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PSYCHOGENIC PAIN SYNDROMES
Chronic pain with insufficient or no organic explanation is a common problem. Typical syndromes include chronic headache, failed low back, atypical facial pain, and abdominal or pelvic pain of unknown etiology. The experience of pain for most of these patients is not factitious. However, while accepting that the pain is real, it is better understood as a psychophysiologic, rather than physical, disorder.
The taxonomy of this type of pain has been debated and psychologic hypotheses are as varied as the different schools of thought from which they originate. A recent classification divides patients into (1) those with organic pathology but in whom a psychologic disorder is the predominant influence on the intensity of pain complaints and degree of disability and (2) those with psychogenic pain, in which no organic pathology is seen. Most chronic pain patients fall into the former category; some of those in the latter can be further diagnosed as somatization disorder (numerous, and often dramatic, physical symptoms, including pain, typically involving several organ systems) or hypochondriasis (pathologic preoccupation with minor symptoms).
These patients often develop a pattern of inactivity, social withdrawal, rumination about physical health, and inappropriate use of health care that has been described as abnor-mal illness behavior. In patients without cancer, these behaviors are often referred to as the chronic nonmalignant pain syndrome. A subset of these patients, having what is some-times labeled the chronic intractable pain syndrome, display profound psychologic and social impairment marked by depressed affect and a virtual lack of function.
Without denying the validity of other theoretic frameworks, the nonpsychiatric specialist is usually best able to understand the patient with chronic pain in terms of learning theory--specifically, operant conditioning. From this viewpoint, the pain behaviors manifested by the patient can often be seen to be reinforced by a variety of factors in the patient's environment, including behaviors of family or close associates.
Treatment
Though the degree of physical disease contributing to the patient's disability should be clearly identified, and periodic reevaluation should be done when this factor is not static, primary therapy must be directed at maintaining and improving function and in treating the psychologic disorder. Analgesics can be used, but if used exclusively will undoubtedly fail because pain per se is not the only, or even the major, cause of disability. Rather, from the start and during all analgesic treatments, psychologic and social issues should be explored.
While psychologic consultation is often needed, the nonspecialist can organize a behavioral program that pursues improved patient function even without successfully reducing the pain. Patients should keep a diary of daily activities to pinpoint areas amenable to change. The physician should make specific recommendations for gradually increasing physical activity and social engagement; those for physical activity especially should be time-contingent, rather than pain-contingent. That is, activities should be prescribed in gradually increasing units of time; pain should not, if at all possible, be allowed to abort this commitment to greater function. Activities increased in this way often will be accompanied by reduced pain complaints.
A variety of cognitive techniques of pain control may be useful, including relaxation training, distraction techniques, hypnosis, and biofeedback. Any physician can teach patients a simple method of relaxation involving repeated and systematic contraction and relaxation of different muscle groups. Similarly, instructing patients on the use of distraction by guided imagery (organized fantasy evoking calm and comfort; eg, imagining resting on a beach or lying in a hammock) also may be helpful. Other cognitive-behavioral approaches require special expertise. Attempts also should be made to reduce behaviors within the family or at work that reinforce pain behaviors (eg, constant inquiries about the patient's health or insistence that the patient perform no chores). The physician also should avoid such behavior, should disapprove of maladaptive behaviors, applaud progress, and provide pain treatments while emphasizing return of function.
Nonpharmacologic methods of pain control should be stressed, including TENS and counterirritation, trigger point injection and spray and stretch, and physical therapy.
Drug treatment is sometimes useful; it includes the NSAIDs and tricyclic antidepressants. Doses of the latter may be increased (eg, amitriptyline 200 to 300 mg at bedtime) if indications of depression coexist. Responsible patients can occasionally benefit from opioids (see above and TABLE 119-4 and TABLE 119-8), though their use remains controversial.
Pain clinics provide a multidisciplinary, comprehensive approach most appropriate for the patient with chronic nonmalignant pain syndrome. Referral to such a center is often useful for patients with marked functional impairment or failure to respond to a reasonable attempt at management by the individual physician.
HICCUP
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