Chronic Pain and the Differential Diagnosis of Mood Disorders

[Fan_of_Meehl]

I need to get people's opinions on a differential diagnostic issue. Situation would be a patient with chronic pain who develops clinically significant depressive symptoms as a result (or, at least with the stress of the chronic pain contributing substantially to mood dysfunction). My contention would be that this would NOT be diagnosed as a 'Depressive Disorder Due to Another Medical Condition' but rather an Adjustment Disorder With Depressed Mood (or even MDD if full criteria for MDD are met). The reasoning is that the depression is developing due to the psychosocial stressor of chronic pain and is not, per se, the 'direct pathophysiological consequence of another medical condition' such as would be the case with respect to endocrine (hypothyroidism) or neurological (stroke) disorders with known mechanisms in terms of directly 'causing' mood disturbance. I realize that there is a great deal of research investigating the ways in which pain may affect the nervous (or other biological) systems, however, my take on it (supported by a recent review article on chronic pain and depression) is that [quoting the article now] "To date, neither the corresponding pathophysiological mechanisms of chronic pain and depression nor their mutual correlation has been identified, which poses a huge challenge for the treatment of pain accompanied by depression."

I seem to recall reviewing (in my grad school days) a DSM-IV case studies book (or could have been the DSM-IV Sourcebook) presenting this exact scenario and clearly arguing that the correct diagnosis for mood disturbance associated with chronic pain was an 'adjustment disorder' (with, of course, MDD being diagnosed if full criteria are met). I've taken a look at the full text of DSM-5 but can't EXACTLY nail down a slam dunk answer but I could swear that this exact issue has been highlighted elsewhere in some of the official companion texts to the DSM.

Thoughts or opinions on this?

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[PsyDr]

In many spinal diagnoses, the psychological factors are predictive of chronic pain and not the other way round.

 

[AcronymAllergy]

I need to get people's opinions on a differential diagnostic issue. Situation would be a patient with chronic pain who develops clinically significant depressive symptoms as a result (or, at least with the stress of the chronic pain contributing substantially to mood dysfunction). My contention would be that this would NOT be diagnosed as a 'Depressive Disorder Due to Another Medical Condition' but rather an Adjustment Disorder With Depressed Mood (or even MDD if full criteria for MDD are met). The reasoning is that the depression is developing due to the psychosocial stressor of chronic pain and is not, per se, the 'direct pathophysiological consequence of another medical condition' such as would be the case with respect to endocrine (hypothyroidism) or neurological (stroke) disorders with known mechanisms in terms of directly 'causing' mood disturbance. I realize that there is a great deal of research investigating the ways in which pain may affect the nervous (or other biological) systems, however, my take on it (supported by a recent review article on chronic pain and depression) is that [quoting the article now] "To date, neither the corresponding pathophysiological mechanisms of chronic pain and depression nor their mutual correlation has been identified, which poses a huge challenge for the treatment of pain accompanied by depression."

I seem to recall reviewing (in my grad school days) a DSM-IV case studies book (or could have been the DSM-IV Sourcebook) presenting this exact scenario and clearly arguing that the correct diagnosis for mood disturbance associated with chronic pain was an 'adjustment disorder' (with, of course, MDD being diagnosed if full criteria are met). I've taken a look at the full text of DSM-5 but can't EXACTLY nail down a slam dunk answer but I could swear that this exact issue has been highlighted elsewhere in some of the official companion texts to the DSM.

Thoughts or opinions on this?

I would diagnose similarly to your understanding (i.e., adjustment disorder or MDD) if you believed the MDD/depression was a reaction to the medical condition (i.e., pain), but was not a direct physiological effect of the medical condition.

Although like you, I'll frequently see folks do the opposite (i.e., diagnose "due to another medical condition" and say it's basically a reaction to pain).

And as PsyDr mentions, it's also very possible the person has a h/o pre-pain depression, whether or not they report that or recall it that way.

 

[R. Matey]

If the patient meets criteria for depression, I think depression would be appropriate choice. Many depressive episodes are in response to overwhelming psychosocial factors and MDD has a different symptom profile than AD w/ depression.

 

[AcronymAllergy]

If the patient meets criteria for depression, I think depression would be appropriate choice. Many depressive episodes are in response to overwhelming psychosocial factors and MDD has a different symptom profile than AD w/ depression.

Also agree with this, which I think was in the original post as well. If full criteria for MDD are met, diagnose MDD, just not "due to another medical condition."

 

[cara susanna]

I had a very similar question and ended up diagnosing MDD. I felt like due to a medical condition was more applicable to things like Parkinsons.

 

[Sanman]

It would really depend on the cause of the chronic pain as well as the duration of sx. I generally start with adjustment d/o if onset is under 3 mos following a physical trauma. Or if chronic/inc pain with no immediate physiological injury may be related to psychosocial factors. Persistent sx for more than 3 Mos could be a chronic adj issue or mdd d/t med condition.

 

[borne_before]

Did chronic pain develop from never doing anything physical?

 

[Fan_of_Meehl]

Did chronic pain develop from never doing anything physical?

Don't know. I know this sounds weird but we're not actually a case in my caseload, just a situation being discussed in terms of proper diagnosis.

I don't think that it is correct to diagnose, for example, 'depressive disorder due to degenerative joint disease'in a situation where a pts DJD causes chronic pain that (as a psychosocial stressor) contributes to their depression

This is to be contrasted with, say, a situation in which the depressive sxs are a direct pathophysiological consequence of, say, low thyroid hormones in the bloodstream in uncontrolled hypothyroidism.

 

[Sanman]

Don't know. I know this sounds weird but we're not actually a case in my caseload, just a situation being discussed in terms of proper diagnosis.

I don't think that it is correct to diagnose, for example, 'depressive disorder due to degenerative joint disease'in a situation where a pts DJD causes chronic pain that (as a psychosocial stressor) contributes to their depression

This is to be contrasted with, say, a situation in which the depressive sxs are a direct pathophysiological consequence of, say, low thyroid hormones in the bloodstream in uncontrolled hypothyroidism.

It gets complicated with the patients I see often. Usually a CVA with hemiparesis, failed or refused rehab, largely bedbound and depressed at home 1-2 yrs later.

 

[texanpsychdoc]

I need to get people's opinions on a differential diagnostic issue. Situation would be a patient with chronic pain who develops clinically significant depressive symptoms as a result (or, at least with the stress of the chronic pain contributing substantially to mood dysfunction). My contention would be that this would NOT be diagnosed as a 'Depressive Disorder Due to Another Medical Condition' but rather an Adjustment Disorder With Depressed Mood (or even MDD if full criteria for MDD are met). The reasoning is that the depression is developing due to the psychosocial stressor of chronic pain and is not, per se, the 'direct pathophysiological consequence of another medical condition' such as would be the case with respect to endocrine (hypothyroidism) or neurological (stroke) disorders with known mechanisms in terms of directly 'causing' mood disturbance. I realize that there is a great deal of research investigating the ways in which pain may affect the nervous (or other biological) systems, however, my take on it (supported by a recent review article on chronic pain and depression) is that [quoting the article now] "To date, neither the corresponding pathophysiological mechanisms of chronic pain and depression nor their mutual correlation has been identified, which poses a huge challenge for the treatment of pain accompanied by depression."

I seem to recall reviewing (in my grad school days) a DSM-IV case studies book (or could have been the DSM-IV Sourcebook) presenting this exact scenario and clearly arguing that the correct diagnosis for mood disturbance associated with chronic pain was an 'adjustment disorder' (with, of course, MDD being diagnosed if full criteria are met). I've taken a look at the full text of DSM-5 but can't EXACTLY nail down a slam dunk answer but I could swear that this exact issue has been highlighted elsewhere in some of the official companion texts to the DSM.

Thoughts or opinions on this?

I am inclined to agree with this. I actually worked in a pain clinic at one of my previous VAs, so my focus was exclusively on providing psychological assessments and interventions for chronic pain, and most often co-occuring syndromes such as SUD and PTSD. I think you could be fine diagnosing either Adjustment Disorder or MDD, I would likely explore more of the cognitions situated around depression to identify the classic triad as well as relevant behavior aspects (e.g., less positive reinforcement, more aversive exposures) that reinforce the cycle of being sedentary or withdrawing from activities that reinforce the cognitions of depression. I would typically use CBT-CP as a first line treatment to help with the cognitive behavioral aspects, and if that wasn't sufficient, I would shift over to ACT.

 

[smalltownpsych]

I also think of “due to another medical condition” as more of a direct effect. In my chronic pain patients, I will diagnose either Adjustment Disorder or MDD depending on which is more appropriate and this usually reflects severity of symptoms. I will document that the patient has a relevant medical disorder that is causing chronic pain with just as I would have back in the days of the multi-axial diagnosis. Axis lll was useful for that.

 

[Fan_of_Meehl]

I also think of “due to another medical condition” as more of a direct effect. In my chronic pain patients, I will diagnose either Adjustment Disorder or MDD depending on which is more appropriate and this usually reflects severity of symptoms. I will document that the patient has a relevant medical disorder that is causing chronic pain with just as I would have back in the days of the multiracial diagnosis. Axis lll was useful for that.

Exactly. The mood disturbance is supposed to be a 'direct pathophysiological consequence' of the medical condition. Such as altered levels of thyroid stimulating hormone in the blood stream causing depression. Correct the hypothyroidism with medication, mood disturbance goes away. The relationship between pain and depression is generally going to be more complex/interactive with reciprocal causality / maintenance between them. It's why we have 'CBT for Chronic Pain' but not 'CBT for Hypothyroidism.'

 

[PsyDr]

Looked through the dsm5 differential dx book: the answer is MDD.