Psychosozial bedingte Unterschiede in Kognitionsmustern von chronischen Schmerzpatienten mit und ohne arterieller Hypertonie – Implikationen für die Arzt-Patienten Interaktion Eine multizentrische, quantitative Studie im Querschnittsdesign

The subjective perception of chronic pain disorders is a complex construct that involves both functional limitations and psychological burdens in social coexistence of the patient. Current therapy recommendations for chronic pain include drug-based approaches, as well as multimodal pain therapy concepts. In order to explore further therapies, the scientific focus is increasingly on the chronification of pain. Many scientific papers explore neuroanatomical structures related to neuronal plasticity in which repetitive neuronal impulse activity is discussed as a cause for pain chronification. Among these is the reflex loop of the nucleus tractus solitarii, which is located in the medulla oblongata. It modulates neuronal impulses of the blood pressure regulation and pain perception, mediated by fibers of the CVLM and RVLM. In literature, a key structure for cognitive processing of pain is seen in the BRS, which is connected to the NTS-reflex loop. In this context, research on autonomic pain responses under stress exposure in a cluster of fibromyalgia patients with reduced BRS, higher pain intensity and an accompanying hypertonic circulatory response was demonstrated. These can be found in the literature, subdivided into AC, DYS and ID as psychosocial subgroups in chronic pain. Using the MPI-D in the previously mentioned study of autonomic stress responses in fibromyalgia patients, only the psychosocial subgroup DYS showed a reduced BRS. Following these findings, it can be suggested that the NTS-reflex loop is subject to unconscious heterogeneous modulation in reliance on BRS in chronic pain patients. It can be assumed that operant-learned behavioral patterns in the context of psychosocial interaction are linked to differential impulse activity of the BRS. As a consequence the core interest of this work is directed to the identification of subgroups of specific, unconscious learning processes as a starting point for individual therapy options for chronic pain and its accompanying vegetative reactions. In a multicenter cross-sectional design, a sample (n=524) divided into chronic pain patients with and without arterial hypertension was each classified into three subgroups, AC, ID, and DYS, using k-means cluster analysis. Subsequently, after variance-analytical evaluation, subgroup-specific characteristics were identified and compared by means of post-hoc analysis at the level of the subtests of the questionnaires. Finally, using correlation analytic values, mediation analyses were conducted to identify behavioral patterns. Characteristically, AC showed low levels of pain with high levels of independent physical activity and experienced support in social interaction. Specifically, self-efficacy and life control hold a key role in managing chronic pain as part of independent and active engagement. Health-promoting and health-damaging behaviors can be differentiated from one another, which must be promoted by physicians. For DYS, the highest level of subjective pain as well as impairment is shown, with the lowest level of pain-related life control and physical activity. Furthermore, the results indicate an indistinct disease theory with unclear awareness of the origin of the disease correlating with an associated strong, catastrophizing coping with chronic pain. Following on from this, negative stress coping strategies, such as resignation and self-pity, were shown to have positive correlations with dysthymeric and anxious behaviors. The results suggest the focus on pain symptomatology as a consequence of an unconsciously learned pain behavior. This results in activation of the pain network and the omission of pain-relieving activities. Therapeutic options, with the involvement and education of caregivers, include the patient's caregivers, are seen in the prevention of activating impulses of the pain pain memory as well as psychological psychotherapy. For ID, the lowest level of affectionate- and distracting partner behavior is shown with the highest level of activity in the household and low perception of pain at the same time. Positive correlations between a punishing partner behavior and an increase in activity in the household, in conjunction with again positive correlations to resignation, indicate a paradoxical learning process. Following findings from previous studies, interpersonally impaired pain patients, through the psychological and physical limitations of their caregiver, may be unable to assess the cause of insufficient affection by the caregiver. Punishing partner behavior is consequently not perceived as such, leading them to attribute their upset care as supposedly insufficient. As a result of this psychosocial learning mechanism, they strain themselves into a state of exhaustion in everyday life. Thus it is only in phases of relaxation that the resulting stress analgesia enables dealing adequately with the own symptomatology. We see therapeutic options in cognitive behavioral pain therapy for a long-term implementation of healthy thinking, feeling, and acting. No relevant differences were found for the comparison of characteristic traits between the three subgroups in cSoaH and cSmaH. The results of this study provide a better understanding of the heterogeneous behavioral patterns in chronic pain disorders and classify the relevance of individual therapy concepts.