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Somatic Symptoms: Mental Health Approach and Differential Diagnosis

November 2008

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V. Pain

A. Assessment and Diagnosis

Recommendations:

Clinicians should have a heightened awareness of pain among HIV-infected patients and should ask patients about pain at each visit.

Clinicians should assess for fatigue and mental health disorders in patients with chronic pain.

Pain is a complex phenomenon that includes both a sensory component and a component of psychological distress. Pain can be described in a variety of ways (see Table 4), and careful diagnostic evaluation results in better treatment and outcomes.


Table 4: Descriptions of Pain
Acute nociceptive pain*
Typically constant, well-localized, and either sharp or stabbing or dull and cramping, depending on the area and injury involved
Chronic pain syndromes Involve more complex sensations and descriptions but can mimic any of the sensations associated with acute pain

Neuropathic pain*
Characteristically burning, tingling, lancinating, or electric-like
* Sometimes pain is a mixture of nociceptive and neuropathic factors.


The experience of pain cannot be easily separated from either the mental health or the physical state of the patient. Pain is often associated with fatigue, anxiety, sleep disorders, changes in appetite, and depressive symptoms, and HIV-infected patients are at increased risk for certain painful conditions, such as neuropathy. Social environments, cultural backgrounds, and psychological and emotional pain contribute to the manner in which people perceive and cope with physical pain. In addition, pain prevalence in injection drug users (IDUs) may be different from that in non-IDUs.9 Current or former IDUs may have lower pain tolerance, or higher tolerance to analgesics, than non-IDUs.

Possible medical etiologies are assessed first and, once excluded, are followed by assessment for mental health and substance use etiologies (see Table 5).


Table 5: Differential Diagnosis for Patients With Pain
Medical Etiologies
  • HIV progression
Severity of pain, its distribution, and its effect on quality of life all increase as HIV progresses; declining CD4 cell counts are directly related to the likelihood of developing pain syndromes10
  • Diabetes
Diabetes can cause or contribute to neuropathic and nociceptive pain
  • Opportunistic infections
Herpes simplex virus or varicella zoster virus can cause or contribute to neuropathic and nociceptive pain
  • Postherpetic neuralgia
A fairly common problem in patients who have had advanced HIV; the condition usually has many of the features of other neuropathic pain syndromes, with burning and prickly sensations in combination with pain
  • Complications of the peripheral or central nervous system
Injury or malfunction in the peripheral or central nervous system, such as those resulting from tumors or scar tissue, can cause inflammation or compression of nerves
Mental Health Etiologies
  • Depression
Pain is often a presenting symptom of depression and is more likely to persist in patients with depression; depressed patients often have a lower threshold for pain
  • Post-traumatic stress disorder and anxiety disorders
A substantial proportion of people living with HIV/AIDS have symptoms of post-traumatic stress disorder (PTSD) or another anxiety disorder. Patients with PTSD symptoms report greater pain severity and greater disturbance of affect and interference with performance of daily function than those without this disorder.11 Any anxiety disorder can lower the threshold for pain
  • Substance use
Substance use may contribute to the development of pain and inability to tolerate pain, as well as to the development of mental health disorders; in turn, patients with pain may develop substance use problems or dependence on prescribed analgesics
  • Psychosocial problems
  • Stressful living conditions or family crises (e.g., loss of a job, the death of a loved one)
  • Domestic violence
  • Daily activities that cause pain, including employment responsibilities that may cause or exacerbate pain


B. Management

Recommendation:

Clinicians should consider referring patients with chronic pain to a pain management specialist or consider consulting with a specialist during management.

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Acute pain associated with immediate injury is usually handled with direct antinociceptive treatments, including narcotics and antiinflammatory drugs. Chronic pain, which is often associated with psychological and functional morbidity, may require more complex and multidisciplinary approaches. Despite the importance of pain management, chronic pain remains undertreated in the HIV-infected population.12 Clinicians report lack of knowledge, inadequate availability of pain management specialists, and concerns about prescribing opioids and possible drug abuse as major obstacles to improved pain management. Although limited studies exist, some evidence suggests that non-white race, fewer years of education, greater numbers of physical symptoms, and greater psychological distress are independent factors associated with inadequate pain management. Furthermore, it is often difficult for patients living in predominantly non-white neighborhoods to fill prescriptions for opioids.13


1. Patient Response to Pharmacologic Pain Treatment

Experts in pain management have established definitions of dependence, tolerance, and pseudoaddiction to describe patients' responses to pain treatment (see Table 6).14 These definitions can assist clinicians in understanding patients' behavior in response to treatment and to determine whether changes to patients' treatment should be made accordingly. Importantly, the definitions in Table 6 are different from those established by the Diagnostic and  Statistical Manual IV, which describes the terms tolerance and dependence in the context of intoxication and substance abuse.


Table 6: Patient Responses to Pain Medication
Dependence
  • Does not refer to a disorder
  • Refers to the situation in which there has been enough exposure to a substance that its abrupt cessation would lead to a withdrawal syndrome
  • Occurs in relation to many classes of drugs, including opioids and certain antihypertensives and antidepressants

Tolerance
  • Is not used to characterize addiction
  • Indicates the need for a higher dose of drug to maintain the same level of effect
  • Is common to many classes of drugs and may or may not signal a progression of underlying disease

Pseudoaddiction
  • Occurs when medical staff interpret the attempts of patients to obtain analgesics as addictive behaviors when the behavior is actually a consequence of untreated or undertreated pain15


When a patient exhibits drug-seeking behavior, the minimal differential diagnosis includes dependence, tolerance, pseudoaddiction, psychiatric comorbidity, addiction, and criminal intent. Distinction among these entities by a psychiatrist or by a clinician with experience in identifying underlying causes of drug-seeking behavior will enable the primary care clinician to respond appropriately to such behavior.


2. Pain, Fatigue and Depression

Recommendation:

Clinicians should refer patients to a psychiatrist when there is concern that an active mental health disorder is complicating the management of pain.

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Pain is often accompanied by fatigue and depression, and these conditions can sustain one another and complicate treatment.16,17 In patients with depression, the presence of chronic pain increases the severity of the physical symptoms of depression (including fatigue and insomnia), the duration of depressive episodes, and the frequency of recurring depressive episodes.18 Although most studies have evaluated the relationship of pain and depression, pain may also be related to other psychiatric disorders, such as PTSD and anxiety disorders. In patients with comorbid PTSD and chronic pain, it is likely that several factors mutually maintain the PTSD and the chronic pain, so that treating one in isolation from the other will be less effective than addressing both.

For additional information regarding depression, see Depression and Mania in Patients With HIV/AIDS; for post-traumatic stress disorder, see Trauma and Post-Traumatic Stress Disorder in Patients With HIV/AIDS.


3. Pain in Substance Users

Recommendation:

Clinicians should not deny patients treatment of pain because of a history of addiction.

A multidisciplinary approach should be used for the management of pain in patients with comorbid substance use and mental health disorders. Pain is often undertreated in this population, and it can be particularly difficult to treat in the primary care setting, which often does not provide mental health services or substance use treatment services. Management of pain in HIV-infected substance users is further complicated by the possibility that these patients may require higher doses of medications for the pain to be alleviated. Clinicians also need to be aware of the possibility of the pain medicine being used or distributed illicitly.

For a detailed discussion regarding the treatment of pain in HIV-infected substance user, see the Substance Use Guidelines Pain in the HIV-Infected Substance User.


VI. Fatigue

A. Assessment and Diagnosis

Recommendation:

Clinicians should maintain a high level of suspicion for depression in patients presenting with fatigue.

Fatigue is a frequent and distressing symptom for people with HIV infection. The prevalence of fatigue among outpatients with HIV may be as high as 37%.19 Fatigue is generally multifactorial and can accompany other symptoms, such as pain, weight gain, and sexual dysfunction. In HIV-infected patients, fatigue is strongly associated with clinical AIDS and hemoglobin levels ≤12 g/dL.19 Fatigue is both predictive and a consequence of depression.20 In a study of primary care patients from the general population, approximately 40% of patients suffering from fatigue had a past diagnosis of depression or anxiety disorder, with 17.2% receiving a current diagnosis of major depression.21

Possible medical, medication-related, and mental health etiologies for fatigue are listed in Table 7.


Table 7: Differential Diagnosis for Patients Presenting With Fatigue
Medical Etiologies
  • Infections, especially:
    • Chronic viral hepatitis
    • Mononucleosis
    • Cytomegalovirus
    • Extrapulmonary mycobacterium tuberculosis
    • M. avium complex
  • Malignancies
  • Neurologic disorders including multiple sclerosis and stroke
  • Systemic/metabolic/endocrinologic disorders
    • Electrolyte imbalance
    • HIV-associated neuropathy
    • Type 2 diabetes
    • Anemia
    • Endocrine disorders including hypothyroidism and hypogonadism
    • Connective tissue disorders
    • Obesity and nutritional deficiencies
    • Major organ impairment or failure
  • Disrupted sleep, including sleep apnea
  • Pregnancy and menopause
HIV-Related Medications
  • Zidovudine and other nucleoside analogs
  • PIs
  • Ganciclovir
  • Trimethoprim-sulfamethoxazole (TMP-SMX)
  • Interferon
Mental Health Etiologies
  • Affective disorders, especially major depression and dysthymia
  • Anxiety disorders
  • Somatoform disorders
  • Substance use


B. Management

Recommendation:

Clinicians should use caution when prescribing psychostimulants for fatigue.

If fatigue is not related to depression, psychostimulants may offer some benefit in managing severe HIV-related fatigue. Psychostimulants may also be used to treat fatigue associated with a variety of medical and psychiatric conditions, such as hepatitis C virus, medication-related depression, HIV dementia, and pain. However, psychostimulants should be prescribed with caution. Modafinil, a non-amphetamine-derived psychostimulant, has demonstrated efficacy in some patients with HIV-related fatigue and may have less abuse potential than traditional psychostimulants.22

Fatigue related to sleep apnea may require treatment with continuous positive airway pressure (CPAP). Evaluation of sleep in a laboratory is often required for such a diagnosis.

When fatigue is related to hypogonadism, replacement therapy with testosterone, either through biweekly injections or gel preparations, has been shown to be safe and effective in testosterone-deficient HIV-infected men. Dehydroepiandrosterone (DHEA) or testosterone replacement therapy has been studied in women,23,24 but safety and efficacy have not been established.

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This article was provided by New York State Department of Health AIDS Institute.
 
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