Pain as a Psychiatric Symptom: Comparison Between Low Back Pain and Depression TOSHIHIKO MARUTA, M.D., DAVID W. SWANSON, M.D. AND WENDELL M. SWANSON, Ph.D.
Frequent references in the psychiatric literature suggest a correlation between certain pain syndromes and depression. Often depression is not evident and the pain is conceptualized as a psychophysiologic symptom with or without depression.)·~ conversion symptom,:l dcpressive cquivalent,l or masked depression. I.:' In his review of the literature on pain, Sternbach'; notcd that in cases of persistent pain, either with no or with minimal organic findings, the affective description of the patient was likely to be one of depression. Sternbach et al.!.~ noted that thcse patients usually were dcpressed and that their illness might be aptly termed a "psychophysiologic musculoskeletal reaction with depression." Gentry et al.,' in a study of chronic back pain. noted a psychologic profile. emphasizing high repression. low anxiety, and conversion tendencies based on thc Minnesota Multiphasic Personality Inventory (MMPI).~ The D-scale was. however, third highest and was close to 70. Hanvik" reported similar findings on the MMPI and others!.'" have emphasized a neurotic triad. that is, an clevation of the first three scales. Engel" notcd that patients with conversion hysteria constitute the largcst population of the pain-prone population; interestingly enough. however, his psychodynamic formulation of conversion pain is expressed in terms of object relationship. aggression, guilt, and a process of introjection that is identical with that of melancholia by Freud. ll Rosenbaum and Steinhilber' ~ noted the presence of depression and the need for physical therapy as a "face-saving maneuver" to help the patient with low back pain through psychiatric treatment. Lopez Ibor 4 emphasized the importance of good rapport with the patients having "depression without depression" (depressive equivalent and masked depression). Maruta et alY' noted that in patients with pain a conversion diagnosis was present more frequently on their admission to a psychiatric unit, whereas a diagnosis of depression was present more frequently on dismissal. Toshihiko Manila, M.D. is Senior Resident in Psychiatry, Mayo Clinic and Mayo Foundation, Rochester, Minnesota. David W. Swanson, M.D. is Consultant in Adult Psychiatry, Mayo Clinic and Mayo Foundation; Professor of Psychiatry, Mayo Medical School; Rochester, Minnesota. Wendell M. Swenson, Ph.D. is Consultant in Psychology, Mayo Clinic and Mayo Foundation; Professor of Psychology, Mayo Medical School; Rochester, Minnesota. Read at the meeting of the Academy of Psychosomatic Medicine, New Orleans, November 16 to 19, 1975. July.' August/September, 1976
THE SAMPLE STUDIED
The present paper compares age- and sex-matched patients who were admitted to the psychiatric service of a general hospital with a complaint of back pain versus those with a primary complaint of depression. Of the 216 open-ward patients in 1973. 31 (14%) had low back pain as the primary complaint. Five patients were excluded because of incomplete examination data due to their demand for early dismissal. A group of 26 depressed patients whose age and sex matched those of the remaining 26 patients with low back pain was then selected from the 1 10 (51 %) depressed patients. The patients in the low back pain group ranged in age from 19 to 61 years (mean, 41.0 years) and those in the depression group, from 19 to 56 years (mean, 39.7 years). Of the 26 patients in each group, 16 were females and 10 were males in the low back pain group whereas in the depression group, 17 were females and 9 were males. The parents' mean age at the patient's birth, loss of the parents by death or separation before the patient reached the age of 18 years, relationship of the parents with the patient. number of siblings, and incidence of family psychiatric disorders were compared. No statistically significant difference was found in these areas. The mean number of siblings is higher in the low back pain group but to an insignificant degree (6.0 vs. 5.0). The distribution of the marital status, the age at marriage, number of children, and age at the time of birth of the first child were compared and were similar. Marital discord before the present illness was higher, but not significantly so, in the depression group. Educational level varied from 6 to 20 years Table 1 Academic and Work History
Years of education High school education* 4-year college education * Academic maladjustment Age when started working Started working at 18 yr of age or less* Inadequate work adjustment * P < 0.05
Group Low hack pain Depression 11.9 14.3 65% 88% 12% 42% 27% 15% 16.8yr 18.7yr 88% 27%
58% 31% 123
PSYCHOSOMATICS
(mean, 11.9 years) in the low back pain group and from 8 to 20 years (mean, 14.3 years) in the depression group (Table I). Of the low back pain subjects, 65 % were graduates from high school and 12 % were college graduates. This was significantly different from the depression group with 88% graduates from high school and 42% graduates from college. Academic maladjustment was reported in 27% of the low back pain group but in only 15% of the depression group. The number of subjects who started working at age 18 or less was 88 % in the low back pain group and 58% in the depression group. This difference is statistically significant (Table I). Inadequate work adjustments were similar in both groups. Medical History (Table 2)
Major medical illnesses requiring hospitalization or long-term home care, physical trauma requiring a surgical procedure, number of operations, and past psychiatric treatment were compared. Not surprisingly, trauma was significantly higher in the low back pain group and psychiatric treatment in the depression group. More operations were reported by patients in the low back pain group, even though major illness happened more frequently among persons in the depression group. Present Illness and Mental Status
Duration of illness in the low back pain group varied from 9 months to 32 years with a mean of 7.9 years; in the depression group duration varied from I month to 20 years with a mean of 2.9 years. Symptoms, with emphasis on those of depression, are listed in Table 3. Physical concerns, loss of social activity, and compensation were higher in the low back pain group and depression, suicidal ideas, and anorexia, in the depression group. These differences are statistically significant. Other symptoms were reportedly similar in both groups. The fact that nearly two-thirds of the low back pain patients reported depressive feelings should be emphasized. Mental status at the time of initial psychiatric evaluation involved a rating of six factors on a scale of o to 4 (0 = none and 4 = severe): anxiety-agitation, depression, physical concerns, dependency-passivity, dramatization-manipulation, and rigidity-hostility-no insight (Table 4). Physical concerns and dramatization-manipulation were rated significantly higher in the low back pain group. It is of particular interest that depression was rated similarly in both groups. Minnesota Multiphasic Personality Inventory
In both male and female sets of profiles (Fig. I and 2), the general deviation of the low back pain patients and of the depression patients from the general medical population!:! is significant. Both males and females 124
reflected significant psychopathologic findings. In the general medical population, none of the T scores were significantly above 60. Males in the low back pain and depression groups had roughly similar profiles. A clearly significant difference existed in the hypochondriasis scale which indicated much greater hypochondriacal concern among the low back pain patients than among the depression patients. The remaining two scales of the neurotic triad (depression and hysteria) are relatively similar. The depression group had a significantly higher score in psychopathic deviate scale (about I SO). This would reflect much greater interpersonal difficulty and family concerns in the depression group. Persons in the depression group also were somewhat more compulsive, obsessive, and anxious, as indicated by the higher psyTable 2 Medical History
Major medical illness Physical trauma * Number of operations Psychiatric treatment" * P < 0.05.
Group Low back pain 54% 62% 3.4 38%
Depression 65% 27% 1.77 73%
Table 3 Symptoms and Signs Group Low back pain, Depression, Physical concerns* Loss of social activity':' Lack of energy Depressed mood* Insomnia Loss of sexual interests Drug dependency Weight change Compensation* Guilt feeling Anorexiat Suicidal ideas* Decreased ability to concentrate * P < 0.01. -:- P < 0.05.
%
%
100
42
92
58
77
81
62 58
100 62 35 15
42 35 31 27 23 19 15 4
42
o 38 50 50 15
Table 4 Mental Status Examination Group* Low back pain, Depression,
% Physical concernst Dramatization-manipulationt Dependency-passivity Anxiety-agitation Rigidity-hostility-no insight Depression * Percent of patients with score of 3 t P < 0.01. t P < 0.05.
%
100 69 54 46 46 38 or 4 on a scale of
23 38 38 38 38 34 0 10 4.
Volume XVII
PAIN AS PSYCHIATRIC SYMPTOM-MARUTA, ET AL.
chasthenia score, than those in the low back pain group.
depression group to have a higher score in the depression scale than the low back pain group but in the male sex those two groups are almost identical in terms of depression elevation.
Among the females there seemed to be a much greater element of depression in the depression group than in the low back pain group. The depression T score was 87 whereas in the low back pain group. the depression T score was less than 70. Likewise there was a significant difference in the psychasthenia score with the depression group yielding a much higher score. This combination of high depression and psychasthenia is typical among depressed anxious patients and, therefore. this difference would be expected between these two groups.
Hospital Course and Treatment A mean duration of hospital stay was 21.4 days in the low back pain group and 20.5 days in the depression group. Treatment consisted of a minimum of 2 hours per week of individual psychotherapy for both groups, which varied from supportive to insight oriented. Group psychotherapy was combined with individual therapy for 92 % of the low back pain group and for 85 % of the depression group. This again varied from supportive to confronting. Of low back pain patients, 77 percent had I to 2 hours daily of physical therapy and in many instances this was
It is of particular interest that there was not a greater difference in the male sex between the two groups in terms of depression. One would expect the
........·24277 General medical population - - 10 Low back pain patients - - - 8 Depression patients
90 80
70 60
50
Low back pain Depression
GMP
~ .....
.....................
Fig. I . Mean MMPI profile of male patients.
.........
L 50 48 50
F
K
o
Hs
Hy Pd Mf Po Pt
Sc Mo Si
60 55 83 78 79 65 59 64 70 71 58 57 61 57 67 82 73 78 61 69 76 73 59 56 53 56 62 61 61 56 56 54 55 52 52 52
···..····25723 General medical population - - 16 Low back pain patients - - - 16 Depression patients
90
~
I \
80
I
\
I
70
/ ...........
\
I
\
I
I
I
tI
•
60
I
......................
I '.
50
I
.. •
..... \"
'
\ \
\
\
• I
\
I
Fig. 2. Mean MMPI profile of female patients.
~I .
\ I
\/
40'--~--=--..JL--'----L.---l_.L-~---L_L-...-L-l...---JL..-_
L
Hs
54
70 67 71 66 87 71 61 59 61
Low back pain Depression
48
GMP
52
July, August 'September, 1976
0
Hy Pd Mf Po Pt
Sc Mo Si
60 51
59 62 67 61 52 71 41 69 82 78 53 67 55 50 55 56 55 51 54 125
PSYCHOSOMATICS
utilized as a face-saving maneuver. The number of medications used varied from 0 to 8 in the low back pain group with a mean of 2.7 and from 0 to 4 with a mean of 1.8 in the depression group. Antidepressants were prescribed more for depression patients and sleeping medications for patients with low back pain; the difference, however, was not statistically significant. Minor tranquilizers were used significantly more often in the low back pain group (Table 5). Response to treatment and cooperation of a patient were rated on a 0 to 4 scale (0 = none and 4 = marked). Even though there was no significant difference between the two groups, low back pain patients rated lower in both areas, particularly in response to treatment (Table 5). Dismissal Diagnosis Primary and secondary diagnoses are summarized in Table 6. The most frequent diagnosis was neurotic depression in both the depression group (80%) and the low back pain group (38%). Other diagnoses in the low back pain group were psychophysiologic disorder (31 %) and conversion hysteria (12 % ). Table 5 Treatment and Result Group Low back pain, Depression, Medication Antidepressant Minor tranquilizer* Sleeping pills Psychotherapy Individual Group Resultst Response Cooperation * P < 0.05. t Percent of patients with score of 3
%
%
3I 54 54
46 23 35
100 92
100 85
27
46
42
50
or 4 on a scale of 0 to 4.
Table 6 Dismissal Diagnosis Group Low back pain, Depression.
% Primary diagno
Frequent references in the psychiatric literature suggest a correlation between certain pain syndromes and depression. Often depression is not evident and the pain is conceptualized as a psychophysiologic symptom with or without depression.)·~ conversion symptom,:l dcpressive cquivalent,l or masked depression. I.:' In his review of the literature on pain, Sternbach'; notcd that in cases of persistent pain, either with no or with minimal organic findings, the affective description of the patient was likely to be one of depression. Sternbach et al.!.~ noted that thcse patients usually were dcpressed and that their illness might be aptly termed a "psychophysiologic musculoskeletal reaction with depression." Gentry et al.,' in a study of chronic back pain. noted a psychologic profile. emphasizing high repression. low anxiety, and conversion tendencies based on thc Minnesota Multiphasic Personality Inventory (MMPI).~ The D-scale was. however, third highest and was close to 70. Hanvik" reported similar findings on the MMPI and others!.'" have emphasized a neurotic triad. that is, an clevation of the first three scales. Engel" notcd that patients with conversion hysteria constitute the largcst population of the pain-prone population; interestingly enough. however, his psychodynamic formulation of conversion pain is expressed in terms of object relationship. aggression, guilt, and a process of introjection that is identical with that of melancholia by Freud. ll Rosenbaum and Steinhilber' ~ noted the presence of depression and the need for physical therapy as a "face-saving maneuver" to help the patient with low back pain through psychiatric treatment. Lopez Ibor 4 emphasized the importance of good rapport with the patients having "depression without depression" (depressive equivalent and masked depression). Maruta et alY' noted that in patients with pain a conversion diagnosis was present more frequently on their admission to a psychiatric unit, whereas a diagnosis of depression was present more frequently on dismissal. Toshihiko Manila, M.D. is Senior Resident in Psychiatry, Mayo Clinic and Mayo Foundation, Rochester, Minnesota. David W. Swanson, M.D. is Consultant in Adult Psychiatry, Mayo Clinic and Mayo Foundation; Professor of Psychiatry, Mayo Medical School; Rochester, Minnesota. Wendell M. Swenson, Ph.D. is Consultant in Psychology, Mayo Clinic and Mayo Foundation; Professor of Psychology, Mayo Medical School; Rochester, Minnesota. Read at the meeting of the Academy of Psychosomatic Medicine, New Orleans, November 16 to 19, 1975. July.' August/September, 1976
THE SAMPLE STUDIED
The present paper compares age- and sex-matched patients who were admitted to the psychiatric service of a general hospital with a complaint of back pain versus those with a primary complaint of depression. Of the 216 open-ward patients in 1973. 31 (14%) had low back pain as the primary complaint. Five patients were excluded because of incomplete examination data due to their demand for early dismissal. A group of 26 depressed patients whose age and sex matched those of the remaining 26 patients with low back pain was then selected from the 1 10 (51 %) depressed patients. The patients in the low back pain group ranged in age from 19 to 61 years (mean, 41.0 years) and those in the depression group, from 19 to 56 years (mean, 39.7 years). Of the 26 patients in each group, 16 were females and 10 were males in the low back pain group whereas in the depression group, 17 were females and 9 were males. The parents' mean age at the patient's birth, loss of the parents by death or separation before the patient reached the age of 18 years, relationship of the parents with the patient. number of siblings, and incidence of family psychiatric disorders were compared. No statistically significant difference was found in these areas. The mean number of siblings is higher in the low back pain group but to an insignificant degree (6.0 vs. 5.0). The distribution of the marital status, the age at marriage, number of children, and age at the time of birth of the first child were compared and were similar. Marital discord before the present illness was higher, but not significantly so, in the depression group. Educational level varied from 6 to 20 years Table 1 Academic and Work History
Years of education High school education* 4-year college education * Academic maladjustment Age when started working Started working at 18 yr of age or less* Inadequate work adjustment * P < 0.05
Group Low hack pain Depression 11.9 14.3 65% 88% 12% 42% 27% 15% 16.8yr 18.7yr 88% 27%
58% 31% 123
PSYCHOSOMATICS
(mean, 11.9 years) in the low back pain group and from 8 to 20 years (mean, 14.3 years) in the depression group (Table I). Of the low back pain subjects, 65 % were graduates from high school and 12 % were college graduates. This was significantly different from the depression group with 88% graduates from high school and 42% graduates from college. Academic maladjustment was reported in 27% of the low back pain group but in only 15% of the depression group. The number of subjects who started working at age 18 or less was 88 % in the low back pain group and 58% in the depression group. This difference is statistically significant (Table I). Inadequate work adjustments were similar in both groups. Medical History (Table 2)
Major medical illnesses requiring hospitalization or long-term home care, physical trauma requiring a surgical procedure, number of operations, and past psychiatric treatment were compared. Not surprisingly, trauma was significantly higher in the low back pain group and psychiatric treatment in the depression group. More operations were reported by patients in the low back pain group, even though major illness happened more frequently among persons in the depression group. Present Illness and Mental Status
Duration of illness in the low back pain group varied from 9 months to 32 years with a mean of 7.9 years; in the depression group duration varied from I month to 20 years with a mean of 2.9 years. Symptoms, with emphasis on those of depression, are listed in Table 3. Physical concerns, loss of social activity, and compensation were higher in the low back pain group and depression, suicidal ideas, and anorexia, in the depression group. These differences are statistically significant. Other symptoms were reportedly similar in both groups. The fact that nearly two-thirds of the low back pain patients reported depressive feelings should be emphasized. Mental status at the time of initial psychiatric evaluation involved a rating of six factors on a scale of o to 4 (0 = none and 4 = severe): anxiety-agitation, depression, physical concerns, dependency-passivity, dramatization-manipulation, and rigidity-hostility-no insight (Table 4). Physical concerns and dramatization-manipulation were rated significantly higher in the low back pain group. It is of particular interest that depression was rated similarly in both groups. Minnesota Multiphasic Personality Inventory
In both male and female sets of profiles (Fig. I and 2), the general deviation of the low back pain patients and of the depression patients from the general medical population!:! is significant. Both males and females 124
reflected significant psychopathologic findings. In the general medical population, none of the T scores were significantly above 60. Males in the low back pain and depression groups had roughly similar profiles. A clearly significant difference existed in the hypochondriasis scale which indicated much greater hypochondriacal concern among the low back pain patients than among the depression patients. The remaining two scales of the neurotic triad (depression and hysteria) are relatively similar. The depression group had a significantly higher score in psychopathic deviate scale (about I SO). This would reflect much greater interpersonal difficulty and family concerns in the depression group. Persons in the depression group also were somewhat more compulsive, obsessive, and anxious, as indicated by the higher psyTable 2 Medical History
Major medical illness Physical trauma * Number of operations Psychiatric treatment" * P < 0.05.
Group Low back pain 54% 62% 3.4 38%
Depression 65% 27% 1.77 73%
Table 3 Symptoms and Signs Group Low back pain, Depression, Physical concerns* Loss of social activity':' Lack of energy Depressed mood* Insomnia Loss of sexual interests Drug dependency Weight change Compensation* Guilt feeling Anorexiat Suicidal ideas* Decreased ability to concentrate * P < 0.01. -:- P < 0.05.
%
%
100
42
92
58
77
81
62 58
100 62 35 15
42 35 31 27 23 19 15 4
42
o 38 50 50 15
Table 4 Mental Status Examination Group* Low back pain, Depression,
% Physical concernst Dramatization-manipulationt Dependency-passivity Anxiety-agitation Rigidity-hostility-no insight Depression * Percent of patients with score of 3 t P < 0.01. t P < 0.05.
%
100 69 54 46 46 38 or 4 on a scale of
23 38 38 38 38 34 0 10 4.
Volume XVII
PAIN AS PSYCHIATRIC SYMPTOM-MARUTA, ET AL.
chasthenia score, than those in the low back pain group.
depression group to have a higher score in the depression scale than the low back pain group but in the male sex those two groups are almost identical in terms of depression elevation.
Among the females there seemed to be a much greater element of depression in the depression group than in the low back pain group. The depression T score was 87 whereas in the low back pain group. the depression T score was less than 70. Likewise there was a significant difference in the psychasthenia score with the depression group yielding a much higher score. This combination of high depression and psychasthenia is typical among depressed anxious patients and, therefore. this difference would be expected between these two groups.
Hospital Course and Treatment A mean duration of hospital stay was 21.4 days in the low back pain group and 20.5 days in the depression group. Treatment consisted of a minimum of 2 hours per week of individual psychotherapy for both groups, which varied from supportive to insight oriented. Group psychotherapy was combined with individual therapy for 92 % of the low back pain group and for 85 % of the depression group. This again varied from supportive to confronting. Of low back pain patients, 77 percent had I to 2 hours daily of physical therapy and in many instances this was
It is of particular interest that there was not a greater difference in the male sex between the two groups in terms of depression. One would expect the
........·24277 General medical population - - 10 Low back pain patients - - - 8 Depression patients
90 80
70 60
50
Low back pain Depression
GMP
~ .....
.....................
Fig. I . Mean MMPI profile of male patients.
.........
L 50 48 50
F
K
o
Hs
Hy Pd Mf Po Pt
Sc Mo Si
60 55 83 78 79 65 59 64 70 71 58 57 61 57 67 82 73 78 61 69 76 73 59 56 53 56 62 61 61 56 56 54 55 52 52 52
···..····25723 General medical population - - 16 Low back pain patients - - - 16 Depression patients
90
~
I \
80
I
\
I
70
/ ...........
\
I
\
I
I
I
tI
•
60
I
......................
I '.
50
I
.. •
..... \"
'
\ \
\
\
• I
\
I
Fig. 2. Mean MMPI profile of female patients.
~I .
\ I
\/
40'--~--=--..JL--'----L.---l_.L-~---L_L-...-L-l...---JL..-_
L
Hs
54
70 67 71 66 87 71 61 59 61
Low back pain Depression
48
GMP
52
July, August 'September, 1976
0
Hy Pd Mf Po Pt
Sc Mo Si
60 51
59 62 67 61 52 71 41 69 82 78 53 67 55 50 55 56 55 51 54 125
PSYCHOSOMATICS
utilized as a face-saving maneuver. The number of medications used varied from 0 to 8 in the low back pain group with a mean of 2.7 and from 0 to 4 with a mean of 1.8 in the depression group. Antidepressants were prescribed more for depression patients and sleeping medications for patients with low back pain; the difference, however, was not statistically significant. Minor tranquilizers were used significantly more often in the low back pain group (Table 5). Response to treatment and cooperation of a patient were rated on a 0 to 4 scale (0 = none and 4 = marked). Even though there was no significant difference between the two groups, low back pain patients rated lower in both areas, particularly in response to treatment (Table 5). Dismissal Diagnosis Primary and secondary diagnoses are summarized in Table 6. The most frequent diagnosis was neurotic depression in both the depression group (80%) and the low back pain group (38%). Other diagnoses in the low back pain group were psychophysiologic disorder (31 %) and conversion hysteria (12 % ). Table 5 Treatment and Result Group Low back pain, Depression, Medication Antidepressant Minor tranquilizer* Sleeping pills Psychotherapy Individual Group Resultst Response Cooperation * P < 0.05. t Percent of patients with score of 3
%
%
3I 54 54
46 23 35
100 92
100 85
27
46
42
50
or 4 on a scale of 0 to 4.
Table 6 Dismissal Diagnosis Group Low back pain, Depression.
% Primary diagno
