Psychosocial factors are important determinants of pain intensity and disability associated with disabling musculoskeletal pain.
Depression, pain catastrophizing, and health anxiety are key elements that influence outcomes of musculoskeletal pain.
Most pain conditions are better conceptualized and treated via a biopsychosocial framework with emphasis on the mind–body interaction.
The psychosocial aspects of disabling musculoskeletal pain include cognitive (e.g., beliefs, expectations, and coping style); affective (e.g., depression, pain anxiety, heightened illness concern, anger); behavioral (e.g., avoidance); social (e.g., secondary gain); and cultural factors.
The effectiveness of cognitive behavioral therapy and other treatments that address the psychosocial aspects of disabling musculoskeletal pain has been confirmed in numerous high-quality studies.
Multidisciplinary models of care with emphasis on shared decision making are consistent with evidence-based practice.
This chapter emphasizes the psychological, sociological, and behavioral aspects of all illness, many of which represent promising targets for improving health, wellness, and ability. Consistent with current research and recommendations on pain conceptualization, assessment, and treatment, this chapter emphasizes a biopsychosocial rather than biomedical approach. The biopsychosocial approach specifies an interrelation between physical and psychosocial factors in the etiology and maintenance of pain conditions, with an understanding that the relative importance of these factors varies across time and individuals.
The psychosocial aspects of illness usually manifest in the difference between disease, nociception, and impairment on one hand, and illness, pain, and disability on the other. Disease is defined as an “objective biological event” that involves disruption of specific body structures or organ systems caused by pathologic, anatomic, or physiologic changes. Impairment represents an “objective loss of function” consistent with the magnitude of the biological event. Nociception entails stimulation of nerves that convey information about tissue damage to the brain.
In contrast, illness is defined as a “subjective experience or self-attribution” that a disease is present, this leads to physical discomfort, emotional distress, behavioral limitations, and psychosocial disruption. Illness is thus how the sick person, the social network, and perhaps the society perceive, live with, and respond to physical symptoms. Disability is the effect of this subjective experience. Pain is the subjective perception that results from the modulation of the sensory input filtered through a person’s genetic makeup, prior learning history, and current physiologic status, appraisals, expectations, mood, and sociocultural factors.
The psychosocial aspects of illness are often considered as all or none (dichotomous); for instance, a patient might say, “You think it’s all in my head.” The fact is that illness, pain, and disability are not dichotomous and neither are the psychosocial and behavioral aspects of illness. They occur on a continuum from adaptation and resiliency to maintained function despite either substantial impairment on one hand or disproportionate complaints and disability with little or no objective impairment on the other. Beyond the underlying pathophysiology or disease, the illness encompasses the complex human reaction to injury and illness. Illness, disability, and pain are always interactive, mind–body events.
Hand specialists are familiar with some of the psychosocial factors associated with arm pain, in particular issues associated with secondary gain, such as active litigation, disability claims, worker’s compensation disputes, and narcotic addictions. Hand specialists may be less familiar and perhaps less appreciative of the importance of other psychosocial factors, such as depression, pain catastrophizing, health anxiety, and heightened illness concern.
Depression, Pain Catastrophizing, and Health Anxiety
Consistent with findings in chronic pain throughout the body, the most common psychosocial factors that influence reported pain intensity and disability are depression, pain catastrophizing or negative pain thoughts, and heightened illness concerns. Previously well-compensated psychosocial factors may become problematic when one is confronted with pain. For instance, a person who tends to worry about minor matters may develop pain catastrophizing (a tendency to magnify the pain experience, to feel helpless when thinking about pain, and to ruminate on the pain experience). Someone who has a tendency to worry about his or her health may start viewing a benign pain condition as a sign of serious pathology and may have a difficult time accepting reassurance that the condition is benign ( heightened illness concern, health anxiety, or hypochondriasis ). A depressed patient may make internal (“It’s my fault”), global (“Everything is going wrong”), and stable (“I will never get over this”) attributions about the pain condition. Pain may exacerbate a predisposition toward depression , may intensify an already existent depression, or may become a somatic focus for depressive symptoms. A tendency toward negative thinking and appraisal of life situations may translate into a similar appraisal of the pain condition. All of this may convert into reports of increased pain and disability.
Several measures have been developed for assessing these aspects of illness, and some are specific for pain. They use Likert-type scales, asking specific questions from the psychological domain specific to the construct being assessed. Depression is most often assessed with the Center for the Epidemiologic Study of Depression (CESD ) scale, the Beck Depression Inventory (BDI ), or the Depression Subscale of the Patient Health Questionnaire (PHQ ). These measures inquire about typical symptoms of depression, and they vary in terms of their relative emphasis on the somatic or cognitive components of depression. Although major depression is a discrete diagnosis these scales measure depressive traits or symptoms along the continuous spectrum and indicate how they affect illness behavior.
Pain catastrophizing is assessed with the Pain Catastrophizing Scale (PCS ), a 13-item measure with three subscales: magnification (e.g., “I become afraid that pain may get worse”), helplessness (e.g., “It is awful and I feel that it overwhelms me”), and rumination (e.g., “I can’t seem to keep it out of my mind”). Pain catastrophizing is one of the strongest predictors of pain intensity and disability across a variety of pain conditions.
Health anxiety can be assessed with the Health Anxiety Inventory, Whitley Index, and Somatic Symptoms Inventory (SSI ). The SSI inquires about the extent to which patients experience certain bodily functions (e.g., nausea and vomiting, hot or cold spells, heart pounding, heavy arms). The Health Anxiety Inventory and Whitley Index include questions assessing the extent to which patients endorse cognitive aspects of health anxiety (e.g., “Do you worry about your health?,” “Do you often worry about the possibility that you have a serious illness?”). Health anxiety and hypochondriasis are increasingly recognized correlates of pain intensity and disability in chronic pain conditions.
The use of these validated measures may facilitate the health provider’s ability to address these sensitive topics. Empathy and practiced communication skills are requisite. According to the model developed in other fields, these issues may be best addressed by multidisciplinary teams, with the various health providers (surgeons, nonoperative providers such as physiatrists, certified hand therapists, and behavioral medicine specialists or psychologists) working as a team. Such multidisciplinary treatment teams have been successful in treatment of several pain conditions.
Secondary Gain Issues
Secondary gain describes external psychological motivating factors for the initiation or perpetuation of painful symptoms. The patient may or may not be consciously aware of these psychoemotional motivating factors.
Early psychodynamic theories described secondary gain as responsible for the repression of emotional issues and development of psychosomatic pain. More current theories follow a cognitive behavioral approach and emphasize secondary gain as a social learning model where environmental external factors are reinforcing chronicity. For example, a doting spouse, escape from a stressful job, or sympathy from family and friends may all reinforce chronicity. Within this new framework the term unconscious means unawareness or a lack of a conscious plan for the gain. Unconscious thus means unawareness that the loss of holding onto the condition is often far greater than the perceived gain. Patients may or may not realize the benefits of secondary gain, but they do not consciously cause it to be. This is not the same phenomenon as a patient who purposely pretends to be sick or exaggerates a condition in order to gain a particular objective (e.g., malingering), though conscious malingering and unconscious seeking of the benefits of illness represent extremes of the continuum of secondary gain.
Fordyce, the founder of the social learning theory model of pain, believed that pain is behavior designed to protect oneself or solicit aid and that pain increases (i.e., this behavior is strengthened) when followed by desirable consequences. Fordyce argued that if pain persisted beyond the normal healing time in an environment with secondary gains, the pain would become chronic. He gave as examples of secondary gains, or “desirable consequences” of pain, the following factors: attention and sympathy from family, friends, and physicians; release from task responsibilities at home and at work; narcotic medications; and monetary compensation. Unfortunately patients and hand specialists are not sufficiently mindful of the undesirable consequences of these behaviors, such as anger and rejection when family and friends get tired of having to take on the patient’s daily tasks or exasperation about the patient’s failure to get well; frustration with complicated bureaucracy; increased physical suffering due to chronic narcotic use and dependency; unpleasant side effects with medication; and constant bitter battles for disability benefits during which the patient must take on and exaggerate the sick role. An open discussion of the issues raised by secondary gain and discussion of the long-term consequences can greatly contribute to healing and can prevent chronicity of symptoms and disability.
Psychological Factors Familiar to Hand Specialists
Psychosocial factors are particularly important when a patient’s problem is puzzling (noncharacteristic, nonanatomic, or disproportionately symptomatic and disabling) and the examination and diagnostic procedures are inconclusive or contradictory. The desire to act immediately and help the patient using typical means available to a hand specialist (e.g., surgery, injections, etc.), although understandable, can be counterproductive in this context. Perhaps hand specialists can learn to take a step back, embrace the limitations of modern medicine, and approach treatment within a biopsychosocial behavioral framework. Approaching illness from a biopsychosocial rather than a purely biomedical approach may create several important possibilities for improving health and peace of mind.
In this section we discuss psychiatric diagnoses and puzzling hand and arm conditions—conditions that are instructive of the interrelation between medical and psychological factors—from factitious disorders, in which medical symptoms are consciously produced, to somatization disorder in which normal bodily symptoms are amplified via cognitive processes. The interrelation between medical and psychological factors is acknowledged and incorporated within the fourth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM-IV). Using different axes to depict psychological (axis I), personality (axis II), medical (axis III), psychosocial stressor (axis IV), and global functioning (axis V), aspects of illness help to form a comprehensive image of a patient.
Factitious disorders are conditions in which a person acts as if he or she has an illness by deliberately producing, feigning, or exaggerating symptoms. There is a motivation to assume the sick role and an absence of external incentives. Patients may lie about or fake symptoms, hurt themselves to bring on symptoms, or even alter diagnostic tests (e.g., contaminating a urine sample). People might be motivated to perpetrate factitious disorders either as a patient or by proxy as a caregiver to gain any variety of benefits, including attention, nurturance, sympathy, and leniency, which are perceived as otherwise unobtainable. Patients with factitious disorders deny responsibility, yet they deliberately injure themselves to fulfill psychological needs, sometimes without regard to economic or social gain.
Patients with upper extremity problems rarely meet DSM-IV criteria for a factitious disorder. Conversely, patients can present with elements of a factitious disorder, which can sometimes occur in the context of a clear medical condition. Factitious disorders are “a spectrum of consciously simulated disease, ranging from occasional falsification of disease—perhaps in the midst of stress—to the repetitive presentation of exaggerated or false symptoms and conscious production of signs.”
Factitious disorders are particularly challenging for hand specialists who are generally pragmatists trained to convert observed details into a specific medical diagnosis that leads to straightforward treatment with fairly predictable results.
Clenched Fist Posturing
The clenched fist is a condition in which the arm is healthy, but all or one, two, or three fingers are tightly flexed. Often, the index finger and thumb are not involved, thereby allowing the patient useful hand function. The conceptualization of the clenched fist syndrome is controversial, with some including it as a factitious disorder, and others as a conversion disorder, acknowledging that the motivation and source of this condition may be unconscious. In the short term, the diagnosis can be confirmed by anesthetizing the extremity or the patient and demonstrating the absence of fixed contracture, but in longstanding cases, fixed contracture can develop. A variation on this theme is the stiff index finger that “won’t bend” except under anesthesia.
Factitious Lymphedema and Unexplained Swelling
Unexplained swelling of the hand or arm may be a result of the patient’s surreptitious application of a tourniquet to the extremity. Examples of objects that may be used this way include elastic bandages, sphygmomanometer cuffs, rubber bands, or pieces of string. Placing the extremity in a plaster cast allows the swelling to subside and prevents further application of the constricting band. Many conditions may cause edema of the limb. However, with factitious lymphedema caused by intermittent application of a tourniquet, a so-called broken windowpane pattern of collateral lymphatic circulation distal to the site of tourniquet obstruction is seen. Ruptured lymph channels due to recurrent lymph stasis and direct constriction may also be seen. The size and distribution of the lymphatics are normal, however. There is no abnormality of the lymph nodes.
Self-Inflicted Wounds and Wound Manipulation
Voluntary self-inflicted wounds often have an obvious origin. Cigarette burns, stab wounds, subcutaneous injection of feces and other noxious substances, and even bite wounds are seen in these patients. The clinician must discriminate between the deliberate self-inflicted wound and the accidental one in patients with other types of mental problems such as the hand that is damaged by accidental intra-arterial injection by a drug addict.
Self-cutting is rare but can be quite spectacular, with dozens, sometimes hundreds, of lacerations or scars on the forearms and hands. The lacerations usually involve only the epidermis but occasionally are deeper. The wounds are usually longitudinal or oblique and are most common on the dorsum of the hand and forearm. Self-cutting is common in patients with a borderline personality disorder and is usually conceptualized as means of coping with intense psychological pain as well as need for attention.
Secrétan’s syndrome (also known as peritendinous fibrosis, post-traumatic hard edema, and factitious lymphedema) is a condition caused by the patient repeatedly striking the dorsum of the hand with a blunt object or against a blunt object, causing diffuse swelling as a result of a peritendinous fibrosis of the extensor tendons. The literature suggests that Secrétan’s syndrome is an injury that is self-inflicted either for secondary gain or as a conversion reaction and that is best treated with conservative care and psychiatric counseling.
Patients with Munchausen’s syndrome present themselves as sufferers of all sorts of symptoms and ailments involving any and all parts of the body, including the hand. They often have a long history of many illnesses and treatments, including multiple operations. They are often migratory, going to one medical facility after another, giving detailed histories of specific ailments, and begging for yet another operation. These people are generally well read in the medical literature and often know more about the ailment they are projecting than does the physician they are consulting. When found out, they simply transfer their medical attentions to another part of the country. The patient who has had multiple carpal tunnel operations may well be a variant of this condition.
Patients with SHAFT syndrome (sad, hostile, anxious, frustrating, and tenacious) have pain as a typical complaint, usually without objective physical findings that would support a more definitive diagnosis. Patients with SHAFT syndrome attempt to manipulate the surgeon to perform one or more invasive procedures, despite the lack of objective findings and without relief of symptoms.
Ten criteria were identified that characterize the medical and psychosocial factors common to patients with SHAFT syndrome: (1) multiple invasive procedures, (2) absence of objective findings, (3) multiple physicians, (4) multiple medications (psychotrophic and analgesic), (5) psychiatric treatment, (6) history of being off work, (7) disproportionate self-characterization and verbalization of symptoms, (8) history of crying with pain, (9) family history of disability, and (10) history of abuse (emotional, physical, or sexual). The development of this profile by hand surgeons is an example that some surgeons do recognize the possibility that patients who present with symptoms that do not fit an objective or anatomic pathology may have a primarily psychosocial rather than physical basis for their complaints.
The Somatoform Disorders
The somatoform disorders are conditions in which the presence of physical symptoms suggests a medical condition, but the symptoms are not fully explained by disease (pathophysiology) or by another mental disorder. These disorders include pain disorder, somatization disorder, conversion disorder, and hypochondriasis.
Pain disorder is diagnosed when pain is the predominant focus of the clinical presentation, when the pain causes substantial disability and distress, and when psychological factors are judged to have an important role in the onset, severity, exacerbation, or maintenance of the pain. Pain disorders can be diagnosed in both acute and chronic pain. Pain disorders can be subclassified as pain disorder with psychological factors (in which psychological factors are considered a primary component in the etiology and maintenance of pain) and pain disorder with both psychological and medical factors (in which psychological and medical factors are given equal importance). Pain disorders are the most common psychiatric diagnosis in patients with pain, with prevalence rates as high as 97% in some samples of postinjury patients with chronic low back pain in an inpatient rehabilitation setting.
Somatization disorder is diagnosed in patients with multiple somatic symptoms—including digestive, sexual, and neurologic symptoms in addition to pain—that cannot be explained by a physical disorder. In order to meet the full criteria for somatization disorder, patients have to have four pain, two gastrointestinal, one sexual, and one pseudoneurologic symptom. In addition, these symptoms are not a function of an underlying medical condition, or, when a medical condition is present, symptoms are in excess of what is normally expected from the history, physical examination, or laboratory findings. Although somatization is common among patients with chronic pain, few patients meet the full diagnostic criteria for somatization disorder. The process of somatization is currently conceptualized as involving the focusing of attention on internal stimuli and development of “sensory amplification,” along with denial of psychological or interpersonal difficulties, resulting in an increase in somatic symptoms that remain partly or completely unexplained by objective disease processes.
Hypochondriasis represents a preoccupation with fears of having, or the idea that one has, a serious disease based on a misinterpretation of bodily symptoms. This preoccupation persists despite appropriate medical evaluation and reassurance. The belief is not delusional and is not restricted to appearance only (e.g., body dysmorphic disorder). In addition, this preoccupation causes significant distress or impairment in social, occupational, or other important areas of functioning. In order to meet the full criteria, the disturbance must last longer than 6 months and may not be better accounted for by other psychological disorders such as obsessive compulsive disorder, pain disorder, or generalized anxiety disorder.
Only a small number of hand and arm patients meet the full criteria for hypochondriasis. However, a larger number present with heightened illness concern or health anxiety, which are less severe, yet distressing conditions in which the patient’s concern with a medical or perceived medical condition is exaggerated and consuming. It is important to note that most people are affected and concerned by the presence of pain. However, the majority readily accept reassurance with regard to their pain symptoms and are able to put worries at rest if told that their condition is not dangerous or severe. In patients with heightened illness concern (and its extreme, hypochondriasis), no amount of reassurance is sufficient, and they continue to believe that the doctors “missed” something. Recent research supports the theory that heightened illness concern is an important mechanism for the development of chronic pain conditions.
Conversion disorder is diagnosed when one or more deficits affecting voluntary or sensory function suggest a neurologic or other general medical condition. Psychological factors are judged to be associated with the symptoms or deficits because the initiation or exacerbation of the symptoms or deficits is preceded by conflicts or other stressors. Symptoms are not intentionally produced or feigned (as in factitious disorders or malingering) and cannot, after appropriate investigations, be fully explained by a general medical condition, by substance abuse effects, or culturally sanctioned behaviors. In addition, the symptoms cause clinically significant distress or impairment in social, occupational, or other areas of functioning. The symptoms are not limited to pain or sexual dysfunction, do not occur only as part of somatization disorder, and are not better accounted for by a medical condition. Based on type of symptom deficits, conversion disorders are classified as (1) with motor symptoms or deficits, (2) with sensory symptoms or deficits, (3) with seizures or convulsions, or (4) with mixed presentation. Conversion disorders are rare in pain patients. However, patients may present with symptoms of a conversion disorder, such as sudden onset of arm weakness and perhaps inability to lift the hand, which is found to have no medical explanation.
Other Chronic Unexplained or Puzzling Pain Problems—A Personal Perspective
Many illness constructs used by hand specialists and currently described in the literature as purely medical (based on a biomedical framework) have minimal or no objective, verifiable pathology but, as research is increasingly demonstrating, do have strong psychosocial correlates. A biopsychosocial behavioral approach may be more appropriate in conceptualizing and treating these conditions.
Repetitive Strain Injury
Repetitive strain injury—also known as writer’s cramp, cumulative trauma disorder, occupational overuse syndrome, and work-related upper limb disorder, among other terms—is an unverifiable diagnosis (essentially a social illness construct, which is defined as a term “invented” or “constructed” by our culture and society, which exists because people agree to behave as if it exists) diagnosed on the basis of chronic activity-associated pain, typically in the upper limb. Although the illness construct implies injury or damage, an important characteristic of this diagnosis is that there are no objective signs of damage or disease. The illness is entirely subjective, and there are no objective tests to verify the diagnosis.
Several unverifiable pain conditions are accepted illness constructs within hand surgery and medicine including radial tunnel syndrome, pronator syndrome, as well as electrophysiologically normal thoracic outlet, carpal tunnel, and cubital tunnel syndromes, not to mention dynamic scapholunate instability, occult dorsal ganglion, among others. These debatable and unverifiable conditions are similar to other nonspecific conditions, such as fibromylagia and chronic fatigue syndrome, which are often comorbid.
The nomenclature of these illness constructs is somewhat troubling, as it implies an understanding of the pathophysiology and a known physical basis where one is by definition lacking. It is recognized, but underappreciated, that chronic nonspecific arm pain is comorbid with depression, health anxiety, pain catastrophizing, and somatization, which are perhaps the only clear targets of intervention in the absence of verifiable and treatable objective pathology.
From a biopsychosocial perspective patients with repetitive strain injury can also be conceptualized as presenting with features of conversion disorder, heightened illness concern, and somatoform disorder. Distress may also manifest in the form of anxiety and depression. Perhaps a biopsychosocial approach similar to that described in the DSM-IV, which considers both medical and psychological factors, should replace the purely medical focus that currently hinders comprehensive management of these illnesses. In this way, unnecessary medical procedures can be avoided, and psychological distress can be addressed, thus increasing the patient’s quality of life and functioning. Some state that these medical labels serve the patient’s need to emphasize the physical rather than the psychosocial or somatoform aspect of his or her illness, and thus avoid stigmatization, but the benefit of these diagnoses is short-lived. In the long run, a focus on a purely medical condition and the administration of numerous tests and medical procedures act to reinforce a “sick role” and do not address core issues, such as acceptance, adaptation, and resiliency. No matter the advances to come in medicine, illness will always be a part of human existence, and effective coping skills will improve ability, wellness, and peace of mind.
Complex Regional Pain Syndromes
Complex regional pain syndromes (CRPSs) represent another puzzling chronically painful condition with little epidemiologic information, a lack of understanding with regard to natural course or basic pathophysiology, and lack of agreement even on definition and diagnostic criteria. The most up-to-date definition of CRPS currently adopted by the International Association for the Study of Pain (IASP) reflects the evolution of the controversies of the concepts of reflex sympathetic dystrophy, sympathetically maintained pain, and sympathetically independent pain and attempts to provide a definition focused on a description without any presumption about underlying mechanisms. The current nomenclature reflects the complexity of this condition, the regional distribution of symptoms (which mostly affects hands), and the cardinal symptom of pain. Two types of disorders are included in this category: (1) CRPS I, in which the onset of pain occurs after an injury and involves continued pain, hypersensitivity or allodynia, and evidence of edema or abnormal sudomotor activity, and (2) CRPS II, which has similar criteria, but it implies a known nerve injury, that is, however, not limited to the distribution of the particular nerve.
These diagnostic criteria have been strongly criticized as being too vague, thereby allowing for overdiagnosis. Furthermore, the pathogenesis of this disorder is unclear, failing to explain why only a small percentage of patients develop CRPS after an injury or well-defined nerve trauma but the majority do not; whether there is a genetic predisposition, and why such a significant variability exists among the different symptom classes of abnormalities seen in patients with CRPS.
There is general agreement that many patients with CRPS manifest important and profound behavioral and emotional issues, as well as reports of intense pain and severe disability. There is also some evidence that depression, anxiety, and life stressors (frequently reported as present in CRPS patients) might influence the development of this condition through α-adrenaline activity. Van Houdenhove and colleagues articulated a conceptualization suggesting the role of hyperarousal due to life stress or other factors preceding or around the time of injury or during the subsequent initial period of healing and difficulties coping.
CRPS is seen as overlapping with several conditions, including neuromas and phantom limb pain. The key element in all these conditions is that pain is considered “sympathetically maintained.”
Neuromas are chronic pain conditions that, if severe enough, may severely curtail any useful function of the hand. Surgical management of painful neuromas has not been as effective as we might wish.
Phantom Limb Pain
Phantom limb pain is a clinical condition in which patients experience pain in a limb after amputation. A phantom limb is the sensation that an amputated or missing limb (even an organ, like the appendix) is still attached to the body and is moving appropriately with other body parts. Approximately 50% to 80% of individuals with an amputation experience phantom sensations in their amputated limb, and the majority of the sensations are painful. Phantom limb sensations usually disappear or decrease over time. When phantom limb pain continues for more than 6 months, the prognosis for spontaneous improvement is poor, and pain can become disabling and can lead to a lifelong struggle with chronic pain. Research has identified that, among other factors, pain and psychiatric distress in the form of depression, anxiety, and somatization are predictors of chronicity of phantom limb pain.