The psychiatric aspects of pain have gained front-line prominence in recent years, because experimenters and clinicians both conclude that they are important in treatment. Some earlier attempts at differentiation of "psychicfunctional" pain from "organic-somatic" pain appear to have been simplistic. Pain is very complex and cannot be seen in isolation from the patient, with his own disease processes and responses, life-style, personality, and present circumstances.1 It is an intensely individual matter, and private concepts influence its description; in other words, pain has a "psychic signature."2 It has an unpleasant quality that leads to its becoming the focus of the patient's attention and behavior. This has been brought into focus by studies of frontal lobotomy, which diminishes the aversive quality of pain and the desire to seek relief. Patients so treated report that their pain has not disappeared but no longer bothers them, and consequently their suffering has diminished.3
Pain is a personal sensation that signals current or impending tissue damage; it is also a complicated pattern of responses, such as escape and physiologic and neurochemical changes, that serve to protect the organism from harm. These responses can vary from the molecular to the gross behavioral.4,5
The pattern of chronic pain often cannot be understood in purely neurologic or physiologic terms; the "organic factor" is missing or minimal in relation to the level of pain.4,5 It is therefore important to consider not only the pain pattern but also the patient's life-style, which is frequently maladaptive. Treatment is aimed at affecting the pain experience and substituting one life-style for another - a career of useful action, with hope and purpose, instead of a career of pain.
THE "PAIN PRONE" PERSON
A "pain prone" person is one who frequently uses pain as a psychic regulator. He has a background in which pain has been used to deal with stress. He is often depressed, anxious, and guilty and generally has a history of significant procedures, operations, and painful injuries. He may also have a history of defeat and cannot tolerate success, because with it he feels a loss of emotional supports. The pain then becomes a way of dealing with the stress of loss and may provide new maladaptive supports.2
A separated, unemployed 28-year-old schoolteacher was seen in consultation. She described herself as less pretty, less successful, and less accomplished than her twin sister. She felt deprived of suffitient love and attention from her parents. Over the years but particularly during adolescence, minor illnesses such as colds turned into long and complicated processes. She described being bedridden at these times, with her mother providing special nursing care. She complained of undiagnosable abdominal pain, depression, sleep difficulties, and a low energy level. She had visited medical centers around the country and had undergone many surgical procedures and major diagnostic studies.
This young woman had come to experience "pleasure in displeasure" in her relationship with her mother. She felt that the only way she could gain her mother's love was to have pain and be sick. In a sense, she had substituted pain for her mother's love. Her pain was also a statement to the world around her, and particularly to her mother, of her anger at not having her needs fulfilled. These early patterns were major precursors of her later behavior.
The location of pain may be determined by the patient's own experiences with it,2 and the pain itself may result from identification with a loved one.
A 49-year-old man was referred for persistent chest pain. Results of medical workup, including cardiac catheterization, were normal. His pain had started some months before, as he approached his 49th birthday. He was moderately depressed and was preoccupied with his father's and grandfather's deaths at the age of 49 from heart disease. The pain apparently represented identification with these loved figures and his concern over the possibility of his own death.
THE DOCTOR-PATIENT RELATIONSHIP
The patient with chronic pain is best served by one physician who takes a genuine and more than ordinary interest. These patients demand a significant degree of flexibility on the part of the physician and, at times, more than the expected amount of time and energy. It is the opinion of Bonica, an anesthesiologist and long-time worker in the area of pain treatment, that the major reason for treatment failures and iatrogenic complications is a poor relationship and an insufficient amount of time spent with patients.6 The physician must be available to the patient to talk about currents and eddies in the patient's life, and he must feel that he is providing a service in giving psychologic and supportive medical treatment, which is at the heart of caring for patients with chronic illness.
These patients require an attitude oí hopefulness and a therapeutic outlook that they will improve. As with all patients, they experience successes, failures, advances, and relapses. The physician must be tolerant in accepting these gains and failures.
It is particularly important to be honest and nonjudgmental about the prognosis and the treatment plan. Unrealistic therapeutic expectations tend to increase the patient's mistrust of his physician and may perpetuate the illness or the tendency to doctor-shop. It is often easier for the patient to cling to vague magical wishes that things will get better. But it is important for him to realize that he must come to terms with his problem, which requires an honest and open assessment.
These patients may provoke aggression, frustration, and anger. They seem to emit an air of failure and despair, unresponsive to the ministrations of numerous physicians. Superficially, they may have a set of values different from the physician's; they do not work and seemingly benefit by being paid for an illness and a life of leisure. The physician's frustration may be a reflection of the patient's own frustration, so a history of this frustration and anger is particularly helpful in understanding how the patient deals with the physician specifically and the world in general. Attempts to admonish the patient and cajole him into changing his behavior may be viewed as harassment and most of the time are not successful. Rejection and hostility over his life-style are attitudes with which the patient is quite familiar. He may agree with the physician that he ought to lead a fuller life, but change is a complicated and difficult matter.
A number of pain centers treat their patients in specialized units. The treatment team may consist of neurosurgeons, anesthesiologists, psychiatrists, psychiatric nurses, psychologists, social workers, occupational and physical therapists, etc. The team approach affords evaluation and treatment with a broad perspective.
It is essential to evaluate all the components in the problems of patients with pain. From this evaluation will flow the plan for treatment. Both assessment and treatment should take place in three related but different areas.
The first is psychiatric diagnosis. Pain is found most frequently in the diagnostic categories of situational stress, chronic anxiety, conversion reaction, hypochondriasis, psychosis, and depression.5,7·8 Following the diagnosis, the psychiatric treatment and use of medication can be determined.
The second is determination of the social and transactional factors and the extent and limits of the chronic-illness pattern. Behavior that perpetuates the illness pattern ("pain games") must be evaluated. Assessment of the family is necessary, since the relationship between patient and family can reinforce the pain-oriented behavior.
The third area is the indication for specific treatment techniques, such as behavior modification, hypnosis, and biofeedback.
SPECIFIC DIAGNOSTIC CONSIDERATIONS
Addiction. The patient with chronic pain may be addicted to various medications, ranging from narcotics to barbiturates and amphetamines. The goal is to be free of all addicting medications.
It is important to locate the source of the patient's medications and become the sole prescriber. If the patient is asked to bring in all his medications periodically so that they may be reviewed, this reinforces compliance with the regimen. The patient who is addicted may need to be hospitalized for baseline assessment and withdrawal, since addiction to and withdrawal from barbiturates, amphetamines, and opiates have been associated with significant medical problems.9
The patient with chronic pain usually takes medication on an "as needed" basis, thereby reinforcing pain behavior. Pain is rewarded by an analgesic, with its euphoric and relaxing properties. Fordyce10"13 recommends that after a baseline level of medication is established, it be given on a strictly scheduled basis. This decreases the reinforcement of pain and helps manage the addiction while still providing analgesia. Gradually, addicting medications can be tapered and withdrawn.
Situational stress. Pain most commonly arises in the context of situational stresses.7,14 A large percentage of transient aches and pains are associated with the trials and tribulations of everyday living. Witness to this phenomenon is the enormous market for over-the-counter analgesics and patent medicines. These pains usually pass and do not come to the physician's attention, but when patients do seek medical advice, they are often placed in "catchall" diagnostic categories, such as neuralgia, lumbago, or sinus problems.7
Chronic anxiety. The chronically anxious person has heightened irritability and is in a state of "readiness for discharge." He is tense, jittery, and overreactive to any sort of stimulus, with marked decrease in the pain threshold.4,7
Chronic anxiety is often translated into painful muscular contractions, most commonly around the back, neck, and shoulders.
A 22-year-old woman with neck and hack pain was seen in psychiatric consultation for nine months. She had developed the pain following an automobile accident, and it had increased in severity over the nine months. She described herself as a tense and "nervous" person and indicated that when she became anxious, she felt "little knots" in her back and neck. These disappeared, as did the pain, when she was able to relax. When the patient had pain, she was pessimistic about ever feeling better; this led to increased pain. She negated her own needs and felt responsible for the well-being of everyone and everything around her. It was as if the patient were carrying the weight of the world on her shoulders.
The pain was felt to be secondary to muscular contractions resulting from anxiety. The patient was taught self-hypnosis and progressive relaxation techniques, which considerably reduced her pain.
Treatment in these cases should be aimed primarily at reducing the patient's anxiety. This may include psychotherapy to help deal with conflicts; antianxiety agents, such as chlordiazepoxide (Librium®), diazepam (Valium®), and oxazepam (Serax®); and biofeedback, hypnosis, or behavior relaxation techniques.9,15"23
Conversion pain. Pain as the expression of emotional difficulties5,7,8 is probably the most common form of conversion reaction.24 It may be the exaggeration of an underlying physical process, occur in the context of an ongoing illness in which pain is experienced at a different location, or be a purely psychologic phenomenon without physical findings.25 McCranie8 talks about conversion pain as a symbolic somatic representation of depression, psychic suffering that is displaced and represented by physical pain. Pain is often a depressive equivalent, so treatment of the depression may diminish the conversion pain.
Hypochondriasis. Some patients with pain have many hypochondriacal complaints; they are preoccupied with their bodies and are fearful of disease.26 The complaints seem to be fixed and unresponsive to reassurance. Depression is often associated with hypochondriacal thoughts. The preoccupation with the body may be of psychotic and delusional proportions.
Psychosis. Pain occasionally occurs in psychotic patients, most commonly those with schizophrenia or psychotic depression. The pain sensation may be hallucinated or be part of a somatic delusional system, such as the delusion of an abdominal tumor and a feeling of rotting inside.7 The patient may present with only the complaint of pain, but in this instance pain is only one aspect of the psychotic behavior and treatment is aimed at the underlying process.
Depression. "Depression," in general, has two meanings. The first refers to disordered mood or affect and is described by such words as "low," "blue," "down," "sad," and "depressed. " The second refers to a syndrome that includes a disturbed mood, sleep disorder, appetite disturbance with either weight loss or weight gain, constipation, decrease in energy and activity, a pessimistic view of the world, decrease in sexual interest, and suicidal thoughts. In these cases, it is absolutely necessary to treat the depression.27 A patient with chronic pain who is psychotically depressed, with delusions in addition to the depressive syndrome, should be managed by a psychiatrist and often requires hospitalization. The seriously suicidal patient is also best treated in the protective setting of a hospital.9,28
The patient may refer all his depressive symptoms to his pain. When asked if he feels depressed, he may respond, "Who wouldn't be depressed with so much pain?" In regard to sleeping difficulties, he may say that he would sleep quite well were it not for the fact that pain awakens him at night. Many patients with no evidence of organic damage are awakened by their pain, and, contrary to expectation, many patients with clearly organic chronic pain are able to sleep well. The difference in sleep patterns seems to be a function more of the degree of anxiety or depression than of the source of the pain.27,29
Patients with a significant loss, real or fantasied, may have reactive depressions accompanied by pain. For example, a patient who has lost a spouse without appropriate grieving may complain of pain. Patients with chronic pain from an identifiable source may have a change in routine and develop depression in reaction to the loss of previous supports. Losses and subsequent depressions are important to note, since treatment of the depression may necessitate helping the patient come to terms with the losses.
A 30-year-old man was referred to the pain clinic of a local hospital for evaluation of neck and shoulder pain. The physical examination, including mental status evaluation, was unremarkable except for limitation of neck movement and evidence of moderate depression. The pain had started four months earlier, after his wife left him. It resulted in inability to use his left hand, so that he was unable to work at his usual occupation as saddlemaker or in his parttime position as guitar player. He revealed a preoccupation not only with the loss of his wife and family but also with his father's death 10 years earlier. In addition, he was concerned because his father had had a rightsided stroke that had left him with an inability to use his left arm. The patient had a significant sleep disorder, experienced a weight loss of 40 pounds over six months, and felt depressed and suicidal.
Treatment was directed towards the resolution of his grief over the loss of his father and wife, assisted with antidepressant medication. The pain diminished and disappeared as he dealt with his losses.
Penman, a neurosurgeon, has documented that patients with peripheral sources of chronic pain adapt to a particular way of life that includes the pain as a way of coping.30 When the source of pain was removed, a significant percentage of the patients in his study became clinically depressed. The pain had become an "old friend," a treasured possession. The patients had adapted quite well to a life-style incorporating the pain and were unable to give this up; many of them experienced the eventual onset of other, debilitating pain.
The treatment of depression employs psychotherapy and psychotropic medication. Psychotherapy occurs on two levels: supportive measures and conflict resolution. Supportive therapy requires the physician to be available, listen to the patient, accept his views and opinions, and maintain a hopeful attitude that he will do well. Conflict resolution helps the patient with chronic pain to uncover and deal with such unresolved conflicts as grief and significant loss, real or fantasied.
Beck, a worker in the field of depression, helps the depressed patient to organize and structure his life so that he becomes functional, achieves success in his activities, and increases his self-esteem.28 One technique is to mobilize the patient to do small activities that he has neglected, such as phoning, doing the laundry, or completing a long-overdue project. The techniques of Fordyce and Sternbach, who work in the field of pain therapy, also help organize and restructure the patient's life.10,3,27
The medical treatment of depression may include antidepressant medication or electroconvulsive therapy. The tricyclics - such as amitriptyline (Elavil®), Imipramine (Tofranil®), and doxepin (Sinequan®) - are first-line drugs. They seem to be most effective with patients having the most intense physiologic symptoms of depression, such as marked sleep disorders, appetite disturbances, and constipation. They may also be tried on patients with less intense depressive symptoms.
If the depression is unresponsive to medication or the patient is a severe suicide risk, electroconvulsive therapy may be indicated. This form of therapy has been shown to be as effective as medication for severe forms of depression.9,15,16,28
SOCIAL AND TRANSACTIONAL FACTORS
Interpersonal aspects. Szasz describes the patient with pain in terms of having a "pain career" and participating in "pain games."31 He talks of "l'homme douloureux," the painful person, who with little or no organic defect complains of unbearable or intractable pain. The fact that there is a "game" does not, however, mean that the patient is not depressed. The chronicity of the pain indicates that the patient wishes to occupy the sick role; its pain and suffering verify his identity. This patient engages in a game in which undiagnosable pain and unrelated suffering are produced. The physician's identity, which rests on his ability to diagnose pain and relieve suffering, is thus challenged and often negated. This failure causes the physician to employ even more drastic diagnoses and therapeutic interventions.
Sternbach, a psychologist, elaborates more fully on Szasz's idea of "pain games" to include analyses of the activities of patient, family, and doctor that center on pain.29,29,33 No surgery, medication, physical therapy, or psychotherapy is helpful for long. With the initially favorable response to treatment, the patient seduces the doctor into pursuing a full course of treatment yet eventually defeats him by not getting better. Many of these patients are addicts. They express horror at the idea of having to take medications on which they might become dependent, yet they present their problems in such a fashion that the doctor offers them stronger and stronger analgesics. They are also concerned with financial rewards through compensation claims, litigation, unemployment benefits, etc. It would seem that for some patients the goal is not money or drugs but confounding the doctor. For a variety of reasons, they use their behavior to control others, and their behavior perpetuates their patienthood.
Sternbach describes a method for dealing with the chronic-pain patient, using a transactional approach.27,32 A contract is made with the patient that contains specified directions for change. For example, the patient is asked what life would be like for him without the pain. He is then asked to imagine performing some of these things without the pain and is encouraged to do so. This is also an interesting and important way of assessing the patient's motivation. He sets his own pace, with very specific goals, and is prompted to achieve these goals and thereby achieve success. He is given structure, his confidence level and self-esteem are raised, and the habit patterns are interrupted. Family aspects. Pain may be an important dynamic in establishing or maintaining family equilibrium. It may also be the mechanism for fulfilling other needs in the family.
A 35-year-old man with chronic low-back pain was seen in psychiatric consultation. He had undergone numerous procedures, all of which produced meager therapeutic results. Since his early 20s he had been living in a homosexual relationship with a much older man who had sheltered and protected him. He had feelings of great ambivalence toward his partner and had intermittently considered leaving but was quite fearful of being on his own. The partner had periods of extreme jealousy and excessive demands that were difficult to placate; at these times the patient's pain increased.
Pain represented a genuine statement of his distress over his difficulties in the relationship, his fear of becoming independent, and his anger at his partner for not giving him his freedom. It also constituted a "time out" from his partner's demands, including sexual, and was a way of controlling his partner. On the other hand, the partner was quite clear about the patient's desires to withdraw from the relationship and viewed his incapacitated state as a way of maintaining their relationship. The interaction reinforced and maintained the pain problem and represented the complex dynamics of this couple's relationship. The pain and pain behavior decreased when the couple finally did separate.
While treatment of the patient with pain may be attempted on an outpatient basis, hospitalization is often necessary to interrupt the family's reinforcement of his pain behavior. During this period of hospitalization, it is advisable to work with the family to make them aware of the dynamics at work in their relationship with the patient.
Cultural aspects. Culture is an important variable in shaping a person's response to pain. In American culture, the pain of childbirth is considered to be incapacitating. However, anthropologists report other cultures in which the woman shows no distress during childbirth.2,34 In some primitive cultures of South America, Africa, India, and China, a pregnant woman continues to work until her child is about to be born. At that time, her husband gets into bed and goes through the motions of having the labor, with great pain, while she bears the child. In extreme cases the husband stays in bed with the baby to recover from the terrible ordeal, and the mother returns to her daily chores.
Zborowski studied four cultural groups: Jewish, Italian, Irish, and Old-American.36 The patients of Jewish and Italian origin tended to be more emotional while experiencing and expressing pain than the Irish and Old- American; they expressed less confidence in the doctor's skill and were more likely to doctor-shop. Both the Irish and the Old-Americans, particularly the latter, tended to delay consultation with physicians. In another study,4 the Irish were felt to suppress their suffering and concern for the implications of pain.
Many of these patients live lives of chronic illness. Psychologic problems are denied, and all their difficulties are discussed in physical terms. They stay in bed a great deal, take many medications, visit numerous physicians, and have minimal activities outside their career of pain. Depression is a constant companion, and often there is a paucity of interpersonal relationships. Activities become joyless; previously maintained skills may be lost. Many of these patients mourn their lost vitality and in some magical fashion wish to recapture their previous abilities. For many, these wishes are unrealistic.
This, then, is the chronic-illness pattern that treatment seeks to interrupt. Whenever possible, this treatment should be provided on an outpatient basis; if this proves unsuccessful, however, admission to the hospital may be necessary. Here the patient experiences consistent reinforcement for behavior change and strict control over his medication.
SPECIFIC TREATMENT TECHNIQUES
Behavior modification. Fordyce emphasizes the importance of learning in relation to the pain response.11*13 He considers the responses and reactions to pain manifested by important people in the patient's past and describes the steps that a person may have taken to guard himself from pain. Several routine medical procedures lead to the reinforcement, and therefore the continuation, of the pain symptom. Giving medication on an as-needed basis instead of a fixed-dosage schedule is seen as a conditioning process that reinforces the pain behavior. The physician's excessive attention to the patient with chronic pain, in the form of tests and procedures, can also reinforce the pain. Being rescued from unpleasant situations and receiving "time out" from difficult life situations by pain are also powerful reinforcers.
Using an operant conditioning model, Fordyce notes that pain patients work to tolerance. In other words, the patient works until he hurts and then he rests, so that rest is a reward for developing pain. To counteract this, Fordyce uses a system of working to quota. He determines the baseline level of work to the point of pain and then sets a quota at, or slightly below, the amount of exercise or work that can be completed without major pain or fatigue. This working to quota has the sequence of work-rest, not work-pain-rest; the reward of rest is given to reinforce the work rather than the pain. The quota is gradually increased as the tolerance level rises. This produces a pattern of success for the patient and increases his self-esteem.10-13
Various behavior modification techniques have been used in the treatment of chronic pain. One is to teach the patient to relax in situations that ordinarily bring forth pain responses. This is a substitution technique and has been used successfully in natural childbirth. The patient with chronic muscle spasm can also be taught a variety of relaxation procedures. Aversive conditioning, in which a noxious stimulus such as a shock is presented whenever a pain behavior appears, is another behavior therapy technique that can be used to eliminate pain responses. When patients with pain are taught to relax and perform a variety of tasks, they eventually give up thinking of themselves as having pain. This is known as paradoxical intention.
Other techniques that help the patient gain control over his pain have been described. For instance, the patient can tally the frequency of pain, make a graph, and keep elaborate diaries of the stimuli and events associated with the pain. Negative practice has been employed, in which the patient deliberately attempts to induce or increase the pain.3,23 These techniques can make a major impact on the pain experience and pain behavior. In all cases, if the methods are to be permanently effective, the patient must eventually alter his self-image and stop thinking of himself as having pain.
Hypnosis. This has been described as a useful method of treating pain.17,18 For the relatively few people who are highly hypnotizable, the pain experience can be modified directly. For the majority, hypnosis modifies the pain experience indirectly and is used as an adjunct to relaxation, anxiety reduction, and attempts to change the focus of attention. Both groups need continual reinforcement with periodic hypnotic sessions. The reduction of pain by hypnosis is enhanced by other pain -experience modifiers, such as biofeedback.
Hypnosis has little direct effect, however, on the chronic-illness pattern and life-style aspects of pain. Also, the capacity of the patient to be hypnotized is decreased with addiction.
Biofeedback. This refers to instrumentation that provides information to a person about changes in his body functions of which he is usually unaware. This information is useful to the patient in learning to control these previously involuntary functions.19
Electroencephalographic feedback techniques, which primarily utilize increases in alpha-wave production, alter mood, change the focus of attention, and reduce anxiety. A second biofeedback technique, one that seems to have the greatest potential in the area of pain control, is electromyographic feedback.19 This has been shown to have a direct effect on chronic pain related to muscle tension, as well as an indirect effect through relaxation and concurrent anxiety reduction. It has been used to alleviate tension headaches and chronic upper-back and neck pain.
Fluctuations in galvanic skin response have been used to provide information about arousal as a means to reduce anxiety.20
Some workers in the treatment of pain have used biofeedback techniques successfully in conjunction with hypnosis and behavioral methods.21,22 A good relationship between the therapist and patient, as well as motivation on the part of the patient, is essential in order for biofeedback to be successful. Biofeedback is less effective if environmental factors are contributing to the patient's difficulties. As in the case of hypnosis, the patient needs periodic reinforcement and retraining.
Anxiety, depression, and psychosis may all be operating in the patient with chronic pain. Treatment should consequently be aimed at both affecting the pain experience and modifying the pain behavior-chronic-illness pattern. Among the factors that must be considered by the physician are the need to detoxify the patient of addicting drugs, treatment for specific psychiatric syndromes, family treatment, hypnosis, biofeedback, and behavioral modification techniques. A combination of several of these procedures may be needed to bring some patients back to a more productive life.
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