- Email: [email protected]
Non-organic chronic intractable pain: A comparative study
Pain, 19 (1984)
87-94
87
Elsevier
PAI 00635
Non-Organic Chronic Intractable Pain: a Comparative Study Santosh K. Chaturvedi **‘, Vijoy K. Varma ** and Anil Malhotra ** * Department of Psychiatry, National Insiiture of Mental Health and Neurosciences, Bangalore 560 029, ** Department
of Psychiatry,
Postgraduate Chandigarh
(Received
Institute of Medical Education
and
and Research,
160 012 (India)
18 July 1983, accepted
7 November
1983)
Summary This report compares patients with non-organic chronic intractable (NOCI) pain with those having chronic pain associated with diagnosed physical illness though it was insufficient to explain the severity and nature of pain. Samples were selected after strict screening procedures. The results reveal that NOCI pain is more often seen in those who are younger, unmarried, with higher education and belonging to a professional group of occupation. Chronic pain associated with physical illness is reported more by elderly, married, those with lesser education and housewives. However, only slight differences were noticeable in the clinical characteristics of pain. Thus there are two distinct groups of chronic pain patients. These differences, along with less predominance of low back pain and high number of whole body pain in the samples suggest cultural differences in localisation and presentation of chronic pain.
Introduction Chronic pain is currently recognised as a specific psychobiological disorder [2]. However, it has remained a vaguely defined entity - a puzzle [8]. Black (11 characterised chronic pain patients as having intractable, often multiple pain complaints. ‘Organicity’ or presence of a ‘peripheral pain generator’ in chronic pain
’ Address Institute
all correspondence of Mental Health
0304-3959/84/$03.00
to: Dr. S.K. Chaturvedi, Lecturer, Department and Neurosciences, Bangalore 560 029, India.
0 1984 Elsevier
Science Publishers
B.V.
of Psychiatry.
National
patients has been reported among 20-70% of the patients by Merskey [9], Psychological characteristics [13], clinical features [2] and illness behaviour [lo] of chronic pain patients have been described. A number of studies have failed to reveal any significant differences on psychological testing between pain patients with and without organic pathology [3,13,14]. However, Leavitt and Garron [6] and Leavitt et al. [7] have reported significant differences between low back pain patients with and without organic disease as regards clinical description of pain and their psychological status. The role of physical or organic factors in chronic pain may be trivial. Many times patients with diagnosed physical illness report pain which is considered exaggerated or out of proportion by their physicians. It would be worthwhile to compare such a group of patients with those who have absolutely no physical illness or organicity. The studies quoted above do not make such a comparison. The primary purpose of the present study is to closely look into differences between the following two groups of patients as regards socio-demographic characteristics, clinical descriptions and psychiatric status: (a) Patients with chronic intractable pain with absolutely no identifiable physical disease or illness, i.e., patients with non-organic chronic intractable (NOCI) pain. (b) Patients having diagnosed physical illness or definite organic pathology, presenting with chronic intractable pain where the physicians did not consider the physical illness or organic lesions to be adequate to explain the nature and severity of pain. In this group, however, the locus of pain conformed to the site of physical illness, e.g., patients with rheumatoid arthritis had pain affecting the joints. This helps us in making a comparison between non-organic chronic pain and chronic pain with organicity (physical illness) and also in studying an absolutely pure group of non-organic chronic pain (i.e., NOCI pain).
Method Two hundred consecutive new patients reporting to various medical, surgical and pain clinics of the Postgraduate Institute of Medical Education and Research, Chandigarh were included after screening. The sample included patients with the first or second volunteered complaint of ‘pain’ of a duration of 3 months or more and whose pain free period had not exceeded 4 days at a time. Patients had no significant relief from conventional treatment for at least 1 month. For the purpose of this study, pain was operationally defined as the complaint of ‘pain’ referred to the body or any part of it. Patients below 15 years of age or above 65 years of age and those with gross organic lesion sufficient to explain the severity of pain were excluded. The patients thus included in the study were examined and interviewed clinically to collect data regarding their: (1) socio-demographic characteristics, as age, sex, marital status, religion, education, occupation and residential background; (ii) clinical characteristics of pain, as the site of pain, quality of pain, severity, duration and frequency of pain. (iii) Psychiatric examination was done and psychiatric and physical diagnoses were given wherever applicable. (iv) Psycho-social problems encountered as a result of pain were enquired into.
89
These details were taken from the patient as well as reliable informants accompanying the patient. The patients were divided into two groups. Those having absolutely no physical illness or problem, i.e., non-organic chronic intractable (NOCI) pain and those having associated physical illness although it was not considered sufficient to explain the nature or severity of pain by the medical specialists in their respective clinics. There were 100 patients in each group.
TABLE
i
SOCIO-DEMOG~PHIC
DISTRIBUTION N
NOCl pain
Chronic pain with some organicity
113 87
63 37
50 50
N.S.
57 77 66
42 39 19
15 38 47
< 0.001
39 161
30 70
9 91
<: 0.001
137 59 4
74 23 3
63 36 1
N.S.
54
29
25
62 63
33 22
29 41
21
16
5
42 54 104
16 16 68
26 38 36
P
Sex Male Female Age (years) 15-29 30-44 45-65 Man’raf sifitl4.s Unmarried Married Religron Hindu Sikh Others Occupation Professional Clerical unskilled Housewives Students and others
< 0.02
Education Upto primary Upto matric. Above matric.
-z 0.001
Residence Rural Urban
30
14
16
170
86
84
N.S.
90
Results One hundred patients in the sample had no organic pathology of any severity associated with the chronic pain. An evaluation of these 100 NOCl pain subjects reveals that 63% were males, though this is not statistically different from the ‘associated physical illness’ group. There is a very significant difference (P c:0.001) as regards age. Most patients were of the younger age group, only 19% being above 45 years of age. The pain is significantly (P -c0.001) more often reported by the unmarried. Seventy-seven per cent of the unmarried population included in the
TABLE
II
CLINICAL
DESCRIPTION
OF PAIN N
Site
NOCI pain
Chronic pain with some organicity
56 4-l 30 41 26
29 22 15 20 14
27 25 15 21 12
71 48
42 26
35 22
34 41
13 19
31 22
119 69 12
66 29 5
53 40 7
32
19
7
21 147
I 74
14 73
41 9
23 3
18 6
3 147
0 14
3 73
P
ofpain
Head and face Chest/abdomen Pelvis and back Extremities Whole body
NS
Qualitative description Dull Pricking/burning Squeezing, pulling, boring Throbbing
i 0.05
Intensity of pain Mild Moderate Severe
N.S.
Frequency of pain Once a week or more Once or several times a day Continuous
N.S
Duration of pain Less than 1 day One day to 1 week One week to 1 month Continuous
N.S
sample lacked any organic pathology. Most of the married (91%) had chronic pain along with some organic pathology. NOCI pain is significantly more (P < 0.001) seen in those educated above matriculation. There was no statistical difference with regard to residential background or religion. Students and professionals have significantly more often (P < 0.02) reported NOCI pain whereas housewives usually strongly emphasised pain in the presence of physical illness (Table I). Clinical characteristics of the pain (Table II) The NOCI pain was uniformly represented over various parts of the body, head, face and neck (29%), chest and abdomen (22%) extremities (20%) 14% had pain all over the body. There is a significant difference (P < 0.05) as regards qualitative description. ‘Dull’ aching pain was the predominant type though the other varieties of pain were also reported. Sixty-six per cent reported pain to be ‘mild’ in intensity; ‘moderate’ and ‘severe’ pain were more often reported by patients with associated physical illness. This was not significantly different (P > 0.1). There was no difference in the two groups of chronic pain patients as regards frequency and duration of pain. Seventy-four per cent of NOCI pain patients had ‘continuous’ pain. Seven per cent had pain daily and 19% had pain once a week or more. Twenty-three per cent reported pain to be lasting less than 1 day in the category of ‘duration of pain.’ Forty-two per cent of patients with physical illness had no psychiatric illness. There is a significant difference (P < 0.001) in the psychiatric diagnosis between NOCI pain and the organic group (Table IVa, b). Psycho-social disturbance (Table III) Non-organic chronic pain has caused marked psycho-social disability. Eighty-one per cent had personal dissatisfaction. Fifty-five per cent reported disinterest in work and lack of work motivation. Ninety per cent denied marital discord. Forty-one per
TABLE
III
PSYCHO-SOCIAL
PROBLEMS
NOCI pain
Chronic pain with some organicity
P
71 16
41 10
30 6
N.S. N.S.
116
55
61
N.S.
165
81
84
N.S.
15
12
3
110 87
54 41
56 46
N.S. N.S.
44
26
18
NS
N
Absenteeism Marital discord Lack of work motivation Personal dissatisfactions School-college disruption Disinterest in work Social problem Domestic problem
ENCOUNTERED
i 0.02
92 TABLE
IV --.-
------------
Psychiatric diagnosis
-... ~-~---.
_
._~
NOC‘I pain
Chronic pain with physical illness
22 32 19 5 8 14
I6 ‘9 7 1 5 42
._.._.
_
lu) Psychiatric
drugnosis f I. C. D. 9)
Anxiety neurosis Depressive neurosis Hysteria and ~ypocbondriasis Psychalgia Others and psychosis Niil psychiatry
xz = 23.98
16) Diagnosis
ofpatients
with physical
illness
P < 0.001
(broad categories only have been mentioned)
(1) Musculoskeletal disorders (arthralgia, rheumatoid arthritis, spondylosis etc.) (2) Gastrointestinal disturbances (irritable bowel syndrome, peptic ulcer, pain abdomen syndrome) (3) Trigeminal and other neuralgias (4) Malignancy and neoplasms (any part of the body) (5) Genito-urinary problems, gynecological problems and others Total cases
42 14 21 10 I3 100
cent had social problems and 26% domestic problems. However, these were not statistically different from patients with addil~onal physical illness, except school/college disruption which was more (P < 0.02) in NOCI pain patients. Thus the two groups have an equal amount of psycho-social disruption.
Discussion In this report we have compared two groups of patients having chronic pain. All the patients were considered as having either ‘psychogenic pain’ or ‘psychological elaboration’ of the pain, But as is evident from the comparative tables there are certain differences which are significant in the two groups. The differences are more in the socio-demographic distribution of the patients. NOCl pain seems to be predominant in a particular group of people, those who are younger, unmarried, with higher education and belonging to a professional or semi-professional group of occupation or students. On the other hand, chronic pain associated with physical illness is reported more by elderly, married, housewives and those with lesser education, On close examination of the samples the differences in marital and educational status are not due to the age effect. Large [5] reported over-representation by middle-aged and females in his pain clinic patients where 92% of cases also had physical diagnosis.
93
However, the clinical description of the pain in the two groups is not very different, except as regards the qualitative description. Pain patients with associated organic pathology have more of squeezing, pulling or boring type of pain. Clinically one might not consider this very useful as almost all types of pain were reported by both groups of patients. Thus, chronic pain, with or without organic pathology affects any site or organ, is often dull aching and continuous. NOCI pain is more often of a mild type. The organic pathology could be responsible for the increased severity of pain, since a great majority (47%) of patients with physical illness have moderate to severe pain. Leavitt and Garron [6] and Leavitt et al. [7], however, reported diffuse, more severe and exaggerated pain in low back pain patients with no diagnosable organic disease in contrast to our finding. Psycho-social problems are quite predominant in both groups without much difference. School or college disruption in NOCI pain patients could be due more to the demographic distribution of pain, NOCI pain occurring more often in younger age and among students. There is a high degree of subjective personal distress or dissatisfaction, disinterest and lack of work motivation, social problems and absenteeism in both groups of chronic pain patients. This makes the two groups more comparable regarding socio-demographic and clinical characteristics as severity of psycho-social disruption is equivalent. All the patients, in both groups, would be diagnosed as Psychogenic Pain Disorder according to the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association (D.S.M.-III). But the present investigation clearly brings to light two, to some extent, distinct demographic and clinical groups of chronic pain disorder. These should, hence, be identified as separate types of intractable chronic pain disorders. There are certain other findings in this report that require separate mention. Firstly, only 15% of patients, in either group, reported backache. Most Western researches have reported backache as the predominant site of pain, like Large (51 who had 41% of patients presenting with backache, and Pilowsky and Spence’s [lo] pain clinic patient group which had 27% of patients with backache. Also 14% of NOCI pain patients had whole body pain. We have not come across any report where whole body pain has been quoted in such a high number. Some reports have mentioned multiple sites of pain but those are definitely different from our patients, who clearly described pain to be present all over the body. These findings of difference in presentation of low back pain and whole body pain along with the presentation of NOCI pain in a younger, unmarried and educated group of patients could possibly be indicating cultural differences in the presentation of pain. Culture is widely recognised to be an important determinant of pain response, yet little is known about the interactions of culture with other variables [11,16]. Most researches [4,11,15,16] have been directed towards assessment of pain tolerance and reaction to pain in different races or ethnic groups. But we have not come across any reports regarding cultural differences in presentation of non-organic chronic pain or psychogenic pain. The present study, nevertheless, highlights the necessity for examination of this aspect also,
94
Acknowledgements This work was supported by the Indian Council of Medical Research. The authors wish to thank the Consultants of the Project and the Indian Council of Medical Research. We would like to thank Ms. Ritu Nehra for statistical assistance and Mr. K.N. Krishna Murthy for typing the manuscript.
References 1 Black, R.G., The chronic pain syndrome, Surg. Clin. N. Amer., 55 (1975) 999-1011. 2 Blumer, D. and Heilbronn, M., Chronic pain as a variant of depressive disease, J. nerv. ment. Dis.. 170 (1982) 381-406. 3 Castelnuovo-Tedesco, P. and &out. B.M., Psychosomatic aspects of chronic pelvic pain, Int. J. Psychiat. Med., 1 (1970) 109-126. 4 Knox. V., Shum, K. and Mclaughlin, D.M., Response to cold pressor pain and to acupuncture analgesia in oriental and occidental subjects, Pain. 4 (1977) 49-57. 5 Large, R.G., The psychiatrist and the chronic pain patient: 172 anecdotes, Pain, 9 (1980) 253-263. 6 Leavitt. F. and Garron, D.C., Psychological disturbance and pain report differences in both organic and non-organic low back pain patients, Pain, 7 (1979) 187-195. 7 Leavitt, F., Garron, D.C., D’Angelo, CM. and McNeil], T.W., Low back pain in patients with and without demonstrable organic disease, Pain, 6 (1979) 191-200. 8 Melzack, R., The Puzzle of Pain, Basic Books, New York, 1973. 9 Merskey, H., The role of the psychiatrist in the investigation and treatment of pain, Res. Publ. Ass. nerv. ment. Dis., 58 (1980) 249-260. 10 Pilowsky, I. and Spence, N.D., Patterns of illness behaviour in patients with intractable pain, J. psychosom. Res., 19 (1975) 279-287. 11 Sterltzer, J. and Wade, T.C., The influence of cultural group on the undertreatment of post-operative pain, Psychosom. Med., 43 (1981) 397-403. 12 Sternbach, R.A., Clinical aspects of pain. In: R.A. Sternbach (Ed.), The Psychology of Pain, Raven Press, New York, 1978, pp. 241-264. 13 Sternbach, R.A., Wolf, S.R., Murphy, R.W. et al., Aspects of chronic low back pain. Psychosomatics. 14 (1973) 52-56. 14 Woodforde, J.M. and Merskey, H., Personality traits of patients with chronic pain. J. psychosom. Res.. 16 (1972) 167-172. 15 Woodrow, K.M., Friedman, G.D., Siegelaub, A.B. and Collen, M.F., Pain differences according to age, sex and race, Psychosom. Med., 34 (1972) 548-556. 16 Zborowski. M., Cultural components in responses to pain, J. sot. 1~s.. 8 (1952) 16630.
87-94
87
Elsevier
PAI 00635
Non-Organic Chronic Intractable Pain: a Comparative Study Santosh K. Chaturvedi **‘, Vijoy K. Varma ** and Anil Malhotra ** * Department of Psychiatry, National Insiiture of Mental Health and Neurosciences, Bangalore 560 029, ** Department
of Psychiatry,
Postgraduate Chandigarh
(Received
Institute of Medical Education
and
and Research,
160 012 (India)
18 July 1983, accepted
7 November
1983)
Summary This report compares patients with non-organic chronic intractable (NOCI) pain with those having chronic pain associated with diagnosed physical illness though it was insufficient to explain the severity and nature of pain. Samples were selected after strict screening procedures. The results reveal that NOCI pain is more often seen in those who are younger, unmarried, with higher education and belonging to a professional group of occupation. Chronic pain associated with physical illness is reported more by elderly, married, those with lesser education and housewives. However, only slight differences were noticeable in the clinical characteristics of pain. Thus there are two distinct groups of chronic pain patients. These differences, along with less predominance of low back pain and high number of whole body pain in the samples suggest cultural differences in localisation and presentation of chronic pain.
Introduction Chronic pain is currently recognised as a specific psychobiological disorder [2]. However, it has remained a vaguely defined entity - a puzzle [8]. Black (11 characterised chronic pain patients as having intractable, often multiple pain complaints. ‘Organicity’ or presence of a ‘peripheral pain generator’ in chronic pain
’ Address Institute
all correspondence of Mental Health
0304-3959/84/$03.00
to: Dr. S.K. Chaturvedi, Lecturer, Department and Neurosciences, Bangalore 560 029, India.
0 1984 Elsevier
Science Publishers
B.V.
of Psychiatry.
National
patients has been reported among 20-70% of the patients by Merskey [9], Psychological characteristics [13], clinical features [2] and illness behaviour [lo] of chronic pain patients have been described. A number of studies have failed to reveal any significant differences on psychological testing between pain patients with and without organic pathology [3,13,14]. However, Leavitt and Garron [6] and Leavitt et al. [7] have reported significant differences between low back pain patients with and without organic disease as regards clinical description of pain and their psychological status. The role of physical or organic factors in chronic pain may be trivial. Many times patients with diagnosed physical illness report pain which is considered exaggerated or out of proportion by their physicians. It would be worthwhile to compare such a group of patients with those who have absolutely no physical illness or organicity. The studies quoted above do not make such a comparison. The primary purpose of the present study is to closely look into differences between the following two groups of patients as regards socio-demographic characteristics, clinical descriptions and psychiatric status: (a) Patients with chronic intractable pain with absolutely no identifiable physical disease or illness, i.e., patients with non-organic chronic intractable (NOCI) pain. (b) Patients having diagnosed physical illness or definite organic pathology, presenting with chronic intractable pain where the physicians did not consider the physical illness or organic lesions to be adequate to explain the nature and severity of pain. In this group, however, the locus of pain conformed to the site of physical illness, e.g., patients with rheumatoid arthritis had pain affecting the joints. This helps us in making a comparison between non-organic chronic pain and chronic pain with organicity (physical illness) and also in studying an absolutely pure group of non-organic chronic pain (i.e., NOCI pain).
Method Two hundred consecutive new patients reporting to various medical, surgical and pain clinics of the Postgraduate Institute of Medical Education and Research, Chandigarh were included after screening. The sample included patients with the first or second volunteered complaint of ‘pain’ of a duration of 3 months or more and whose pain free period had not exceeded 4 days at a time. Patients had no significant relief from conventional treatment for at least 1 month. For the purpose of this study, pain was operationally defined as the complaint of ‘pain’ referred to the body or any part of it. Patients below 15 years of age or above 65 years of age and those with gross organic lesion sufficient to explain the severity of pain were excluded. The patients thus included in the study were examined and interviewed clinically to collect data regarding their: (1) socio-demographic characteristics, as age, sex, marital status, religion, education, occupation and residential background; (ii) clinical characteristics of pain, as the site of pain, quality of pain, severity, duration and frequency of pain. (iii) Psychiatric examination was done and psychiatric and physical diagnoses were given wherever applicable. (iv) Psycho-social problems encountered as a result of pain were enquired into.
89
These details were taken from the patient as well as reliable informants accompanying the patient. The patients were divided into two groups. Those having absolutely no physical illness or problem, i.e., non-organic chronic intractable (NOCI) pain and those having associated physical illness although it was not considered sufficient to explain the nature or severity of pain by the medical specialists in their respective clinics. There were 100 patients in each group.
TABLE
i
SOCIO-DEMOG~PHIC
DISTRIBUTION N
NOCl pain
Chronic pain with some organicity
113 87
63 37
50 50
N.S.
57 77 66
42 39 19
15 38 47
< 0.001
39 161
30 70
9 91
<: 0.001
137 59 4
74 23 3
63 36 1
N.S.
54
29
25
62 63
33 22
29 41
21
16
5
42 54 104
16 16 68
26 38 36
P
Sex Male Female Age (years) 15-29 30-44 45-65 Man’raf sifitl4.s Unmarried Married Religron Hindu Sikh Others Occupation Professional Clerical unskilled Housewives Students and others
< 0.02
Education Upto primary Upto matric. Above matric.
-z 0.001
Residence Rural Urban
30
14
16
170
86
84
N.S.
90
Results One hundred patients in the sample had no organic pathology of any severity associated with the chronic pain. An evaluation of these 100 NOCl pain subjects reveals that 63% were males, though this is not statistically different from the ‘associated physical illness’ group. There is a very significant difference (P c:0.001) as regards age. Most patients were of the younger age group, only 19% being above 45 years of age. The pain is significantly (P -c0.001) more often reported by the unmarried. Seventy-seven per cent of the unmarried population included in the
TABLE
II
CLINICAL
DESCRIPTION
OF PAIN N
Site
NOCI pain
Chronic pain with some organicity
56 4-l 30 41 26
29 22 15 20 14
27 25 15 21 12
71 48
42 26
35 22
34 41
13 19
31 22
119 69 12
66 29 5
53 40 7
32
19
7
21 147
I 74
14 73
41 9
23 3
18 6
3 147
0 14
3 73
P
ofpain
Head and face Chest/abdomen Pelvis and back Extremities Whole body
NS
Qualitative description Dull Pricking/burning Squeezing, pulling, boring Throbbing
i 0.05
Intensity of pain Mild Moderate Severe
N.S.
Frequency of pain Once a week or more Once or several times a day Continuous
N.S
Duration of pain Less than 1 day One day to 1 week One week to 1 month Continuous
N.S
sample lacked any organic pathology. Most of the married (91%) had chronic pain along with some organic pathology. NOCI pain is significantly more (P < 0.001) seen in those educated above matriculation. There was no statistical difference with regard to residential background or religion. Students and professionals have significantly more often (P < 0.02) reported NOCI pain whereas housewives usually strongly emphasised pain in the presence of physical illness (Table I). Clinical characteristics of the pain (Table II) The NOCI pain was uniformly represented over various parts of the body, head, face and neck (29%), chest and abdomen (22%) extremities (20%) 14% had pain all over the body. There is a significant difference (P < 0.05) as regards qualitative description. ‘Dull’ aching pain was the predominant type though the other varieties of pain were also reported. Sixty-six per cent reported pain to be ‘mild’ in intensity; ‘moderate’ and ‘severe’ pain were more often reported by patients with associated physical illness. This was not significantly different (P > 0.1). There was no difference in the two groups of chronic pain patients as regards frequency and duration of pain. Seventy-four per cent of NOCI pain patients had ‘continuous’ pain. Seven per cent had pain daily and 19% had pain once a week or more. Twenty-three per cent reported pain to be lasting less than 1 day in the category of ‘duration of pain.’ Forty-two per cent of patients with physical illness had no psychiatric illness. There is a significant difference (P < 0.001) in the psychiatric diagnosis between NOCI pain and the organic group (Table IVa, b). Psycho-social disturbance (Table III) Non-organic chronic pain has caused marked psycho-social disability. Eighty-one per cent had personal dissatisfaction. Fifty-five per cent reported disinterest in work and lack of work motivation. Ninety per cent denied marital discord. Forty-one per
TABLE
III
PSYCHO-SOCIAL
PROBLEMS
NOCI pain
Chronic pain with some organicity
P
71 16
41 10
30 6
N.S. N.S.
116
55
61
N.S.
165
81
84
N.S.
15
12
3
110 87
54 41
56 46
N.S. N.S.
44
26
18
NS
N
Absenteeism Marital discord Lack of work motivation Personal dissatisfactions School-college disruption Disinterest in work Social problem Domestic problem
ENCOUNTERED
i 0.02
92 TABLE
IV --.-
------------
Psychiatric diagnosis
-... ~-~---.
_
._~
NOC‘I pain
Chronic pain with physical illness
22 32 19 5 8 14
I6 ‘9 7 1 5 42
._.._.
_
lu) Psychiatric
drugnosis f I. C. D. 9)
Anxiety neurosis Depressive neurosis Hysteria and ~ypocbondriasis Psychalgia Others and psychosis Niil psychiatry
xz = 23.98
16) Diagnosis
ofpatients
with physical
illness
P < 0.001
(broad categories only have been mentioned)
(1) Musculoskeletal disorders (arthralgia, rheumatoid arthritis, spondylosis etc.) (2) Gastrointestinal disturbances (irritable bowel syndrome, peptic ulcer, pain abdomen syndrome) (3) Trigeminal and other neuralgias (4) Malignancy and neoplasms (any part of the body) (5) Genito-urinary problems, gynecological problems and others Total cases
42 14 21 10 I3 100
cent had social problems and 26% domestic problems. However, these were not statistically different from patients with addil~onal physical illness, except school/college disruption which was more (P < 0.02) in NOCI pain patients. Thus the two groups have an equal amount of psycho-social disruption.
Discussion In this report we have compared two groups of patients having chronic pain. All the patients were considered as having either ‘psychogenic pain’ or ‘psychological elaboration’ of the pain, But as is evident from the comparative tables there are certain differences which are significant in the two groups. The differences are more in the socio-demographic distribution of the patients. NOCl pain seems to be predominant in a particular group of people, those who are younger, unmarried, with higher education and belonging to a professional or semi-professional group of occupation or students. On the other hand, chronic pain associated with physical illness is reported more by elderly, married, housewives and those with lesser education, On close examination of the samples the differences in marital and educational status are not due to the age effect. Large [5] reported over-representation by middle-aged and females in his pain clinic patients where 92% of cases also had physical diagnosis.
93
However, the clinical description of the pain in the two groups is not very different, except as regards the qualitative description. Pain patients with associated organic pathology have more of squeezing, pulling or boring type of pain. Clinically one might not consider this very useful as almost all types of pain were reported by both groups of patients. Thus, chronic pain, with or without organic pathology affects any site or organ, is often dull aching and continuous. NOCI pain is more often of a mild type. The organic pathology could be responsible for the increased severity of pain, since a great majority (47%) of patients with physical illness have moderate to severe pain. Leavitt and Garron [6] and Leavitt et al. [7], however, reported diffuse, more severe and exaggerated pain in low back pain patients with no diagnosable organic disease in contrast to our finding. Psycho-social problems are quite predominant in both groups without much difference. School or college disruption in NOCI pain patients could be due more to the demographic distribution of pain, NOCI pain occurring more often in younger age and among students. There is a high degree of subjective personal distress or dissatisfaction, disinterest and lack of work motivation, social problems and absenteeism in both groups of chronic pain patients. This makes the two groups more comparable regarding socio-demographic and clinical characteristics as severity of psycho-social disruption is equivalent. All the patients, in both groups, would be diagnosed as Psychogenic Pain Disorder according to the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association (D.S.M.-III). But the present investigation clearly brings to light two, to some extent, distinct demographic and clinical groups of chronic pain disorder. These should, hence, be identified as separate types of intractable chronic pain disorders. There are certain other findings in this report that require separate mention. Firstly, only 15% of patients, in either group, reported backache. Most Western researches have reported backache as the predominant site of pain, like Large (51 who had 41% of patients presenting with backache, and Pilowsky and Spence’s [lo] pain clinic patient group which had 27% of patients with backache. Also 14% of NOCI pain patients had whole body pain. We have not come across any report where whole body pain has been quoted in such a high number. Some reports have mentioned multiple sites of pain but those are definitely different from our patients, who clearly described pain to be present all over the body. These findings of difference in presentation of low back pain and whole body pain along with the presentation of NOCI pain in a younger, unmarried and educated group of patients could possibly be indicating cultural differences in the presentation of pain. Culture is widely recognised to be an important determinant of pain response, yet little is known about the interactions of culture with other variables [11,16]. Most researches [4,11,15,16] have been directed towards assessment of pain tolerance and reaction to pain in different races or ethnic groups. But we have not come across any reports regarding cultural differences in presentation of non-organic chronic pain or psychogenic pain. The present study, nevertheless, highlights the necessity for examination of this aspect also,
94
Acknowledgements This work was supported by the Indian Council of Medical Research. The authors wish to thank the Consultants of the Project and the Indian Council of Medical Research. We would like to thank Ms. Ritu Nehra for statistical assistance and Mr. K.N. Krishna Murthy for typing the manuscript.
References 1 Black, R.G., The chronic pain syndrome, Surg. Clin. N. Amer., 55 (1975) 999-1011. 2 Blumer, D. and Heilbronn, M., Chronic pain as a variant of depressive disease, J. nerv. ment. Dis.. 170 (1982) 381-406. 3 Castelnuovo-Tedesco, P. and &out. B.M., Psychosomatic aspects of chronic pelvic pain, Int. J. Psychiat. Med., 1 (1970) 109-126. 4 Knox. V., Shum, K. and Mclaughlin, D.M., Response to cold pressor pain and to acupuncture analgesia in oriental and occidental subjects, Pain. 4 (1977) 49-57. 5 Large, R.G., The psychiatrist and the chronic pain patient: 172 anecdotes, Pain, 9 (1980) 253-263. 6 Leavitt. F. and Garron, D.C., Psychological disturbance and pain report differences in both organic and non-organic low back pain patients, Pain, 7 (1979) 187-195. 7 Leavitt, F., Garron, D.C., D’Angelo, CM. and McNeil], T.W., Low back pain in patients with and without demonstrable organic disease, Pain, 6 (1979) 191-200. 8 Melzack, R., The Puzzle of Pain, Basic Books, New York, 1973. 9 Merskey, H., The role of the psychiatrist in the investigation and treatment of pain, Res. Publ. Ass. nerv. ment. Dis., 58 (1980) 249-260. 10 Pilowsky, I. and Spence, N.D., Patterns of illness behaviour in patients with intractable pain, J. psychosom. Res., 19 (1975) 279-287. 11 Sterltzer, J. and Wade, T.C., The influence of cultural group on the undertreatment of post-operative pain, Psychosom. Med., 43 (1981) 397-403. 12 Sternbach, R.A., Clinical aspects of pain. In: R.A. Sternbach (Ed.), The Psychology of Pain, Raven Press, New York, 1978, pp. 241-264. 13 Sternbach, R.A., Wolf, S.R., Murphy, R.W. et al., Aspects of chronic low back pain. Psychosomatics. 14 (1973) 52-56. 14 Woodforde, J.M. and Merskey, H., Personality traits of patients with chronic pain. J. psychosom. Res.. 16 (1972) 167-172. 15 Woodrow, K.M., Friedman, G.D., Siegelaub, A.B. and Collen, M.F., Pain differences according to age, sex and race, Psychosom. Med., 34 (1972) 548-556. 16 Zborowski. M., Cultural components in responses to pain, J. sot. 1~s.. 8 (1952) 16630.