Publications
APS Bulletin • Volume 13, Number 3, 2003
Resource Reviews
John D. Loeser, MD, Department Editor
Anxiety, Depression, and Anger in Pain
Reviewed by W. Crawford Clark, PhD
E. Fernandez, Dallas, TX, Advanced Psychological Resources, 2002, 334 pages, $59.95 (soft cover), ISBN 0-9723164-0-X
Health professionals now have what promises to be a remedy for a persistent problem: the neglect of the manifold roles played by emotions in the pain experience.
Anxiety, Depression, and Anger in Pain highlights the importance of the emotional component of pain. Each of the three key chapters on anxiety, depression, and anger comprehensively review the role of emotions in pain. The sections on emotional assessment instruments and research directions are extraordinarily detailed and exciting; they should do much to direct investigators’ attention to the development of better assessment instruments and understanding of the complex interactions between emotions and pain.
The chapter on anxiety and fear begins with the American Psychiatric Association’s definitions in the Diagnostic Statistical Manual (DSM-IV) of more than a dozen anxiety disorders recognized by psychiatrists and the ways in which they relate to various types of pain. The author discusses the merit of psychological, cognitive, motivational, and behavioral treatment interventions. Also included is a discussion of pharmacological interventions with psychoactive medications. The detailed discussion of the strengths and weaknesses of instruments that assess anxiety and fear is of great empirical interest. The popular State-Trait Anxiety Inventory receives well-deserved attention. Other instruments that assess anxiety, including the Pain Anxiety Symptom Scale, the Fear Avoidance Belief Questionnaire, and the Fear of Pain Questionnaire, are reviewed. Evaluation of these instruments is thorough, and includes many references to factor analytic and other studies.
The chapter on depression and pain properly begins with the psychiatric nosology of DSM-IV. This is important because many pain investigators do not fully understand the differences between major psychotic depression, which typically occurs independently of chronic physical pain, and dysthymia, which may, but not necessarily, be associated with pain. Gender, age, and ethnocultural differences in depression among chronic pain patients are often neglected; here they receive the attention they deserve.
There is an excellent discussion and evaluation of depression-rating instruments. Studies that generally support the usefulness of the Hamilton Rating Scale for Depression, the Beck Depression Inventory, the Symptom Checklist 90 (SCL-90), the Profile of Mood States (POMS), and others are reviewed. The author cogently warns many of the pain symptoms common to non-depressed chronic pain patients, which appear on practically all depression scales, may be mistakenly interpreted as indicating depression in pain patients who are not depressed, arbitrarily raising the cutoff scores on depression scales to correct for this error.
Psychological and pharmacological treatments for depressed pain patients receive detailed attention; adverse side effects are also covered. The author notes the specific analgesic effects of antidepressants when they are used to treat neuropathic pain and pain of central origin. Perhaps this book’s most important contribution is the chapter on anger and hostility. This neglected topic deserves much more study. It is not surprising that pain associated with depression, anxiety, and fear can produce anger directed towards others and/or even towards oneself. While anger is a response to a situation, hostility is a habitual predisposition, serving as a personality trait for people who readily express anger. Ten questionnaires designed to quantify various aspects of anger and/or hostility are reviewed. The Buss-Durkee Hostility Inventory is in common use, but rarely within the realm of pain. The Hostility and Direction of Hostility Questionnaire, which assesses the important anger-in and anger-out dichotomy, receives a favorable review, and the State-Trait Anger Expression Inventory (STAXI-2) is judged “the most thorough instrument of its kind.”
The final chapter on future considerations has many suggestions for research. The causal relationships between emotional states and pain syndromes, as well as the role of age, gender, and ethnocultural differences, is an example. A plea is made for the development of improved assessment tools. Here (this is my only caveat) I missed the mention of the newer mathematical models. These include INDSCAL, a multidimensional individual differences scaling model that can determine quantitatively the degree to which the sensory, emotional, or other pain dimension is more important or “salient” to a particular patient; cluster analysis, which can be used to design pain questionnaires that place a much greater emphasis on emotions because the dimensions were determined objectively by the population at large, not subjectively in an a priori manner by armchair taxonomists; and the contributions of the statistical or medical decision theory model that can evaluate differential diagnoses and treatment risks and benefits, as well as distinguish between response bias (degree of stoicism) and true sensory loss.
Fernandez has written a comprehensive (more than 750 references) and challenging book with dozens of suggestions for future research in the assessment of pain and emotion. These studies will greatly improve the treatment and care of patients. Anxiety, Depression, and Anger in Pain is an absolute must for the library of all clinicians evaluating pain patients and every investigator conducting pain research.
W. Crawford Clark, PhD, is Professor of Medical Psychology in the Department of Psychiatry at the College of Physicians & Surgeons, Columbia University, New York.
Please direct your suggestions for future Resource Reviews to John D. Loeser, MD, Department Editor, at jdloeser@u.washington.edu.