Dr Robert London

Controlling chronic pain - part I

Clinical Psychiatry News - Volume 32, Issue 3, Page 41 (March 2004)

As psychiatrists, not unlike other specialists in medicine, we desperately want to help patients with chronic pain, but we often get as frustrated as they do in coping with this difficult syndrome.

When a patient has been in pain for 2-3 weeks, the pattern of pain-depression-insomnia becomes an illness in itself and requires treatment.

The patient's vocational, personal, and social life changes dramatically. Often, the patient becomes consumed by feelings of depression, alienation, and loss of identity.

Whether the chronic pain is from physical or emotional causes, or from both, psychiatric treatment is available. We can offer specific cognitive treatments and rapid, interpretive intrapsychic approaches to patients.

It is important to help patients understand some dynamics in the development of pain—whether its origin is from structural damage, emotional conflict, or a combination.

Acupuncture, biofeedback, and anesthesia interventions, not unlike some surgical procedures, are not always successful in treating patients with chronic pain.

However, certain psychotherapeutic techniques—such as brief psychodynamically oriented psychotherapy—may indeed help. This means psychiatrists can be a good resource for neurosurgeons, orthopedists, neurologists, rheumatologists, and other professionals.

As psychiatric clinicians, we can evaluate for emotional factors that may be causing or contributing to the pain pattern and either rule them out or treat the patient for these symptoms.

We can also evaluate for symptom substitution—whether taking away one symptom causes it to be replaced by another.

Although symptom substitution may occur in a small number of people, it's by far not a rule, and it still is important for us to treat and alleviate chronic pain problems.

The patterns of chronic pain can be divided into three types:

1. Psychological. For various reasons related to emotions, the central nervous system receives a signal, and emotional discomfort or pain is referred to a specific site. Referred pain can involve headache, backache, or organ systems distress.

2. Psychological/Physiologic. In this category, injury or illness leads to a pathologic focus. Emotional stress or tension may translate into a pain pattern in a physically disturbed or previously traumatized area, which becomes the person's Achilles' heel.

3. Physiologic. The pain results directly from an illness or injury, and the pain pattern remains regardless of the patient's emotional condition.

In the first category is a 32-year-old woman I treated who had chronic, at times severe, lower back pain.

No physical findings were present from previous orthopedic and neurologic consultations.

The patient could not lift objects, stopped participating in sports, and halted her sex life with her husband.

Typically, the surgeon, orthopedist, neurologist, or rheumatologist do not attempt to ask questions about lifestyle or stress-related problems.

And even when they do ask such questions, often, they are not phrased properly, or the patient is not willing to discuss a personal problem during a very short office visit when other patients are waiting to be seen.

In the psychiatric referral, it was learned that the husband had been drinking excessively and had been unfaithful to the patient at times.

The patient's pain was interpreted as the patient taking control of her husband through her pain.

In a family therapy setting, a combination of goal-oriented psychotherapy and brief psychodynamic therapy worked within 12 weeks.

With motivation to solve the problem and an understanding of personal intrapsychic conflicts and the symbolism in each spouse's lifestyle, the patient and her spouse managed to save their marriage—and the patient's chronic back pain began to resolve.

In the psychological/physiologic category is a 40-year-old executive I treated who had chronic back pain. His pain originated from a high school football injury that resulted in his being taken off the high school team.

That pain prevented the patient from playing in college as well.

The patient never wanted to play football, and his ambivalence profoundly disappointed his father—who was controlling, domineering, and, of course, disappointed. The patient's injury was clearly shown by radiography.

Two neurosurgeries were “successful,” but the chronic pain pattern remained. The patient's suffering continued in the workplace.

In fact, the pain worsened to the point in which the patient was hospitalized twice for evaluation; these hospitalizations coincided with conflicts at work with superiors.

The brief dynamic therapy focused on the domineering/controlling father and the patient's symbolism of what the boss represented. The football injury was real, as was the father's powerful negative influence on the patient.

In a short time, the patient was able to reprocess the emotional quagmire presented by his boss's symbolic representation of his authoritarian father.

In general, few of our colleagues in other specialties make these kinds of psychodynamic associations when treating physical illness.

Our job as psychiatrists is to use our understanding of mental mechanisms and complex social and family relationships in order to teach those connections to our patients.

In the third category is a 22-year-old depressed man I treated. This young man had brachial plexus lesions that resulted from a motorcycle accident. Depression developed from losing the use of one arm.

The patient had refused work as an engineer, called off a marriage, and become isolated. Antidepressants were used and helped greatly to restore his mood—but not his perspective.

A psychotherapeutic approach was clearly needed to help this patient understand his personal and professional value.

New perspectives on life with a disability, both vocationally and socially, were offered. As a result, the patient was able to integrate those new outlooks into his life.

As psychiatrists, we are at a distinct advantage. Not only are we experts in mental health, but we have a comprehensive understanding of the multiple problems that affect the body.

Therefore, these advantages place us in a unique position to offer help to individuals who suffer from the “illness” of chronic pain.

Certainly, focused dynamic psychotherapy is not the answer for all patients.

But I think that this approach is almost always worth attempting.

Next month, I will address other specific strategies that we can teach our patients to help them control chronic pain patterns.

In the meantime, please feel free to write me at cpnews@elsevier.com, and let me know about strategies you have used to treat chronic pain. I will try to pass them on to my readers.

PII: S0270-6644(04)71031-0