Self-reported pain in patients with schizophrenia. Results from the national first-step FACE-SZ cohort

https://doi.org/10.1016/j.pnpbp.2018.04.007Get rights and content

Highlights

  • 22% of SZ patients report physical pain, associated with headache, depression and anxiety and history of childhood trauma.

  • Self-reported pain is usually underreported, there may be more subjects with schizophrenia suffering from chronic pain.

  • The treatment of pain should be improved in patients with schizophrenia.

Abstract

Introduction

Little is known about perception of physical pain in schizophrenia (SZ). Some studies have suggested that patients with SZ may have an increased pain threshold, while others have suggested that patients with SZ may suffer from undetected and untreated high physical pain levels. The objectives of this study were (i) to investigate the prevalence of self-reported physical pain in stabilized SZ subjects, and (ii) to determine whether physical pain was associated with psychiatric characteristics and somatic comorbidities (iii) to determine whether antidepressants and benzodiazepine administration were associated with lower self-reported pain.

Method

468 community-dwelling stable SZ subjects (73% men, mean aged 32 years) were recruited in the Schizophrenia Expert Center national network. Patients with moderate to extreme pain, assessed with the EQ5D-5L questionnaire, were classified as belonging to the “pain group”.

Results

104 (22.2%) reported moderate to extreme pain levels. In multivariate analysis, pain has been associated with headache (OR = 2.63 [1.04–6.63], p = 0.04), higher anxiety (OR = 1.61 [1.18–2.21], p = 0.003), higher current depressive symptoms (OR = 1.09 [1.01–1.17], p = 0.03), history of childhood trauma (1.03 [1.01–1.06], p = 0.01) and older age (OR = 1.04 [1.01–1.07], p = 0.03), independently of current psychotic severity, sociodemographic variables, antipsychotic, antidepressant and benzodiazepine treatments. No association with addictive behaviors or illness characteristics has been found.

Conclusion

The present findings suggest that community-dwelling SZ outpatients report a high rate of self-reported physical pain, associated with headache, depression and anxiety and history of childhood trauma. Physical pain should be systematically assessed and specifically treated, when needed, in patients with SZ.

Introduction

Community-dwelling subjects with schizophrenia (SZ) have been described to have high rates of physical chronic medical conditions with a lack of adapted care (Correll et al., 2017; Godin et al., 2015; Vancampfort et al., 2016; Vancampfort et al., 2015). In 2013, a cross-sectional study found that SZ patients were twice more likely to report chronic pain in comparison to those without SZ (Birgenheir et al., 2013). A recent systematic review on pain in SZ subjects concluded that it was currently unknown how many SZ patients have pain issues (Stubbs et al., 2015). Several studies have suggested that SZ individuals may have a higher pain threshold compared to persons with other psychiatric diseases or with healthy individuals (for review see (Engels et al., 2014) and (Singh et al., 2006)). This higher pain threshold has even been suggested as a prodromal predictor of susceptibility for schizophrenia (Singh et al., 2006) and may explain a lack of complaint and adapted treatment. A recent meta-analysis has further suggested that current illness severity moderated increased pain threshold in schizophrenia (Stubbs et al., 2015). The authors suggested that decreased pain sensitivity may be considered as an endophenotype of SZ spectrum disorders and recommended to explore how this alteration links to other dimensions of SZ and physical comorbidity. In another meta-analysis, headache was found to be highly prevalent (29.9%) among 94,043 SZ individuals and the RR compared to 4,248,284 controls was 1.32 (95% CI = 0.85–2.07) (Stubbs et al., 2014). A recent work has further suggested that thermal pain may be related to glutamatergic dysfunctions in SZ patients (Chiappelli et al., 2017).

Beyond symptomatology, psychotropic treatments may modulate self-reported physical pain in psychiatric patients. Antidepressants have been found to be associated with pain relief in a recent meta-analysis (Gebhardt et al., 2016). Selective serotonin reuptake inhibitors have been suggested to be potentially more effective on physical pain compared to other antidepressants (Pan et al., 2015). Benzodiazepines have also been associated with pain improvement in chronic medical conditions (Abdel Shaheed et al., 2017). This may be due to both their anxiolytic, antiepileptic and myorelaxant properties.

In summary, inconsistent findings have been found about physical pain in SZ individuals and there is a need for consensual physical pain measure across illnesses. The health economic guidelines (NICE) recommend to include a generic preference based outcome measure, like EQ-5D (EuroQuol-5 dimensions) in order to allow for comparisons of health related quality of life of patient groups across different illnesses, providing information particular useful to support health policy decisions (Halling Hastrup et al., 2011). The EQ–5D is the most widely used “preference-based” measure of health in healthcare (Brazier, 2010).

The objective of the present study were (i) to investigate the prevalence of self-reported physical pain in a real-world sample of stabilized SZ subjects, and (ii) to determine whether physical pain was associated with illness characteristics and with somatic comorbidities and (iii) to determine if psychotropic medications (antipsychotics, antidepressant, benzodiazepine) prescription were associated with lower pain levels.

Section snippets

Study population

The FACE-SZ (FondaMental Advanced Centers of Expertise for Schizophrenia) cohort is based on a French national network of 10 Schizophrenia Expert Centers (Colombes, Créteil, Strasbourg, Versailles Bordeaux, Lyon, Marseille, Clermont-Ferrand, Grenoble, Montpellier), set up by the French scientific foundation FondaMental (www.fondation-fondamental.org) (Schürhoff et al., 2015).

Inclusion criteria

Consecutive clinically stable patients (defined by no hospitalization and no treatment changes during the 8 weeks before

Results

A sample of 468 community-dwelling stable SZ subjects was included in this study. Table 1 shows demographical and clinical characteristics of the sample, as well as associations with self-reported moderate to extreme pain. 345 (73.7%) were men and the mean age was 32 ± 9.5 years, the mean age at SZ onset was 21.7 ± 6.7 years, and the mean PANSS total score was 71.3 ± 19.1.

Overall, 104 patients (22.2%) had moderate to extreme pain levels (72 moderate, 27 severe and 5 extreme).

In univariate

Discussion

Compared to the results of the last meta-analysis (Stubbs et al., 2014), the present work has yielded important new findings: self-reported moderate to extreme pain levels were reported by one on five SZ patients and were associated with anxiety and depressive symptoms, history of childhood trauma and older age independently of current psychotic severity, sociodemographic variables and antipsychotic treatments. The present work also confirmed a strong association with headache in multivariate

Conclusion

Altogether, the present findings suggest that health-care providers should actively assess and treat pain in SZ individuals. Moderate to extreme pain levels have been reported by almost one quarter of the SZ patients and have been associated with headache, anxiety and depression. Future studies should determine if treating these risk factors may improve physical pain in SZ individuals.

Contributors

GF and LB performed the statistical analysis. GF, LB and PML wrote the first complete manuscript. GF, LB and PML edited earlier versions of the manuscript for important intellectual content. All authors were involved in the patients' recruitment, the clinical evaluation, acquisition of the clinical data, modified the manuscript and approved the final version.

Acknowledgments and funding source

We thank Hakim Laouamri, and his team (Stéphane Beaufort, Seif Ben Salem, Karmène Souyris, Victor Barteau and Mohamed Laaidi) for the development of the FACE-SZ computer interface, data management, quality control and regulatory aspects”.

This work was funded by AP-HM (Assistance Publique des Hôpitaux de Marseille), Fondation FondaMental (RTRS Santé Mentale), by the Investissements d'Avenir program managed by the ANR under reference ANR-11-IDEX-0004-02 and ANR-10-COHO-10-01, and by INSERM (

Conflicts of interest

None declared.

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    FACE-SCZ Group. Andrianarisoa M, MD, Aouizerate B, MD PhD, Berna F, MD PhD, Blanc O, Msc, Brunel L, Msc, Bulzacka E, Msc, Capdevielle D, MD PhD, Chereau-Boudet I, MD, Chesnoy-Servanin G, Msc, Danion Jm, MD, D’Amato T, MD PhD, Deloge A, MD PhD, Delorme C, Msc, Denizot H, MD, Dorey JM, MD, Dubertret C, MD PhD, Dubreucq J, MD, Faget C, MD, Fluttaz C, Msc, Fond G, MD, Fonteneau S, Msc, Gabayet F, Msc, Giraud-Baro E, MD, Honciuc RM, Lacelle D, Msc, Lançon C, MD PhD, Laouamri H, Msc, Leboyer M, MD PhD, Le Gloahec T, Msc, Le Strat Y, MD PhD, Llorca PM, MD PhD, Mallet J, MD PhD, Metairie E, Msc, Misdrahi D, MD, Offerlin-Meyer I, PhD, Passerieux C, MD PhD, Peri P, Msc, Pires S, Msc, Portalier C, Msc, Rey R, MD, Roman C, Msc, Sebilleau M, Msc, Schandrin A, MD, Schurhoff F, MD PhD, Tessier A, Msc, Tronche Am, MD, Urbach Mk,l, MD, Vaillant F, Msc, Vehier A, Msc, Vidailhet P, MD PhD, MD, Vilà E, Msc, Yazbek H, PhD, Zinetti-Bertschy A, Msc.

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