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A problem in the management of pain is the lack of distinction between acute and chronic pain syndromes Most clinicians are adept at dealing with acute pain problems but have difficulty handling the patient with a chronic pain disorder This type of patient frequently takes too many medications, stays in bed a great deal, has seen many clinicians, has lost skills, and experiences little joy in either work or play All relationships suffer (including those with clinicians), and life becomes a constant search for succor The search results in complex clinician-patient relationships that usually include many drug trials, particularly sedatives, with adverse consequences (eg, irritability, depressed mood) related to long-term use Treatment failures provoke angry responses and depression from both the patient and the clinician, and the pain syndrome is exacerbated When frustration becomes too great, a new clinician is found, and the cycle is repeated The longer the existence of the pain disorder, the more important become the psychological factors of anxiety and depression As with all other conditions, it is counterproductive to speculate about whether the pain is real It is real to the patient, and acceptance of the problem must precede a mutual endeavor to alleviate the disturbance
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Changes in lifestyle involve some of the pain behaviors These usually take the form of a family script in which the patient accepts the role of being sick, and this role then becomes the focus of most family interactions and may become important in maintaining the family, so that neither the patient nor the family wants the patient s role to change Demands for attention and efforts to control the behavior of others revolve around the central issue of control of other people (including clinicians) Cultural factors frequently play a role in the behavior of the patient and how the significant people around the patient cope with the problem Some cultures encourage demonstrative behavior, while others value the stoic role Another secondary gain that frequently maintains the patient in the sick role is financial compensation or other benefits ( green poultice ) Frequently, such systems are structured so that they reinforce the maintenance of sickness and discourage any attempts to give up the role Clinicians unwittingly reinforce this role because of the very nature of the practice of medicine, which is to respond to complaints of illness Helpful suggestions from the clinician are often met with responses like, Yes, but Medications then become the principal approach, and drug dependency problems may develop
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The cornerstone of a unified approach to chronic pain syndromes is a comprehensive behavioral program This is necessary to identify and eliminate pain reinforcers, to decrease drug use, and to use effectively those positive reinforcers that shift the focus from the pain It is critical that the patient be made a partner in the effort to alleviate pain The clinician must shift from the idea of biomedical cure to ongoing care of the patient The patient should agree to discuss the pain only with the clinician and not with family members; this tends to stabilize the patient s personal life, since the family is usually tired of the subject At the beginning of treatment, the patient should be assigned self-help tasks graded up to maximal activity as a means of positive reinforcement The tasks should not exceed capability The patient can also be asked to keep a self-rating chart to log accomplishments, so that progress can be measured and remembered Instruct the patient to record degrees of pain on a self-rating scale in relation to various situations and mental attitudes so that similar circumstances can be avoided or modified Avoid positive reinforcers for pain such as marked sympathy and attention to pain Emphasize a positive response to productive activities, which remove the focus of attention from the pain Activity is also desensitizing, since the patient learns to tolerate increasing activity levels Biofeedback techniques (see Somatoform Disorders, above) and hypnosis have been successful in ameliorating some pain syndromes Hypnosis tends to be most effective in patients with a high level of denial, who are more responsive to suggestion Hypnosis can be used to lessen anxiety, alter perception of the length of time that pain is experienced, and encourage relaxation
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Components of the chronic pain syndrome consist of anatomic changes, chronic anxiety and depression, anger, and changed lifestyle Usually, the anatomic problem is irreversible, since it has already been subjected to many interventions with increasingly unsatisfactory results An algorithm for assessing chronic pain and differentiating it from other psychiatric conditions is illustrated in Figure 25 1 Chronic anxiety and depression produce heightened irritability and overreaction to stimuli A marked decrease in pain threshold is apparent This pattern develops into a hypochondriacal preoccupation with the body and a constant need for reassurance The pressure on the clinician becomes wearing and often leads to covert rejection of the patient, such as not being available or making referrals to other clinicians This is perceived by the patient, who then intensifies the effort to find help, and the typical cycle is repeated Anxiety and depression are seldom discussed, almost as if there is a tacit agreement not to deal with these issues
Yes Is the motivation for the behavior apparent to the clinician Is the motivation for the behavior to assume the patient role
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