1. Psychological Pain as a symptom Somatic Symptom Disorder(somatization) Somatic Symptom Disorder(somatization) Illness Anxiety Disorder(hypochondriass) Illness Anxiety Disorder(hypochondriass) Functional Neurological Symptom Disorder(Conversion) Functional Neurological Symptom Disorder(Conversion) Factitious Disorder Factitious Disorder Pain Disorder Pain Disorder

2. Pain Disorder(DSM-5) Prevalence:5-12percent Prevalence:5-12percent Is associated with affective and anxiety disorders Is associated with affective and anxiety disorders Chronic pain most frequently associated with depressive disorders Chronic pain most frequently associated with depressive disorders Acute pain most frequently associated with anxiety disorders Acute pain most frequently associated with anxiety disorders

3. Pain Disorder Depressive disorders, alcohol dependence, and chronic pain are more common in relatives of individuals with chronic pain disorder Depressive disorders, alcohol dependence, and chronic pain are more common in relatives of individuals with chronic pain disorder Increased risk for suicide: Increased risk for suicide: pain associated with severe depression pain associated with severe depression Pain in terminal illness such as cancer Pain in terminal illness such as cancer

4. Etiology Psychodynamic factors Psychodynamic factors Behavioral Factors Behavioral Factors Interpersonal Factors Interpersonal Factors Biological Factors Biological Factors

5. Mind Mind Brain Brain Body Body

6. Psychodynamic Factors: Psychodynamic Factors: Intrapsychic Conflicts and body language Intrapsychic Conflicts and body language Alexythymia Alexythymia Identification Identification

7. Behavioral and interpersonal factors: Behavioral and interpersonal factors: Punishment and Reward Punishment and Reward Secondary gain Secondary gain Manipulation of environment Manipulation of environment

8. Depression and pain commonly occur. Approximately half of patients with depression report pain. 1 Between 30-60% of individuals with pain report having comorbid depression. 2,3,4 1) Katona et al. Clin Med. 2005;5:390-5; 2) Bair et al. Arch Intern Med 2003;163:2433-45 3) Hassett et al. Curr Pain Headache Rep. 2014;418:36; 4) Arnold et al. J Clin Psychiatry 2006;67:1219-25

9. Chronic Pain equivalent of depression Chronic Pain equivalent of depression (Masked depression) (Masked depression)

10. Complexity: Multiple Symptoms Most common complaints: Chronic widespread pain Fatigue Sleep disturbance Poor mood Cognitive difficulties Muscle stiffness Frequently occurring complaints: Gastrointestinal symptoms Headache Genitourinary Numbness and tingling Dizziness/loss of balance Weakness Skin changes Clauw DJ. JAMA 2014;311;1547-55 Mease et al. Arthritis Rheum 2008;59(7):952-60

11. Complexity: High Rates of Co-Morbidity   Comorbidity with other chronic pain states 42-70% of patients with FM also meet criteria for CFS 32-80% of patients with FM meet criteria for IBS 42% of back pain patients meet criteria for FM Aaron & Buchwald. Ann Intern Med 2001;134:868–81 Brummett, Goesling, Tsodikov, Meraj, Wasserman, Clauw &Hassett. Arthritis Rheum 2013;65:3285-92.   Co-Morbidity with chronic systemic disease Rheumatoid arthritis, lupus, inflammatory bowel disease Lee et al. Ann Rheum Dis 2013;72:949-54. Bliddal et al. Best Prac Res Clin Rheumatol 2007;21:391-402 Schlesinger, Hassett et al. Ann Rheum 2009   Psychiatric co-morbidity – mostly anxiety and depression.

12. Neurobiological perspective. Brain regions associated with physical pain overlap with psychological pain processing: Sensory discriminative dimension – –Somatosensory cortices (S1, S2) – –Dorsal posterior insula Affective emotional dimension – –Anterior insula – –Prefrontal cortex – –Anterior cingulate cortex – –Thalamus – –Amygdala – –Hippocampus Goesling, Clauw & Hassett. Curr Psychiatry Rep. 2013;15:421

13. Neurobiological perspective. Neurotransmitters – pain Serotonin Norepinephrine Glutamate GABA Neurotransmitters - depression Serotonin Norepinephrine Glutamate GABA  Similar neurotransmitter anomalies exist.  Both respond to SNRIs, but SSRIs provide little pain relief.  SNRIs might be better thought of as “neuromodulators.”  Pain relief with SNRIs is often independent of changes in depression. Ablin, Buskila & Clauw. Curr Pain Headache Rep 2009;13:343-9

14. Pain, Depression and Sleep Triad Pain Depression(anxiety/stress)Sleep

15. Pain Depression(anxiety/stress)Sleep

16. Sleep Hygiene “Sleep and sleep hygiene” DHHS 64 million Americans have chronic insomnia (> 20%) Disrupting slow wave sleep over several nights in sedentary middle- aged females (without reducing total sleep efficiency) results in a decreased pain threshold, increased discomfort, and fatigue. Lentz et al., J Rheumatol 1999, 26(7), 1586-1592. In FM, >75% report sleep disturbances. Insomnia up to 65%, snoring and arousals up to 78%, RLS up to 41%, excessive daytime sleepiness up to 93%. FM with sleep studies = obstructive sleep apnea ~ 80% Abad et al., Sleep Med Rev 2008;12:211-28

17. Non-Pharmacological Interventions

18. Interventions that enhance positive emotions and resilience!

19. Acknowledgments Dr Alireza Ahmadi