Accepted Manuscript “What we have here is a failure to communicate.” Is it pain in the spine, pain in the brain, or both, or neither? James B. Talmage, MD PII:
S1529-9430(13)01580-5
DOI:
10.1016/j.spinee.2013.10.001
Reference:
SPINEE 55585
To appear in:
The Spine Journal
Received Date: 11 September 2013 Revised Date:
29 September 2013
Accepted Date: 17 October 2013
Please cite this article as: Talmage JB, “What we have here is a failure to communicate.” Is it pain in the spine, pain in the brain, or both, or neither?, The Spine Journal (2013), doi: 10.1016/ j.spinee.2013.10.001. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
“What we have here is a failure to communicate.” Is it pain in the spine, pain in the brain, or both, or neither?
AC C
EP
TE D
M AN U
SC
RI PT
-James B. Talmage MD
ACCEPTED MANUSCRIPT
“What we have here is a failure to communicate.” – A Commentary on: Risk factors for Non-Organic Low Back Pain in Patients with Workers’ Compensation. -James B. Talmage MD
RI PT
Commentary on SPINEE-D-12-00272R1: Risk factors for Non-Organic Low Back Pain in Patient’s with Workers’ Compensation. Rohrlich JT, Sadhu A, et al. The Spine Journal
In1860 Mary was burdened with fatigue. Her doctors told her she had neurasthenia and there was no specific, highly effective treatment. Then thyroid hormone was discovered in the late 1800s [1], and Mary was proven to be hypothyroid. She was then effectively treated.
M AN U
SC
Medically unexplainable symptoms are common [2]. Today we have patients with known specific low back pain syndromes like disc herniation with radiculopathy, or unstable spondylolisthesis. But, at least 85% of low back pain patients are classified as “nonspecific”, meaning with today’s technology we cannot with certainty name the pain generating structure, or level(s) [3,4]. Spine specialists are not alone. Our cardiology colleagues have “non-cardiac chest pain” patients [5]. Our ENT colleagues have “non-vertiginous dizziness” patients[6]. Medically unexplainable pain is a common compliant of patients in the offices of the primary care provider, gastroenterologist, urologist/gynecologist, and rheumatologist, and not just in the offices of the hand surgeon and the spine surgeon.
TE D
Mental disorders and psychosocial stress are common. Medically unexplainable pain was part of the potential presentation of over 100 mental disorders that were diagnosable by the now freshly antiquated Diagnosis and Statistical Manual, 4th Edition, Text Revision (DSM-IV-TR) [7].
AC C
EP
Thus the spine specialist with a low back pain patient, the cardiologist with a chest pain patient, and the ENT specialist with a “dizzy” patient can conceptualize triage/diagnosis into 4 potential categories: 1. known pathology, no apparent mental disorder, normal “stress” level 2. known pathology, apparent co-morbid mental disorder and/or “distress” 3. medically unexplainable symptoms, no apparent mental disorder, normal “stress” level 4. medically unexplainable symptoms, apparent co-morbid mental disorder and/or “distress”. Group 1 patients are “easy”, and represent the group of patients that caused the physician to choose to train in and to practice his/her specialty. Group 2 patients are challenging, and while there is specific pathology and available treatment, the medical outcomes [8, 9 10], and “patient satisfaction surveys” are affected by the mental co-morbidities and/or psychosocial factors.
ACCEPTED MANUSCRIPT
Group 3 patients are fascinating. Our fatigued Mary in the era before the discovery of thyroid hormone would fit here. Reliable and valid tests, and clearly effective evidence based treatments have yet to be discovered. Reassurance that no life-threatening serious disease process explains the symptom(s) is perceived as “nice”, but “frustrating” by many patients. Physicians want to “do something” – that is why we became physicians.
RI PT
Group 4 patients are potentially frustrating for the primary care provider, and for the physician specialist. Many times the physician is more frustrated than the patient.
M AN U
SC
Just as some people are optimists, and some are pessimists, many physician specialists tend to view most patients as in our Group 1[11], while others view many of the same patients as fitting in Groups 2, 3, and 4. Many research studies on treatment are published with inclusion criteria (specific disease) and exclusion criteria (no apparent mental disorder, normal “stress” level). The physicians who tend to view all, or most patients as in Group 1, want to apply treatments to those less likely to be benefitted (Groups 3 and 4). When treatment success is judged by subjective factors (pain, self-reported function by questionnaire, etc) the outcomes may look better than when objective criteria are used (opioid use, return to work rate, mortality, etc.), but by any outcome measure, treatment results are generally less gratifying[8, 9, 10]. This failure to appreciate the co-morbid mental disorder and/or “distress” may be more common than many spine specialists recognize. When studied, spine specialists have not been proven to accurately identify our Groups 2 and 4 [12].
AC C
EP
TE D
Referral to a mental health provider is an option, but many times the referring physician fails to identify for the mental health professional whether the general medical condition symptoms are considered “medically explainable” (Groups 1 and 2) or “medically unexplainable” (Groups 3 and 4). Psychologists and psychiatrists may not be able to discern from the patient’s mental health interview, or from countless pages of electronic medical records (if available) that contain volumes of irrelevant information and that were created by both patient and provider “mouse clicks” that did not permit more accurate recording of history and physical exam findings, whether the general medical condition symptoms are “medically explainable”. Thus, unfortunately, the mental health provider, who isn’t clear on whether the patient’s symptoms are medically explainable, may reply with “depression/anxiety appropriate for the general medical condition”, which does not clarify for the spine surgeon whether there is, or is not, a mental disorder known to be present for which medically unexplainable pain is a common feature. Thus spine specialists, and our non-musculoskeletal physician colleagues (cardiologist, ENT, etc.) should seek ways to classify patients into one of the 4 above groups. In this issue, Rohrlich, Sadhu, et al [13] report on the experience of a single spine surgeon seeing workers’ compensation patients, a group in which suboptimal spine outcomes are well documented as more frequent[14]. The goal of this study appears to be to find a “Clinical Prediction Rule” that would classify spine pain patients as having “non-organic pain” (either our Group 3 or Group 4). Since other researchers are
2
ACCEPTED MANUSCRIPT
evaluating tests to reclassify some of the Group 3 patients into Group 1, and to reclassify some of the Group 4 patients into Group 2, perhaps the term “currently medically unexplainable back pain” would be preferable to “non-organic low back pain”.
RI PT
The clinicians in Rohrlich et al were clearly aware of the suboptimal surgical outcomes associated with patients in Groups 2, 3, and 4. They documented the presence or absence of 13 separate “potential risk factors” for “non-organic pain”. This level of documentation is not usually seen in patients’ charts.
M AN U
SC
The outcome measured is not the presence or absence of diagnosable mental disorders that would potentially clarify the origin of back pain. Rather the authors sought to relate certain historical elements with the number of “Waddell signs” on physical exam, or other clearly similar abnormal pain behaviors on exam. While Waddell signs have been shown to be reliably observable, and to predict suboptimal surgical outcomes, they are not proof of malingering, or proof of the absence of spinal pathology that can produce at least part of the clinical presentation [15]. Multiple pain behavior signs indicate the patient does not have a “straightforward physical problem” [15] (i.e. not our Group 1 patients). The authors’ conclusions are common sense. If minor slips and falls led frequently in “normal” people to chronic disabling spinal pain, society would long ago have banned football, soccer, hockey, rugby, wrestling, etc. Carragee’s work [16] on minor trauma and chronic low back pain illness reinforces this conclusion, and should be familiar to all spine specialists who have to opine on causation.
EP
TE D
Less publicized, but equally significant is the authors’ conclusion on the presence of multiple pain syndromes from minor injury. Certainly high velocity, high force polytrauma occurs and is beautifully managed in Level 1 trauma centers. This type injury is happily rare in workers’ compensation. Minor injury (lifting strain, or slip on a wet floor and fall) that supposedly causes simultaneous injury to multiple spinal regions, none of which manage to heal, and all of which have symptoms that worsen causing function that deteriorates over time would be a “yellow flag”. These “injuries” do not behave like injuries.
AC C
Similarly, the authors’ note that chronic persisting disabling low back illness in a workers’ compensation patient who did not injury his/her back, but developed back pain subsequently (“metastasis” of pain from other sites caused by limping?) should be a “yellow flag”[ 17]. The authors’ conclusion that identifiable factors in the history predict pain behavior on exam may help sensitize physician examiners to look for the “yellow flags” during physical exam. To note that the patient limps sometimes, but not always, or that the leg the person favors (antalgic gait) changes from left to right, and back to left, requires the physician to consciously observe gait continuously throughout the encounter. To note that numbness is migratory, requires the physician to ask about the location of numbness and
3
ACCEPTED MANUSCRIPT
perhaps even to do sensory examination more than once during an exam, which is rarely documented and never reimbursed by insurers.
RI PT
A better description in this article of the demographics of the authors’ workers’ compensation patients would permit the reader to better evaluate how well the authors’ findings would generalize to the reader’s practice. A description of exactly what the authors considered “an organic lesion on MRI” as opposed to a “negative MRI” would be instructive, as many readers may have a vastly different personal definition of a positive or negative MRI. This might stimulate some readers to re-read the systematic review by Endean et al on the value of MRI findings [4].
SC
Unfortunately, just when the reader might think he/she is beginning to understand back pain, the mental disorders that influence symptoms, and communication with mental health providers, change occurs.
M AN U
As science progresses, we better understand the neurologic basis for mental disorders, and psychiatry is progressively becoming neurology [18]. There is still only 1 board that certifies both psychiatrists and neurologists, the American Board of Psychiatry and Neurology. Each specialty rotates residents through the other specialty.
EP
TE D
DSM-IV-TR was replaced in May 2013 by DSM-5[19]. Many of the disorders present in DSM-IV-TR are not present in DSM-5, which will negate applying prior research on back pain and mental disorders to patients diagnosed by mental health professionals after May 2013. The DSM-IV-TR diagnoses most often made by mental health professionals in patients with chronic spinal pain were “somatization disorder”, “undifferentiated somatoform disorder”, and “pain disorder associated with psychological factors”. These diagnoses no longer exist. Some, but not all, of the patients who meet DSM-IV-TR criteria for these diagnoses will meet criteria in DSM-5 for new diagnoses of “somatic symptom disorder” or “illness anxiety disorder”.
AC C
The issue of “medically unexplainable pain” does not exist in DSM-5. The DSM-5 philosophy includes the following elements: • There is no meaningful difference between mental illnesses and other illnesses. • The traditional DSM distinction between mental illness and “general medical conditions” has been eliminated – therefore, the phrase “general medical condition” has been eliminated. Mental illnesses are “medical disorders”, just like any other kind of medical disorder. • Pain that is due to mental illness is not significantly different in any meaningful way from pain that is due to some other type of illness. • Therefore, there is no such thing as “medically unexplainable pain”, because pain that is attributable to mental illness is “medically explained”. • DSM-5 issues regarding pain do not involve any consideration of whether the pain is “medically explainable” – it focuses instead on whether the patient is responding to the pain in some pathological manner. Thus mental health providers
4
ACCEPTED MANUSCRIPT
will be encouraged not to consider the origin of the patient’s pain, but rather how the patient responds to the pain with behaviors and emotions.
RI PT
Spine specialists need to be aware of this change, as communication with mental health disorders about “medically unexplainable” may be more challenging, and trying to sort out for a given patient which of our 4 groups applies may be quite a bit more challenging.
SC
The characterization of spinal pain as “medically explainable” (Groups 1 and 2) or “medically unexplainable” (Groups 3 and 4) will remain an important subject for research studies, and an important consideration in the care of individual patients. The tests we have, the terms we use for diagnosis, and the treatments we have will continue to change, even if the patient population we treat does not. References
AC C
EP
TE D
M AN U
[1] http://www.optimox.com/pics/Iodine/IOD-15/PUB_15.htm – accessed 09/07/13 [2] Klaus K, Rief W, Brähler E, et al. The distinction between “medically unexplained” and “medically explained” in the context of somatoform disorders. Int J Behav Med 2013; 20 (2): 161-71. [3] Balagué F, Mannion AF, Pellisé F, Cedraschi C. Non-specific low back pain. Lancet 2012; 379: 482-91. [4] Endean A, Palmer KT, Coggon D. Potential of Magnetic Resonance Imaging Findings to Refine Case Definition for Mechanical Low Back Pain in Epidemiological Studies. Spine 2011; 36 (2): 160-169. [5] Hocaoglu C, Gulec MY, Durmus I. Psychiatric Comorbidity in Patients with Chest Pain without a Cardiac Etiology. Isr J Psychiatry Rel Sci 2008; 45 (1): 49-54. [6] Clark MR, Sullivan MD, Katon WE, et al. Psychiatric and medical factors associated with disability in patients with dizziness. Psychosomatics 1993; 34 (5): 409-15. [7] Barth RJ. Undiagnosed Mental Illness as the Cause of General Medical Disability Claims. The Guides Newsletter 2006 (Nov/Dec): 1-3 & 8-11 American Medical Association, Chicago. [8] Trief PM, Grant W, Fredrickson B. A prospective study of psychological predictors of lumbar surgery outcome. Spine 2000; 25 (20): 2616-21. [9] Daubs MD, Norvell DC, McGuire R, et al. Fusion versus nonoperative care for chronic low back pain: do psychological factors affect outcomes? Spine 2011; 36 (Suppl 21): S96-S109 [10] Pollack R, Lakkol S, Budithi C, et al. Effect of Psychological Status on Outcome of Posterior Lumbar Interbody Fusion Surgery. Asian Spine Journal 2012: 6 (3): 178-182. [11] Shaw WS, Pransky G, Winters T, et al. Does the Presence of Psychosocial “Yellow Flags” Alter Patient-Provider Communication for Work-Related, Acute Low Back Pain? JOEM 2009; 51: 1032-40. [12] Daubs MD, Patel AA, Willick SE, et al. Clinical Impression Versus Standardized Questionnaire: The Spinal Surgeon’s Ability to Assess Psychological Distress. JBJS 2010; 92: 2878-83. [13] INSERT CITATION FOR THE ARTICLE THAT PRECEEDS THIS COMMENTARY
5
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
[14] Harris I, Mulford J, Solomon M, et al. Association between compensation status and outcome after surgery. JAMA 2005; 293: 1644-1652. [15] Main C and Waddell G. Behavioral Responses to Examination: A Reappraisal of the Interpretation of “Nonorganic Signs”. Spine 1998; 23 (21): 2367-2371. [16] Carragee E, Alamin T, Cheng I, et al. Does Minor Trauma Cause Serious Low Back Pain Illness? Spine 2006; 31 (25): 2942-2949. [17] Kendall NAS, Burton AK. Tackling Musculoskeletal Problems: A Guide for Clinic and Workplace - Identifying Obstacles Using the Psychosocial Flags Framework 2009 The Secretary’s Office, London. http://www.tso.co.uk/news/2009/09/tacklingmusculoskeletal-problems-now-published accessed 09/07/13 [18] White PD, Rickards H, Zeman AZJ. Time to end the distinction between mental and neurologic illnesses. BMJ 2012; 344: e3454 doi: 10.1136/bmj.e3454. [19] Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. American Psychiatric Association, Washington DC, 2013, ISBN 978-0-89042-554-1.
6
S1529-9430(13)01580-5
DOI:
10.1016/j.spinee.2013.10.001
Reference:
SPINEE 55585
To appear in:
The Spine Journal
Received Date: 11 September 2013 Revised Date:
29 September 2013
Accepted Date: 17 October 2013
Please cite this article as: Talmage JB, “What we have here is a failure to communicate.” Is it pain in the spine, pain in the brain, or both, or neither?, The Spine Journal (2013), doi: 10.1016/ j.spinee.2013.10.001. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
“What we have here is a failure to communicate.” Is it pain in the spine, pain in the brain, or both, or neither?
AC C
EP
TE D
M AN U
SC
RI PT
-James B. Talmage MD
ACCEPTED MANUSCRIPT
“What we have here is a failure to communicate.” – A Commentary on: Risk factors for Non-Organic Low Back Pain in Patients with Workers’ Compensation. -James B. Talmage MD
RI PT
Commentary on SPINEE-D-12-00272R1: Risk factors for Non-Organic Low Back Pain in Patient’s with Workers’ Compensation. Rohrlich JT, Sadhu A, et al. The Spine Journal
In1860 Mary was burdened with fatigue. Her doctors told her she had neurasthenia and there was no specific, highly effective treatment. Then thyroid hormone was discovered in the late 1800s [1], and Mary was proven to be hypothyroid. She was then effectively treated.
M AN U
SC
Medically unexplainable symptoms are common [2]. Today we have patients with known specific low back pain syndromes like disc herniation with radiculopathy, or unstable spondylolisthesis. But, at least 85% of low back pain patients are classified as “nonspecific”, meaning with today’s technology we cannot with certainty name the pain generating structure, or level(s) [3,4]. Spine specialists are not alone. Our cardiology colleagues have “non-cardiac chest pain” patients [5]. Our ENT colleagues have “non-vertiginous dizziness” patients[6]. Medically unexplainable pain is a common compliant of patients in the offices of the primary care provider, gastroenterologist, urologist/gynecologist, and rheumatologist, and not just in the offices of the hand surgeon and the spine surgeon.
TE D
Mental disorders and psychosocial stress are common. Medically unexplainable pain was part of the potential presentation of over 100 mental disorders that were diagnosable by the now freshly antiquated Diagnosis and Statistical Manual, 4th Edition, Text Revision (DSM-IV-TR) [7].
AC C
EP
Thus the spine specialist with a low back pain patient, the cardiologist with a chest pain patient, and the ENT specialist with a “dizzy” patient can conceptualize triage/diagnosis into 4 potential categories: 1. known pathology, no apparent mental disorder, normal “stress” level 2. known pathology, apparent co-morbid mental disorder and/or “distress” 3. medically unexplainable symptoms, no apparent mental disorder, normal “stress” level 4. medically unexplainable symptoms, apparent co-morbid mental disorder and/or “distress”. Group 1 patients are “easy”, and represent the group of patients that caused the physician to choose to train in and to practice his/her specialty. Group 2 patients are challenging, and while there is specific pathology and available treatment, the medical outcomes [8, 9 10], and “patient satisfaction surveys” are affected by the mental co-morbidities and/or psychosocial factors.
ACCEPTED MANUSCRIPT
Group 3 patients are fascinating. Our fatigued Mary in the era before the discovery of thyroid hormone would fit here. Reliable and valid tests, and clearly effective evidence based treatments have yet to be discovered. Reassurance that no life-threatening serious disease process explains the symptom(s) is perceived as “nice”, but “frustrating” by many patients. Physicians want to “do something” – that is why we became physicians.
RI PT
Group 4 patients are potentially frustrating for the primary care provider, and for the physician specialist. Many times the physician is more frustrated than the patient.
M AN U
SC
Just as some people are optimists, and some are pessimists, many physician specialists tend to view most patients as in our Group 1[11], while others view many of the same patients as fitting in Groups 2, 3, and 4. Many research studies on treatment are published with inclusion criteria (specific disease) and exclusion criteria (no apparent mental disorder, normal “stress” level). The physicians who tend to view all, or most patients as in Group 1, want to apply treatments to those less likely to be benefitted (Groups 3 and 4). When treatment success is judged by subjective factors (pain, self-reported function by questionnaire, etc) the outcomes may look better than when objective criteria are used (opioid use, return to work rate, mortality, etc.), but by any outcome measure, treatment results are generally less gratifying[8, 9, 10]. This failure to appreciate the co-morbid mental disorder and/or “distress” may be more common than many spine specialists recognize. When studied, spine specialists have not been proven to accurately identify our Groups 2 and 4 [12].
AC C
EP
TE D
Referral to a mental health provider is an option, but many times the referring physician fails to identify for the mental health professional whether the general medical condition symptoms are considered “medically explainable” (Groups 1 and 2) or “medically unexplainable” (Groups 3 and 4). Psychologists and psychiatrists may not be able to discern from the patient’s mental health interview, or from countless pages of electronic medical records (if available) that contain volumes of irrelevant information and that were created by both patient and provider “mouse clicks” that did not permit more accurate recording of history and physical exam findings, whether the general medical condition symptoms are “medically explainable”. Thus, unfortunately, the mental health provider, who isn’t clear on whether the patient’s symptoms are medically explainable, may reply with “depression/anxiety appropriate for the general medical condition”, which does not clarify for the spine surgeon whether there is, or is not, a mental disorder known to be present for which medically unexplainable pain is a common feature. Thus spine specialists, and our non-musculoskeletal physician colleagues (cardiologist, ENT, etc.) should seek ways to classify patients into one of the 4 above groups. In this issue, Rohrlich, Sadhu, et al [13] report on the experience of a single spine surgeon seeing workers’ compensation patients, a group in which suboptimal spine outcomes are well documented as more frequent[14]. The goal of this study appears to be to find a “Clinical Prediction Rule” that would classify spine pain patients as having “non-organic pain” (either our Group 3 or Group 4). Since other researchers are
2
ACCEPTED MANUSCRIPT
evaluating tests to reclassify some of the Group 3 patients into Group 1, and to reclassify some of the Group 4 patients into Group 2, perhaps the term “currently medically unexplainable back pain” would be preferable to “non-organic low back pain”.
RI PT
The clinicians in Rohrlich et al were clearly aware of the suboptimal surgical outcomes associated with patients in Groups 2, 3, and 4. They documented the presence or absence of 13 separate “potential risk factors” for “non-organic pain”. This level of documentation is not usually seen in patients’ charts.
M AN U
SC
The outcome measured is not the presence or absence of diagnosable mental disorders that would potentially clarify the origin of back pain. Rather the authors sought to relate certain historical elements with the number of “Waddell signs” on physical exam, or other clearly similar abnormal pain behaviors on exam. While Waddell signs have been shown to be reliably observable, and to predict suboptimal surgical outcomes, they are not proof of malingering, or proof of the absence of spinal pathology that can produce at least part of the clinical presentation [15]. Multiple pain behavior signs indicate the patient does not have a “straightforward physical problem” [15] (i.e. not our Group 1 patients). The authors’ conclusions are common sense. If minor slips and falls led frequently in “normal” people to chronic disabling spinal pain, society would long ago have banned football, soccer, hockey, rugby, wrestling, etc. Carragee’s work [16] on minor trauma and chronic low back pain illness reinforces this conclusion, and should be familiar to all spine specialists who have to opine on causation.
EP
TE D
Less publicized, but equally significant is the authors’ conclusion on the presence of multiple pain syndromes from minor injury. Certainly high velocity, high force polytrauma occurs and is beautifully managed in Level 1 trauma centers. This type injury is happily rare in workers’ compensation. Minor injury (lifting strain, or slip on a wet floor and fall) that supposedly causes simultaneous injury to multiple spinal regions, none of which manage to heal, and all of which have symptoms that worsen causing function that deteriorates over time would be a “yellow flag”. These “injuries” do not behave like injuries.
AC C
Similarly, the authors’ note that chronic persisting disabling low back illness in a workers’ compensation patient who did not injury his/her back, but developed back pain subsequently (“metastasis” of pain from other sites caused by limping?) should be a “yellow flag”[ 17]. The authors’ conclusion that identifiable factors in the history predict pain behavior on exam may help sensitize physician examiners to look for the “yellow flags” during physical exam. To note that the patient limps sometimes, but not always, or that the leg the person favors (antalgic gait) changes from left to right, and back to left, requires the physician to consciously observe gait continuously throughout the encounter. To note that numbness is migratory, requires the physician to ask about the location of numbness and
3
ACCEPTED MANUSCRIPT
perhaps even to do sensory examination more than once during an exam, which is rarely documented and never reimbursed by insurers.
RI PT
A better description in this article of the demographics of the authors’ workers’ compensation patients would permit the reader to better evaluate how well the authors’ findings would generalize to the reader’s practice. A description of exactly what the authors considered “an organic lesion on MRI” as opposed to a “negative MRI” would be instructive, as many readers may have a vastly different personal definition of a positive or negative MRI. This might stimulate some readers to re-read the systematic review by Endean et al on the value of MRI findings [4].
SC
Unfortunately, just when the reader might think he/she is beginning to understand back pain, the mental disorders that influence symptoms, and communication with mental health providers, change occurs.
M AN U
As science progresses, we better understand the neurologic basis for mental disorders, and psychiatry is progressively becoming neurology [18]. There is still only 1 board that certifies both psychiatrists and neurologists, the American Board of Psychiatry and Neurology. Each specialty rotates residents through the other specialty.
EP
TE D
DSM-IV-TR was replaced in May 2013 by DSM-5[19]. Many of the disorders present in DSM-IV-TR are not present in DSM-5, which will negate applying prior research on back pain and mental disorders to patients diagnosed by mental health professionals after May 2013. The DSM-IV-TR diagnoses most often made by mental health professionals in patients with chronic spinal pain were “somatization disorder”, “undifferentiated somatoform disorder”, and “pain disorder associated with psychological factors”. These diagnoses no longer exist. Some, but not all, of the patients who meet DSM-IV-TR criteria for these diagnoses will meet criteria in DSM-5 for new diagnoses of “somatic symptom disorder” or “illness anxiety disorder”.
AC C
The issue of “medically unexplainable pain” does not exist in DSM-5. The DSM-5 philosophy includes the following elements: • There is no meaningful difference between mental illnesses and other illnesses. • The traditional DSM distinction between mental illness and “general medical conditions” has been eliminated – therefore, the phrase “general medical condition” has been eliminated. Mental illnesses are “medical disorders”, just like any other kind of medical disorder. • Pain that is due to mental illness is not significantly different in any meaningful way from pain that is due to some other type of illness. • Therefore, there is no such thing as “medically unexplainable pain”, because pain that is attributable to mental illness is “medically explained”. • DSM-5 issues regarding pain do not involve any consideration of whether the pain is “medically explainable” – it focuses instead on whether the patient is responding to the pain in some pathological manner. Thus mental health providers
4
ACCEPTED MANUSCRIPT
will be encouraged not to consider the origin of the patient’s pain, but rather how the patient responds to the pain with behaviors and emotions.
RI PT
Spine specialists need to be aware of this change, as communication with mental health disorders about “medically unexplainable” may be more challenging, and trying to sort out for a given patient which of our 4 groups applies may be quite a bit more challenging.
SC
The characterization of spinal pain as “medically explainable” (Groups 1 and 2) or “medically unexplainable” (Groups 3 and 4) will remain an important subject for research studies, and an important consideration in the care of individual patients. The tests we have, the terms we use for diagnosis, and the treatments we have will continue to change, even if the patient population we treat does not. References
AC C
EP
TE D
M AN U
[1] http://www.optimox.com/pics/Iodine/IOD-15/PUB_15.htm – accessed 09/07/13 [2] Klaus K, Rief W, Brähler E, et al. The distinction between “medically unexplained” and “medically explained” in the context of somatoform disorders. Int J Behav Med 2013; 20 (2): 161-71. [3] Balagué F, Mannion AF, Pellisé F, Cedraschi C. Non-specific low back pain. Lancet 2012; 379: 482-91. [4] Endean A, Palmer KT, Coggon D. Potential of Magnetic Resonance Imaging Findings to Refine Case Definition for Mechanical Low Back Pain in Epidemiological Studies. Spine 2011; 36 (2): 160-169. [5] Hocaoglu C, Gulec MY, Durmus I. Psychiatric Comorbidity in Patients with Chest Pain without a Cardiac Etiology. Isr J Psychiatry Rel Sci 2008; 45 (1): 49-54. [6] Clark MR, Sullivan MD, Katon WE, et al. Psychiatric and medical factors associated with disability in patients with dizziness. Psychosomatics 1993; 34 (5): 409-15. [7] Barth RJ. Undiagnosed Mental Illness as the Cause of General Medical Disability Claims. The Guides Newsletter 2006 (Nov/Dec): 1-3 & 8-11 American Medical Association, Chicago. [8] Trief PM, Grant W, Fredrickson B. A prospective study of psychological predictors of lumbar surgery outcome. Spine 2000; 25 (20): 2616-21. [9] Daubs MD, Norvell DC, McGuire R, et al. Fusion versus nonoperative care for chronic low back pain: do psychological factors affect outcomes? Spine 2011; 36 (Suppl 21): S96-S109 [10] Pollack R, Lakkol S, Budithi C, et al. Effect of Psychological Status on Outcome of Posterior Lumbar Interbody Fusion Surgery. Asian Spine Journal 2012: 6 (3): 178-182. [11] Shaw WS, Pransky G, Winters T, et al. Does the Presence of Psychosocial “Yellow Flags” Alter Patient-Provider Communication for Work-Related, Acute Low Back Pain? JOEM 2009; 51: 1032-40. [12] Daubs MD, Patel AA, Willick SE, et al. Clinical Impression Versus Standardized Questionnaire: The Spinal Surgeon’s Ability to Assess Psychological Distress. JBJS 2010; 92: 2878-83. [13] INSERT CITATION FOR THE ARTICLE THAT PRECEEDS THIS COMMENTARY
5
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
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