Arch Womens Ment Health DOI 10.1007/s00737-015-0537-9

ORIGINAL ARTICLE

When treating the pain is not enough: a multidisciplinary approach for chronic pelvic pain Lisa Renee Miller-Matero 1 & Caroline Saulino 1 & Shannon Clark 1 & Mary Bugenski 1 & Anne Eshelman 1 & David Eisenstein 2

Received: 19 January 2015 / Accepted: 22 April 2015 # Springer-Verlag Wien 2015

Abstract Chronic pelvic pain (CPP) is related to psychological distress and interference in daily activities; however, CPP is not as extensively researched as other forms of chronic pain. Therefore, the purpose of this study was to investigate the relationships among pain, psychological distress, and functional impairment in patients with CPP. There were chart reviews conducted of 107 female patients who completed a psychiatric evaluation at a specialty, CPP clinic as a part of a multidisciplinary evaluation. Results suggest that psychological distress and impairment in daily activities are common in CPP patients. Most areas of functional impairment were not associated with pain variables. Rather, several forms of functional impairment were related to higher levels of depression and anxiety. Results from this study suggest the possibility that psychiatric symptoms are contributing to functional impairment in this population. These findings highlight the importance of a multidisciplinary approach in the evaluation and treatment of CPP patients to help decrease functional impairment in these patients.

Keywords Pelvic pain . Depression . Anxiety . Functional impairment

* Lisa Renee Miller-Matero [email protected] 1

Behavioral Health, Henry Ford Health System, Detroit, MI, USA

2

Obstetrics & Gynecology, Henry Ford Health System, Detroit, MI, USA

Introduction Approximately 15 % of women between the ages of 18– 50 experience chronic pelvic pain (CPP) (Stones et al. 2000). Chronic pelvic pain presents unique treatment challenges, given its complex etiology and relationship to psychological distress (Nolan et al. 1992; Helm et al. 1998; Reed et al. 2000; Randolph and Reddy 2006; Romão et al. 2009). However, while there is a great deal of research regarding chronic pain generally, there is limited research specifically targeting CPP. The purpose of this study is to examine CPP from a multidisciplinary approach by investigating the relationships among pain, psychological symptoms, and functional impairment in CPP patients.

Pain and psychological symptoms Pain severity has been linked to psychological symptoms, specifically depression and anxiety, in various types of chronic pain (Verhaak et al. 1998; Blyth et al. 2001; Jakobsson et al. 2003; Cano et al. 2004; Currie and Wang 2004; Miller and Cano 2009). The same is true for CPP. For example, research suggests CPP patients endorse higher rates of depression and anxiety compared to their pain-free peers (Nolan et al. 1992; Helm et al. 1998; Reed et al. 2000; Randolph and Reddy 2006; Romão et al. 2009). Additionally, a positive relationship exists between pain severity in CPP patients and psychological distress (Gomide et al. 2012). However, CPP appears to be different from other forms of chronic pain, since there is an association in some cases with a history of sexual abuse (Harrop-Griffith et al. 1988; Walling et al. 1994; Campbell et al. 2002; Randolph and Reddy 2006).

L.R. Miller-Matero et al.

Pain and functional impairment Not only do chronic pain patients suffer from psychological symptoms, they also often experience interference in daily activities, or functional impairment (Williamson and Schulz 1995). However, functional impairment in CPP patients has not been as extensively researched. Of the research that does exist, there is some evidence to suggest that individuals with CPP endorse a lower quality of life than pain-free individuals and sexual dysfunction appears to be relatively common (Harrop-Griffith et al. 1988; Michael et al. 2000; Verit et al. 2006; Cox et al. 2007; Nnoaham et al. 2011). However, most studies use a general measure of functional impairment; therefore, it is unclear what specific limitations or disabilities these patients are encountering. Further research needs to be conducted to examine this. Relationships between psychological symptoms and functional impairment Given that psychological symptoms and functional impairment both appear to be associated with CPP, research has begun to examine the relationship between these factors. Lower quality of life in CPP patients has been associated with greater depression and anxiety (Romão et al. 2009). Additionally, difficulties with sexual relations in some cases are related to a history of sexual abuse and have been found to be related to depression and anxiety (Ter Kuile et al. 2010). From these findings, it appears that other forms of functional impairment may also be related to psychological symptoms; however, this has not yet been explored. Therefore, more research is needed to investigate the relationship between psychological distress and various types of functional impairment. The purpose of this study is three fold: (1) to investigate psychiatric symptoms and history of abuse as it relates to CPP, (2) to evaluate what specific aspects of daily life are impacted due to CPP, and (3) to examine the relationships between pain, psychiatric symptoms, and functional impairment in CPP patients.

comprised of patients who were evaluated by a physician at a specialty, multidisciplinary CPP clinic. During this appointment, these patients also completed a routine psychiatric evaluation. The psychiatric evaluation consisted of a semistructured interview and questionnaires. Chart reviews were conducted to gather information from the psychiatric evaluation. Informed consent was waived due to the nature of data collection through chart review. Interview The semi-structured interview included a history of pelvic pain. Specifically, patients rated their average pain severity and current pain severity on a visual analog scale of 0–10 as well as the duration of pelvic pain. Functional impairment was also assessed by asking patients whether they experienced interference in a variety of daily activities, including household activities, employment, social activities, sleep, and interpersonal/sexual functioning. Evaluation of psychosocial history, including psychiatric symptoms and emotional/physical/sexual abuse, were also included in semi-structured interview. Hospital Anxiety and Depression Scale (HADS) (Bjelland et al. 2002) The HADS is a 14-item self-report questionnaire used to assess symptoms of depression and anxiety. It contains two subscales: anxiety and depression, each consisting of seven items. A probable diagnosis of depression or anxiety is determined when a score greater than 8 is reported on the respective subscale, with scores being interpreted as mild (8–10), moderate (11–14), or severe (15–21). Analyses Analyses were conducted using SPSS version 20. Descriptive statistics were run to determine prevalence rates of psychiatric symptoms and functional impairment. Correlations were conducted to determine the relationship of pain severity to psychiatric symptoms. Chi-squared analyses were conducted to determine the relationship between the duration of pain (either less than or greater than 5 years) to the types of interference. Independent sample tests were conducted to determine whether those that reported functional impairment in daily activities had higher levels of anxiety and depression.

Materials and methods Participants

Results Chart reviews were conducted of 107 consecutive female patients who were receiving treatment for chronic pelvic pain. Materials and procedure This study has received approval from the hospital’s Institutional Review Board. This was a convenience sample

Participant characteristics Age ranged from 18 to 67 (M=37.77 years, SD=11.82). While the majority of the patients were Caucasian (48.6 %, n=52), 39.3 % (n=42) were African American, and 12.1 % (n=13) were identified as other.

Multidisciplinary approach for pelvic pain

significant differences in those who had an abuse history in terms of their current depressive symptoms (t=−1.53, p=.13).

Psychiatric symptoms and abuse history Depressive and anxiety symptoms verbally reported in the semi-structured interview were common among this population (see Table 1). More than half (53.8 %, n=57) of participants endorsed a history of a depressive episode. The prevalence of current depressive-related symptoms that were verbally reported is in Table 1. Additionally, it was common for patients to verbally report symptoms of anxiety (see Table 1). According to the HADS, 25.7 % (n = 26) endorsed experiencing current probable depression, and 38.6 % (n=39) endorsed experiencing current probable anxiety. There were 44.9 % (n=44) of patients who had experienced a form of abuse, the majority of whom experienced sexual abuse (72.7 %, n=32). Those who experienced a history of sexual abuse were more likely to develop a diagnosis of PTSD than those who experienced physical and/or emotional abuse (X2 =4.20, p=.04). Additionally, those with an abuse history (M=8.27, SD=4.44) reported higher levels of current anxiety than those without an abuse history (M=6.19, SD = 4.56; t = −2.26, p = .03). However, there were no

Table 1 interview

Psychiatric symptoms reported in the semi-structured

Symptoms

%

n

Difficulties sleeping Increased irritability Depressed mood Tearfulness Anhedonia Helplessness Hopelessness Worthlessness Feelings of guilt

52.3 52.3 36.4 34.6 25.2 31.8 29.0 15.0 22.4

56 56 39 37 27 34 31 16 24

Fatigue Social withdrawal Difficulties concentrating Psychomotor disturbance Appetite changes Passive suicidal thoughts Worry Current PTSD-related symptoms History of PTSD-related symptoms Current panic attacks History of panic attacks Phobias Medical anxieties OCD-type behaviors Agoraphobia

44.9 36.4 36.4 16.8 43.9 4.7 41.1 15.0 .9 38.3 18.7 25.2 13.1 7.5 8.4

48 39 39 18 43 5 44 16 1 41 20 27 14 8 9

Pain variables and functional impairment The patient’s usual pain (M=6.53, SD=2.21) was significantly greater than the patient’s current pain rating (M=5.18, SD= 3.23; t=−4.28, p

When treating the pain is not enough: a multidisciplinary approach for chronic pelvic pain.

Chronic pelvic pain (CPP) is related to psychological distress and interference in daily activities; however, CPP is not as extensively researched as ...
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