DIFFERENZE DI GENERE NEL DOLORE:

aspetti psico-emozionali

Riccardo Torta Psicologia Clinica e Oncologica

Città della Salute e della Scienza Università di Torino

la patogenesi del dolore oggi

le differenze di genere nel dolore

antidepressivi ed analgesici

Argomenti

PAIN

cognition

perception

emotion stress mood depression anxiety

fear catastrophising

alexithymia

nociception

somatic components

somatic disease

mechanical flogistic etc. visceral neuropathic etc.

diabetes

TTH

FMS

cancer

pain is awareness of a nociceptive stimulus

depression

pain

chronicity disability

strained relationships central sensitization

reduction of pain threshold

Torta and Lacerenza, 2002; Leo, 2003

emotion and cognition are relevant to the diagnosis

and treatment of pain

SOCIAL

BIO

PSYCHO

bio-psycho-social model of pain

circuits of sensory, affective, cognitive pain dimensions

pain is modulated by

emotion and cognition

pain is influenced bu the perceived

social support

VAS unidimensional

evaluation

McGill multidimensional

evaluation

Chronic pain selectively alters large-scale brain networks. Some common areas represent a “core group”of regions

altered by almost all the chronic pain pathologies and some other areas that are differentially damaged

and that may represent the specific damage of each pathology.

the concept of PAIN MATRIX

is changed

Long-term pain alters the functional connectivity of cortical regions known as pain matrix

Chronic pain has to be prevented as early as possible

in order to keep ‘‘pain memory’’ from being established

chronic pain

emotion memory

reduced brain monoaminergic

transmission

neurotrasnmitter receptor dysfunction

dysregulation HPA HPG HPT axis

increase of proinflammatory

cytokines

reduction of neurotrophic factors

oxidative stress and nitric oxide

Major depression

the concept of MOOD

DEPRESSION is changed

from co-morbidity to co-pathogenesis

Mood Depression Pain HPA hyperactivity

(CNS damage)

neuro inflammation

CNS neurotransmitters reduction

The involvement of frontal lobes could be a factor guiding the changes and the adaptation mechanisms activated as a response by the system (e.g. cytokines production, stress system activation,

immune system responses).

High cytokines levels correlate with mood depression, cognitive dysfunction,

pain and stress levels

la patogenesi del dolore oggi

le differenze di genere nel dolore

meccanismi biologici, psichici e sociali

la fibromialgia: il dolore incompreso

Argomenti

Severity of pain may be more important as a risk for depression in women than in men

Stress and depression may be more closely associated with pain in women that in men

Women and men may have different pain experiences from similar diseases

Women were 1.5 times as likely to be undertreated for their cancer pain

Ovarian steroids have been found to modulate the activity of opioid receptors in healthy women and migraine sufferers

diffe

renz

e di

gen

ere

prevalenza e gravità

valutazioni sperimentali

risposta al trattamento

meccanismi biopsicosociali

le donne dimostrano una maggire sensibilità al dolore quando paragonate ai maschi (1,2)

HPTH= heat pain threshold HPTO= heat pain tolerance IPTH = ischaemic pain threshold IPTO = ischaemic pain tolerance CPTH= cold pain threshold CPTO=cold pain tolerance PPTTrap = pressure pain threshold

ridotta prescrizione oppioide post-chirurgica (3) maggior utilizzo di ansiolitici/sedativi nel dolore(4)

maggiore prescizine di oppioidi al proprio sesso (5)

(1) Hastie et al. 2012; 2) Rahim-Williams et al. 2012; 3) Miaskowski et al., 2000 : 4) Calderone 1990; 5) Weisse et al., 2001)

diffe

renz

e di

gen

ere meccanismi

biologici

ormoni sessuali

attivazione del SNC

sistema oppioide meccanismi

psichici

meccanismi sociali

aspettativa comportamentale

espressione culturale

sensibilizzazione algica

testosterone più antinocicettivo

aumentata sensibilità al dolore in catamenio (fase luteinica)

ridotta attivazione estroprogestinica e bassi livelli di testosterone nelle aree inibenti il dolore (PEG)

bassi livelli di estradiolo: < trasmissione oppioide

esperienze traumatiche (es.abuso) memoria del dolore

latini vs.anglosassoni

mascolinità vs femminilità

maggiore frequenza di depressione dell’umore

Volontarie (donne) attivano le loro aree affettive del dolore (corteccia cingolata anteriore –ACC), in correlazione significativa on il livello di empatia, quando osservano I loro amati che ricevono una (finta) stimolazione dolorosa sulla mano

dolore percepito dal Paziente

numero aree stressogene

livello di distress

DISTRESS THERMOMETER

p < 0.2 p < 0.007

caregiver

analogo visivo problem list

De Laurentis, Ieraci, Torta 2017 in press

distress del caregiver e percezione dolorosa del paziente

ANTIDEPRESSANTS AND ANALGESICS

BETWEEN MOOD AND PAIN

if antidepressants act also on pain, pain killers act also on mood ?

neurotransmitters

hormones

immune system

CNS trophism

ADs and pain

increased neurotransmitters

availability

reduced pro-inflammatory citokines levels

HPA, HGA axis modulation

increased BDNF-NGF expression

mood depression stress and anxiety

NE and 5HT

Opioid system

GLUTAMATE

flogosis

Pain Killer and mood

Pregabalin /Gabapentin (a2δ receptors Ca channels)

Neuropathic pain /Anxiety / Mood

Opioids (µ + δ opioid receptors) Cannabinoids (CB1 + CB2 receptors)

TCAs (δ receptors + endocannab.)

Tramadol (MOR + SRI activities) Tapentadol (MOR + NRI activities)

ASA / Cox 2 inhibition (Pain and mood)

Take home messages

Depression and pain share several pathogenetic mechanisms

Both mood depression and pain have a multifactorial pathogenesis

Sex differencies in pain are present both from biological point of view and in clinical pain management