What does low psychological distress mean in patients with no mental disorders and different pains of the musculoskeletal system?

Introduction

The German Working Group on Nonsurgical Orthopaedic Manual Medicine Acute Hospitals (ANOA: “Arbeitsgemeinschaft der nicht operativen orthopädischen manualmedizinischen Akutkrankenhäuser” – Working Group of Non-surgically Orthopaedic Emergency Hospitals of Manual Medicine) divides different pain processes in disorders of the musculoskeletal system into four different categories (ANOA 1–4):

1. Multifactorial pain disorders

   1. Structural and functional disorders of the locomotoric system.

      1. ANOA 1: Pain of the musculoskeletal system without tangible psychological diagnosis (according to ICD-10), which is to be treated with manual therapy.

   2. Chronic pain disorders of the locomotoric system (somatic and psychic symptoms).

      1. ANOA 2: Chronic pain with clearly definable mental disorder, to be treated multi-modally with manual-medical, pain-medical and pain-psychotherapeutic specialties [1].

      2. ANOA 3 Disorders requiring an optimization of the special pain therapy with medication optimization under inclusion of special pain-psychotherapeutic methods (ANOA 3). It can be seen as a “light variant” of ANOA 2.

2. Pain syndromes resistant to therapy

   1. ANOA 4: Pain progressions of unclear findings that have been resistant to therapy up to present.

The study presented here focusses on the investigation of the psychological distress of the first two groups (ANOA 1 and 2). At the “Sana Klinikum Sommerfeld”, it is known that patients with a multifactorial pain disorder and a concomitant mental disorder (ANOA 2) show high values in the impairment severity score (ISS) according to Schepank [2]. This is a validated questionnaire and part of the routine questioning on admission. In the Sommerfeld Hospital, the questionnaire was evaluated only in the context of the treatment of mental diagnoses in ANOA 2 patients. Internally, this confirmed that patients with mental disorders have a high cumulative value. However, the cumulative value of the ISS was not taken into account in patients classified as ANOA 1 (functional disorders) because they had no signs of psychiatric disorders.

The reason for the assumption that functional disorders of the locomotoric system are associated with a mental finding can be found in the ambiguity of the term “functional”. As a part of manual therapy on the one hand, “functional” is associated with the group of terms

1. dysfunction,

2. functional disease, and

3. functional chains.

In psychosomatic medicine on the other hand, the term functional is understood as a group of patients suffering from psychogenic complaints [3], where psychogenic can be described as persistent non-specific complaints, defined symptom clusters existing over a longer period of time in the terms of syndromes without physical lesions, and pronounced somatoform disorders, which require a considerable impairment of the functional level.

In the synopsis of manual therapy and psychosomatics, there is provision for the possibility that patients with functional disorders can nevertheless have individual mental symptoms or subsyndromal disorders below the level of mental disorders according to ICD-10 [4, 5].

Consequently, the question arises whether the psychological care (as provided for ANOA 2) of patients with no mental disorders according to ICD-10 in ANOA 1 is negligible.

Patients and methods

Results

Of the 60 selected patients, 58 were included in the study. Two patients were retrospectively assigned to ANOA 3 because they did not require multimodal complex treatment (Table 2).

The subgroup with the highest scores is ISS somatic.

The following group characteristics were developed based on the medical history and psychological findings in the patient files (Table 3).

Discussion

We investigated two groups of patients with pain in functional disorders of the musculoskeletal system. ANOA 2 patients had psychological disorders according to ICD-10 in addition to orthopaedic findings, whereas in ANOA 1 patients, no additional mental disorders were found. In ANOA 2, the mean ISS cumulative value is 6.1.

For ANOA 1 patients (without mental disorder), the mean cumulative value of 2.2 is above the sum value for healthy (0–1) set by the test authors [2].

This raises the question of the significance of the ISS exceeding the value 1.

In everyday clinical practice, the ISS according to Schepank was collected but evaluated only for ANOA 2 in the context of (psychotherapeutic) treatment of the mental diagnoses. In contrast, the treatment of ANOA 1 (without a mental disorder) was carried out according to the regulations with a focus on psychoeducation to optimize somatic therapy; consequently, the evaluation of the ISS was not deemed necessary.

The consequence (mental disorders cause only psychic symptoms) can be seen in therapy: In addition to the multimodal interprofessional therapy [8], ANOA 2 patients should be treated specifically for mental disorders. While in ANOA 2 patients, psychopharmacotherapy and psychotherapy are applied, the patients out of ANOA group 1 require other measures of therapy, which can be summarised under the heading “understanding and managing pain, self-care and relaxation” (Table 1).

After retrospectively evaluating the ISS for ANOA 1 patients, both groups had the highest mean value in the somatic subgroup.

Psychiatric diagnoses do not necessarily cause mental symptoms. Nevertheless, they can cause somatic symptoms, for example lead to an increase in muscle tone (i.e., the long back extension muscles) and, thereby, to pain in the musculoskeletal system. This concept is well known and is supported by different reports from the literature [9], [10], [11], [12], [13], [14], [15]. For instance, Simms et al. showed that in depression, somatic symptoms such as pain can be the leading clinical symptoms. According to Löwe et al., the diagnosis of depression also requires eliciting of physical symptoms such as pain [16].

Depressive episodes with mainly somatic symptoms have a lower clinical severity [17]. This includes mental disorders below the syndromes according to ICD-10. In a review of studies on minor depression, Pincus et al. concluded that there are no defined symptom clusters in the range below ICD-10, whereby a lot of different “brand names” for these exist [4].

Nevertheless, patients with untreated subsyndromal depression often have the same poor outcome as patients with untreated depression according to ICD-10 [5].

If one assumes that a low ISS cumulative value and elevated values for the somatic subgroup may be a sign of a mental disorder hidden behind physical symptoms, then the psychoeducation treatment program of ANOA 1 should be supplemented with elements of psychotherapy from ANOA 2.

Summary

In this investigation, we found that the patients of ANOA 2 (with mental disorders) show a high value in the ISS. However, the ISS cumulative value and the somatic subgroup score in the ANOA 1 patients (without mental disorders) is not inconspicuous.

In consequence, one has to note that a mental disorder may present solely through somatic symptoms (ANOA 1); and that disorders considered merely functional can be accompanied by psychological symptoms even without a tangible mental disorder below the level of ICD 10 (subsyndromal).

Therefore, the psychoeducation treatment program of ANOA 1 should be supplemented with elements of psychotherapy from ANOA 2.