A classification of illness behaviour in pain clinic patients.

The Illness Behaviour Questionnaire (IBQ) (Pilowsky and Spence 1983) was administered to 824 pain clinic patients over a 10-year period. Their responses to this 62-item self-report questionnaire were analysed using a numerical taxonomy programme. Of the 6 valid classes generated, 2 classes were delineated by at least 5 unique items. The main difference between these 2 classes, revealed by the item responses, was the acceptance or rejection of a psychological viewpoint. Comparison on the basis of mean IBQ scale scores indicated that, while members of both classes maintained the presence of a somatic disorder, they differed not only in their report of psychological symptoms but also by whether they showed an awareness of life problems unrelated to their physical problems.

A controlled study of psychotherapy and amitriptyline used individually and in combination in the treatment of chronic intractable, 'psychogenic' pain.

This paper reports an investigation into the efficacy of flexible dosage amitriptyline (AMI) and brief psychotherapy individually and together in the treatment of chronic 'psychogenic' pain. The patients included in the study were drawn from those referred to a pain clinic and were randomly assigned to 1 of 4 groups: (1) AMI + psychotherapy (N = 26), twelve 45 min weekly sessions; (2) AMI + support (N = 26), six 15 min fortnightly sessions; (3) placebo tablet + psychotherapy (N = 26), twelve 45 min weekly sessions; (4) placebo tablet + support (N = 24), six 15 min fortnightly sessions. Outcome was assessed on categorical and continuous variables administered immediately post treatment. The results indicate that amitriptyline is effective in increasing the patients' activity level and the reduction of pain intensity. Psychotherapy increases pain intensity, but tends to improve productivity. There also appears to be a role for the use of amitriptyline in combination with psychotherapy, but their interaction is a complex one. Baseline factors associated with withdrawal from treatment are reported, as well as those associated with a positive response to amitriptyline and psychotherapy respectively. Our findings offer tentative guidelines for choosing between therapies and also underline the importance of assessing more than one outcome variable in evaluating outcome. The importance of carrying treatments out in the context of a multidisciplinary pain clinic is emphasised.

Clinical assessment and interpretation of abnormal illness behaviour in low back pain.

Patients with chronic low back pain present with a mixture of symptoms and signs. Some are a direct consequence of physical pathology whereas others are attributable to associated and appropriate psychological and behavioural changes. At times the latter may be out of keeping with the degree of physical pathology and thus have specific significance in terms of the affective and cognitive disturbances that are also present and which may be the basis for abnormal illness behaviour. In an attempt to demonstrate more clearly the relationship between physical, psychological and behavioural components of illness, this paper draws on two data sets in patients with low back pain. The first explores the relationship between behavioural symptoms and signs, objective physical impairment, pain and disability and psychometric measures of distress together with scales making up the illness behaviour questionnaire (IBQ) of Pilowsky and Spence. A second data set is used to assess the value of the IBQ in understanding how psychological distress and behavioural signs and symptoms are related to the outcome of surgical treatment. The results gained reveal that behavioural symptoms and signs are directly related to the physical severity of low back disorder, the patient's report of pain and disability and the outcome of surgical treatment. Scores on the IBQ were strongly related to measures of affective disturbance and psychological distress. More specifically the disease affirmation scale of the IBQ, incorporating scales for disease conviction and psychological versus somatic focussing was an important dimension in relation to the behavioural symptoms and signs, thereby confirming results gained by other workers. Disease conviction and lack of response to clinicians' reassurances regarding illness - a situation in which abnormal illness behaviour is often deemed to exist - should not be seen simply as a function of the disease process, but more as a psychological coping mechanism for certain individuals under stress. The significance of this observation is discussed in relation to decisions regarding the overall assessment of chronic pain patients and their treatment.

Out-patient cognitive-behavioural therapy with amitriptyline for chronic non-malignant pain: a comparative study with 6-month follow-up.

A study was carried out in a multidisciplinary pain clinic with the purpose of comparing the effectiveness of outpatient cognitive-behavioural therapy (CBT) with amitriptyline (AMI) to that of supportive therapy with AMI. The treatments were given weekly over 8 weeks. Global and continuous outcome measures were used. Analysis was by chi-square for global data and MANOVA with baseline scores as covariants for continuous variables. No significant differences could be demonstrated. The scores over a 6-month follow-up period suggested a delayed positive advantage for CBT but this only approached and did not achieve statistical significance. The findings are discussed.

A search for the pathophysiology of the nonspecific "occupational overuse syndrome" in musicians.

The findings of this investigation have suggested a new theory to help explain the origin of activity-related pain. It proposes an as yet unrecognized physiologic process (the physiologic activity limitation process). When the intensity of an activity is greater than that appropriate for an individual's level of fitness for that activity, this process then generates unpleasant sensations, physiologic activity-related pain, the function of which is to limit that activity. The physiologic pain generated by this process will have pathways in common with pain caused by other protective mechanisms.