Sternbach, R.A., Wolf, S.R., Murphy, R.W. and Akeson, W.H., Aspects of chronic low back pain, Psychosom., 14 (1973) 52-56. 27 Stevenson, I., Single physical symptoms as residues of an earlier response to stress, Ann. intern. Med., 70 (1969) 1231-1237. 28 Timmermans, G. and Sternbach, R.A., Factors of chronic human pain: an analysis of personality and pain reaction variables, Science, 184 (1974) 806-808. 29 Walters, A., Psychogenic regional pain alias hysteria1 pain, Brain, 84 (1961) l-18. 30 Woodforde, J. and Fielding, J., Pain and cancer, J. Psychosom. Res., 14 (1970) 365370. 31 Ziegler, F.J., Imboden, J.B. and Meyer, E., Contemporary conversion reactions: a clinical study, Amer. J. Psychiat., 116 (1960) 901-909.
Amsterdam
ILLNESS BEHAVIOUR INTRACTABLE PAIN I. PILOWSKY Department
(Accepted
- Printed
SYNDROMES
in The Netherlands
ASSOCIATED
WITH
and N.D. SPENCE of Psychiatry,
November
University
of Adelaide,
Adelaide
(Australia)
7th, 1975)
SUMMARY
One hundred patients, referred for the management of intractable pain, (IBQ). Responses were completed a 52-item Illness Behaviour Questionnaire scored on 7 scales: general hypochondria&, disease conviction, psychological versus somatic perception of illness, affective inhibition, affective disturbance, denial, and irritability. IBQ scale profiles were subjected to numerical analysis and 6 taxonomic clusters were identified. Patients in groups 1-3 were characterized by a relatively non-neurotic, reality-oriented attitude to illness, as indicated by low scores on the first three scales. Patients in groups 4-6 manifested greater evidence of ‘abnormal illness behaviour’, and presented syndromes resembling ‘hysteria’, ‘conversion reaction’, and ‘hypochondriasis’ respectively.
INTRODUCTION
An individual’s experience of pain is a complex event determined by many cognitive, affective, interpersonal and cultural factors [ 261. The interaction of these variables, which acts to disrupt any simple one-to-one relationship between degree of pathological damage and severity of pain, is exemplified in the clinical presentation of patients whose complaints of pain persist in the absence of adequate somatic pathology. Clinicians and researchers have noted that patients referred with intractable pain tend to show evidence of affective or personality disorders, including depression [ 1,4-6,13,23,24,26,29,30] , hysteria and conversion [2,4,5,7,13,15,20,23,24,26,29,30], anxiety [4,6,13,15,23,29], hypochondriasis [ 2,24,26,30] , resentment and frustration [ 4-6,8,24,28] , and sometimes psychosis [ 5,291. The first 3 diagnoses appear to have the highest inciReprint requests to Professor I. Pilowsky, Hospital, Adelaide 5000, Australia.
Department
of Psychiatry,
Royal
Adelaide
62 dence. Merskey [ 131, for example, reported their percentage rates as 20, 42, and 33 respectively in a sample of psychiatric patients with persistent pain. The aetiology of intractable pain, however, is invariably multifactorially determined, and hence the diagnostic formulations offered to explain it are not mutually exclusive [29]. In the same individual, for example, pain may function as a form of punishment in response to guilt, it may serve a conversion function by neutralizing unpleasant affects and allowing denial or avoidance of conflicts, and it may occur in conjunction with physiological arousal characterised in particular by chronic muscular overactivit,y [21]. A single patient may thus display several different manifestations of psychological maladjustment, all of which can contribute to the persistence of the pain experience, Pilowsky [17] has discussed this nosological problem and suggests that Mechanic’s [12] concept of illness behaviour might provide a more suitable framework in which to examine the behaviour of patients who complain of pain in the absence of adequate pathology. The term ‘illness behaviour’ refers to the ways in which symptoms may be differentially perceived, evaluated and acted (or not acted) upon by different kinds of persons. In this sense, patients wit,h intractable pain may be described as displaying ‘abnormal’ or ‘maladaptive’ illness behaviour in so far as their behaviour deviates from that regarded as appropriate to the degree of somatic pathology observed, and is not modified by suitable explanation and reassurance provided by a doctor [18]. A questionnaire designed to measure these aspects of ‘abnormal’ illness behaviour has been developed by Pilowsky and Spence [19]. It deals with the patient’s attitudes and feelings about his illness, his perception of the reactions of significant others in the environment (including his doctors) to himself and his illness, and the patient’s own view of his current psychosocial situation. The aim of the present study was to employ a form of numerical classification [lo] to sort patients with intractable pain into taxonomic groups on the basis of their responses to this illness behaviour questionnaire, and to consider the clinical relevance of the group characteristics thus obtained. METHOD
The 52-item IBQ was administered to 100 unselected patients referred to either the pain clinic (90 subjects) or the psychiatric service (10 subjects) of a large metropolitan hospital for the management of intractable pain. The sample comprised 48 men and 52 women with a mean age of 49.1 years (S.D. 14.9). The commonest site of pain was in the back, followed by the head and the abdomen. The average length of time that patients had experienced pain was 7.4 years and ranged from 6 weeks to 60 years. There was no significant relationship between age and duration of pain (r = 0.12). Twenty per cent of patients were judged to have definite organic pathology associated with their pain, and 27% reported marked impairment of customary func-
I
Minor 55
Mild 42
Organic pathology
Impairment
21
Head
yr
yr
Moderate 31
Moderate 25
Ches; 8
31-40 18
6 mths-1 11
OF 100 PATIENTS
mths.
Site of pain
<6 12
21-30 11
of
Age
illness
Length
CHARACTERISTICS
TABLE
yr yr
Marked 27
Major 20
Upper 8
41-50 26
l-2 18
limbs
yr
WITH INTRACTABLE
Back 27
51-60 23
2-5 28
yr
PAIN
yr
yr
yr
Abdominal 12
61-70 14
5-10 10
Lower 11
71+ yr 8
lo-20 11
limbs
yr
yr
More than one area 13
>20 10
64 TABLE
II
SUB-SCALES Responses
DERIVED indicated
FROM
each
THE
received
IBQ
a score
of +I.
___ -._ _.__~
Question
Response scored __
Scale
1 (General
hypochondriasis).
tells you that you are looking better, do 9. If you feel ill and someone you become annoyed? to pain than other people? 20. Are you more sensitive 21. Are you afraid of illness? that you worry about your health more than most 24. Do you think people? of other people’s good health? 29. Do you find that you get jealous about your health which you can’t 30. Do you ever get silly thoughts get out of your mind no matter how hard you try? take your illness? 32. Are you upset by the way people fall ill? 37. Do you often think that you might suddenly is brought to your attention (through the radio, tele38. If a disease vision, newspapers or someone you know) do you worry about getting it yourself? Scale
2 (Disease
11. 16. 44. 46. Scale 22. 36. Scale 12. 18. 47.
3 (Psychological
versus
somatic
perception
Do you Do you Do you
Yes
Yes
Yes
Yes Yes No YC,S
No YPS
Yes
No Yes
No
inhibition).
Can you express your personal feelings easily to other people? When you are angry, do you tend to bottle up your feelings? 5 (Affective
Yes:
of illness).
Do you ever think of your illness as a punishment for something you have done wrong in the past? Are you bothered by many pains and aches? Do you think there is something the matter with your mind? Is your bad health the biggest difficulty of your life? 4 (Affective
Yes Yes
conviction)
2. Do you think there is something seriously wrong with your body? 3. Does your illness interfere with your life a great deal? 7. If the doctor told you he could find nothing wrong with you, would you believe him? 10. Do you find that you are often aware of various things happening in your body? 35. Are you sleeping well? 41, Do you find that you are bothered by many different symptoms? Scale
Yes Yes Yes
No Yes
disturbance).
have trouble with your nerves? find that you get anxious easily? find that you get sad easily?
Yes Yes Yes
65 TABLE
II (continued) Response scored
Question
Scale 6 (Den,al
of problems).
27. Except for your illness, do you have any problems 31. Do you have any financial problems? 43. Do you have any family problems?
No No No
in your life?
Scale 7 (IrritabiIity). 4. Are you easy to get on with when you are ill? 17. Does your illness affect the way you get on with your friends a great deal? 51. Do you find that you get angry easily?
Age
No family
or Yes Yes
<40 yr
tioning due to pain. Table I provides a more detailed outline of the characteristics of the patient population. Responses to the IBQ (plus info~ation concerning the patient’s age, sex, and length of pain) were factor analysed using the method of principal component analysis and rotated to orthogonal structure [14]. Seven factors accounting for 63.3% of the variance were extracted. These were labelled general hypochondriasis, disease conviction with somatic preoccupation, psychological versus somatic perception of illness, affective inhibition, affective disturbance, denial, and irritability [ 19 J . Items with loadings greater than 0.40 on these factors were used to construct 7 sub-scales. Scoring was arbitrarily weighted in the direction of ‘abnormal’ or ‘maladaptive’ illness behaviour, such that a value of one was allotted to each ‘abnormal’ response. The items and responses comprising each scale are shown in Table II. The score on a particular scale is thus regarded as an index of the patient’s relative position on the dimension of illness behaviour reflected by the factor. High scores suggest maladaptive ways of perceiving, evaluating, or acting in relation to one’s state of health. In this manner every patient was assigned a score on each of the 7 subscales and 100 illness behaviour profiles were subjected to numerical analysis. The Sokal or average group method of sorting was used to cluster patients on the basis of the sauared Euclidean ‘distance’ between their scores
RESULTS
The results of the numerical analysis showed 6 principal clusters of, patients. The mean scale profile for each group was calculated (Table III) and a
III
PROFILES
a Significant
P < 0.001.
26.2 a
-
KruskalWallis H*
0.52 0.50 0.78 1.00 0.63 6.36
1
o-9
29 18 9 25 8 11
n
Range
1 2 3 4 5 6
~..
Groups
6 GROUPS
10.6
o-4
O-6
62.3 a
0.31 0.61 0.67 0.07 1.25 0.55
3
38.6 a ____
_.~.
o-4
0.31 0.67 3.22 1.68 2.75 2.55
7
a
_
56.5 54.4 34.7 48.5 33.4 45.6
age (yrs) ~_I
Mean
-... _~~_ ~~_
NIJMERICAL
53.3 a 42.6 ---.____
o-3
o-3
o-2
33.0a
2.46 2.83 2.89 2.31 0.38 1.73
6
0.35 2.06 1.78 1.10 2.50 2.18
5
0.52 0.94 1.00 1 .oo 0.63 1.18
4
BY
for each group. ^._-
IDENTIFIED
of pain have been included
FOR
1.97 2.44 1.44 4.38 4.00 4.72
2
Details of age, sex and duration ~..__ -
MEAN SUB-SCALE BEHAVIOUR
TABLE
-.-
48 55 55 56 50 45
_._-
Per cent females
_-.
ANALYSIS
7 DIMENSIONS
10.3 6.4 6.3 7.5 4.7 4.1
Mean duration of illness ( yrs)
ON
OF
ILLNESS
67 Kruskal-Wallis one-way analysis of variance was applied to each dimension to test whether group membership influenced scale score. On all scales except the third (psychological versus somatic perception of illness) it was found that membership had a highly significant effect (P < 0.001). In this population of patients with intractable pain all individuals emphasize a somatic as opposed to a psychological perception of their pain so that scale 3 cannot be used to discriminate between them. Differences on the remaining scales, however, indicate significant group variation. Description of groups Group 1. The first group is characterised by low scores on nearly all scales. Despite the fact that their pain has persisted on average for over 10 years, patients in this group tend not to report feeling sad, anxious (scale 5) or irritable (scale 7). They describe themselves as being able to adequately express their personal feelings, even negative ones, to other people (scale 6). These patients perceive their pain as definitely somatic in origin (scale 3) though they tend to minimize its seriousness (scale 2), and show little phobic concern about illness (scale 1). Overall, group 1 patients present as underreacting to their pain. Neither their pain nor any other aspect of their life is reported as being problematic. Their pattern of responses suggests that these individuals depend heavily on denial as a means of coping. Group 2. The profile of patients in group 2 is similar to that of the first group in that they also tend to deny the existence of problems in their lives (scale 6). They do, however, admit that they are often sad or anxious (scale 5) which suggests their use of denial may be less effective than is the case in group 1 (scale 2). It is significant that they also report some difficulty in expressing angry feelings (scale 4), a trait often associated with the genesis of depressive feelings. It is of interest in this regard that Sternbach et al. [26] have found that MMPI results commonly indicate depressed affect in patients with chronic pain, but that these individuals show little insight and explain their depression as a result of their illness. A similar use of somatization as a coping style may be characteristic of patients in group 2. Group 3. The outstanding feature of the third group is that patients score highly on scale 7. Accordingly, they describe themselves as being easily angered, report that they are in pain and find that their illness interferes with the way they relate to those close to them. These patients do not show a generally hypochondriacal attitude to illness (scales 1 and 2). They tend to deny the presence of current life difficulties (scale 6) and regard illness as their major problem (scale 3). Group 4. Patients in group 4 are characterized by somatic preoccupation and a resistance to reassurance (scale 2). They complain that their pain disturbs their sleep and their daily activities, and that they are troubled by many symptoms. These individuals regard their bad health as the biggest problem of their life (scale 3) and, although they describe themselves as being somewhat affectively inhibited (scale 4), report few other difficulties (scale 6). Given that they are convinced of the seriousness of their illness,
68
they display little anxiety, sadness (scale 5) or irritation (scale 7). The overall attitude of patients in group 4 might be interpreted as one of affective equilibrium. Despite the fact that they have found it necessary to seek help for its relief and they emphasize how serious their pain is, when given the opportunity, they describe their reaction to it in a relatively mild and resigned way, Group 5. In marked contrast to group 4, patients in the fifth group report numerous difficulties in their lives. While they similarly perceive their pain as serious and intrusive and are preoccupied with their symptoms (scale 2), unlike patients in group 4 they show a strong tendency to be depressed and anxious (scale 5) and also appear to be irritable (scale 7). Moreover, the latter is likely to be overtly expressed since these patients are not affectively inhibited (scale 4). Patients in group 5 also report many financial and family problems (scale 6). For patients in group 6 it seems that pain is part of a general state of psychological decompensation. Group 6. The final group of patients with intractable pain is characterised by an anxious hypochondriacal concern about their health (scale 1). It is interesting that these particular individuals are the only ones tending to obtain high scores on this factor. They are thus likely to be afraid of illness and to ruminate about their symptoms. They regard themselves as more sensitive to pain than other people and fear that they might suddenly fall ill. This phobic preoccupation is accompanied by a feeling of being different to other people and not being properly understood by them. The sense of alienation which these patients report is probably accentuated by their marked inability to communicate their misgivings to others (scale 4). Some evidence of resentment is indicated in their irritability with others (scale 7). Patients in group 6, like those of the fifth group, tend to report affective disturbance (scale 5) and certain domestic difficulties (scale 6). However, whereas group 5 patients readily presented themselves in a dependent role, patients in the sixth group seem less willing to explicitly communicate their needs to either doctor or family. DISCUSSION
In this particular sample of patients, the method of numerical taxonomy has identified six groupings, each characterised by a pattern of illness behaviour that is clinically familiar although not necessarily fitting into a particular diagnostic category. In the case of group 1 the leading feature is the apparent capacity for effective use of denial. Where this occurs in the presence of a life-threatening condition, such a defensive strategy may prove of considerable adaptive value 191. However, such patients may, as a consequence, communicate all affective states in terms of the pain experience. Referral of these patients to a pain clinic may be due to non-response of the pain to treatment, but in assessing this, it is crucial to establish whether the patient’s tendency to deny
69
has extended to the under-utilization of prescribed analgesic medication. Group 2 patients correspond to those who also use denial, but in a less effective way. They are often labelled as suffering from a depressive illness but do not respond particularly well to antidepressants. In some cases, the dysphoric state is clearly an unresolved reaction to loss. Such patients may minimize their feelings of sadness and anger, but persist in pain complaints in a manner which puzzles those caring for them. In some instances, the repeated presentation of pain complaints to a doctor may in fact serve as a ‘hostility equivalent’ in patients unable to express the angry feelings which are part of their loss experience. Group 3 patients are characterised by the irritability and interpersonal friction they experience, and the denial of problems other than their state of physical health. It is important to establish with these patients to what degree their inability to relate constitutes a change in usual functioning. If irritability seems uncharacteristic then the possibility of a recent loss experience should be considered, as well as the development of a chronic brain syndrome. Group 4 patients show a behavioural pattern which may be described as ‘somatic preoccupation’ [ 161, but although convinced of the presence of illness, they can rarely be described as psychotic. It is in such patients that the term ‘abnormal illness behaviour’ is a particularly useful first approximation to achieving a final diagnosis, the difficulties of which have been well discussed by Ziegler et al. [31] . What seems clear, however, is that these patients cling to the sick role in order to achieve psychological equilibrium. In the sense that unpleasant affects are thus neutralized, the condition resembles a conversion reaction. From the management point of view, the defensive nature of the illness behaviour must be recognized since a direct onslaught upon the patient’s sick role status must inevitably disrupt therapeutic contact, and intensify the use of the defensive strategy already chosen. Group 5 patients seem to correspond most closely to those described by Lipsett [ 111 as ‘masochistic depressives’. He refers to the hostile dependent relationships they establish and draws attention to an aspect of management which our own clinical experience would tend to confirm. He suggests that, in managing these patients, a pessimistic approach is often more effective than an optimistic one, and notes the lessening of the depressive features when such a stance is adopted. Group 6 patients present a pattern sometimes seen in sensitive personalities who find themselves enmeshed in the compensation process. Under such circumstances they may feel alienated from all in authority in a way which grossly impairs their capacity to interact productively with doctors or lawyers and, furthermore, renders them exquisitely aware of the imperfections which both the medical and legal systems (like all others) inevitably possess. In these patients, the negative counter-transference may be particularly troublesome, and needs to be constantly monitored. In such cases, rapid resolution of the litigation process, where possible, is of advantage, but because of the patient’s attitude not always possible.
70 CONCLUSION
The patterns which have emerged suggest that in terms of illness behaviour, two broad categories may be discerned. The first, encompassing groups 1-3, is characterised by a relatively non-neurotic, reality-oriented attitude to illness as indicated by low scores on the first 3 scales, i.e., general hypochondriasis, disease conviction and somatic vs. psychological perception of illness. In the case of these groups the pain experience seems part of what might be regarded as an adaptive reaction to stress [28] , but one in which it has been so prominent a feature of the clinical presentation as to obscure other aspects of the stress response, with consequent referral to a pain clinic. The second category, which includes groups 4-6, relates more clearly to the syndrome of ‘abnormal illness behaviour’ [19]. Here the pain syndrome does seem interwoven with, and perhaps symptomatic of, a personality disorder or an essentially maladaptive response to psychological stress. These are the syndromes often labelled ‘hysteria’, ‘conversion reaction’ and ‘hypochondriasis’. REFERENCES 1 Bradley, J.J., Severe localized pain associated with the depressive syndrome. Brit. J. Psychiat., 109 (1963) 741-745. 2 Button, A.D., An enquiry into the psychological effects of ACTH administration, Ph.D. Thesis, Stanford University, 1953. 3 Capon, I., Numerical classification program, Computing Centre Library, University of Adelaide, 1971. 4 Ellman, P., Savage, D.A., Wittkower, E. and Rodger, T.F., Fibrositis: a biographical study of fifty civilian and military cases, Ann. Rheum. Dis., 3 (1942) 56-76. 5 Engel, G.L., Psychogenic pain and the pain prone patient, Amer. J. Med., 26 (1959) 899-918. 6 Gidro-Frank, L. and Gordon, T., Reproductive performance of women with pelvic pain of long duration, Fertil. and Steril., 7 (1956) 440-447. 7 Guze, S.B. and Perley, M.J., Observations on the natural history of hysteria, Amer. J. Psychiat., 119 (1963) 960-965. 8 Holmes, T.H. and Wolff, H.G., Life situations, emotions and backache, Res. Pub]. Ass. Res. nerv. ment. Dis., 24 (1949) 750-772. 9 Kubler-Ross, E., On Death and Dying, Collier Macmillan, London, 1969. 10 Lance, G.N. and Williams, W.T., A genera1 theory of classificatory sorting strategies. I. Hierarchical systems, Comput. J., 9 (1967) 373-380. 11 Lipsett, D.R., Integration clinic. In N.E. Zinberg (Ed.), Psychiatry and Medical Practice in a General Hospital, International University Press, New York, 1964, pp. 231249. 12 Mechanic, D., The concept of illness behaviour, J. chron. Dis., 15 (1962) 189-194. 13 Merskey, H., The characteristics of persistent pain in psychological illness, J. Psychosom. Res., 9 (1965) 291-298. 14 Nie, N.H., Bent, D.H. and Hull, C.H., Statistical Package for the Social Sciences, McGraw Hill, New York, 1956. 15 Paul, L., Psychosomatic aspects of low back pain: a review of recent articles, Psychosom. Med., 12 (1950) 116-124. 16 Pilowsky, I., Dimensions of hypochondriasis, Brit. J. Psychiat., 113 (1967) 89-93. 17 Pilowsky, I., Abnormal illness behaviour, Brit. J. med. Psycho]., 42 (1969) 347-351.
71 18 Pilowsky, I., The diagnosis of abnormal illness behaviour, Aust. N.Z. J. Psychiat., 5 (1971) 136-138. 19 Pilowsky, I. and Spence, N.D., Patterns of illness behaviour in patients with intractable pain, J. Psychosom. Res., 19 (1975) 279-287. 20 Purtell, J.J., Robins, E. and Cohen, M.E., Observations on clinical aspects of hysteria: a quantitative study, J, Amer. med. Ass., 146 (1951) 902-909. 21 Rangell, L., Psychiatric aspects of pain, Psychosom. Med., 15 (1953) 22-37. 22 Siegel, S., Nonparametric Statistics for the Social Sciences, McGraw Hill, New York, 1956. 23 Spear, F.G., A study of pain as a symptom in psychiatric illness, M.D. Thesis, University of Bristol, 1964. 24 Smith, D.F., Pilling, L.F., Pearson, J.S., Rushton, J.G., Goldstein, N.P. and Gibilisco, J.A., A psychiatric study of atypical facial pain, Canad. med. Ass. J., 100 (1969) 286-291. 25 Sternbach, R.A., Pain: A Psychophysiological Analysis, Academic Press, New York, 1969. 26 Sternbach, R.A., Wolf, S.R., Murphy, R.W. and Akeson, W.H., Aspects of chronic low back pain, Psychosom., 14 (1973) 52-56. 27 Stevenson, I., Single physical symptoms as residues of an earlier response to stress, Ann. intern. Med., 70 (1969) 1231-1237. 28 Timmermans, G. and Sternbach, R.A., Factors of chronic human pain: an analysis of personality and pain reaction variables, Science, 184 (1974) 806-808. 29 Walters, A., Psychogenic regional pain alias hysteria1 pain, Brain, 84 (1961) l-18. 30 Woodforde, J. and Fielding, J., Pain and cancer, J. Psychosom. Res., 14 (1970) 365370. 31 Ziegler, F.J., Imboden, J.B. and Meyer, E., Contemporary conversion reactions: a clinical study, Amer. J. Psychiat., 116 (1960) 901-909.