Pain is the most common reason for adults to seek medical care. The complaint of pain is frequently cited by the injured worker as a reason for ongoing disability. Pain, the symptom, always has a cause. Pain may be a manifestation of atypical or occult depression. The evaluation of pain in the injured worker entails:
* assessing, defining, and diagnosing the pain,
* establishing the cause or causes of the pain, and
* describing impairment of function and disability.
The etymology of the word pain is relevant. The Latin word poena means penalty, punishing, or suffering. Pain is defined as a basic bodily sensation induced by a noxious stimulus, received by naked nerve endings, characterized by physical discomfort, and typically leading to evasive action. A second definition is acute mental or emotional distress or suffering. Pain has been described as a perception, as a sensation, and as an emotion. Rene Descartes, in the 17th century, postulated that damaged tissue transmitted pain information through nerves in the spinal cord to the brain.1 His partial understanding did not explain pain in the absence of damaged tissue. Archbishop Trench of Dublin, in the 19th century, in company with other theologians, considered pain to be punishment for sin.1 Many patients share this etymological Iy consonant understanding. Sigmund Freud, almost 100 years ago, documented case material in which pain is revealed to be a psychological phenomenon. Most patients and many physicians conceptualize chronic pain as either physical or psychological. Current understanding is that most chronic pain has both physical and psychological dimensions. Cbronic pain is traditionally defined as pain that has persisted for more than six months.2
Chronic pain, as found with cancer, osteoporosis, or rheumatoid arthritis, should be differentiated from chronic pain syndrome. From a general medical or orthopedic standpoint, chronic pain is of organic origin, whereas chronic pain syndrome describes pain largely, if not totally, of functional (ie, nonorganic) origin.3 Although the term chronic pain syndrome is not part of the psychiatric diagnostic nomenclature, it is used extensively in the pain literature. Psychiatrists working in the medicolegal arena must therefore comprehend its meaning.
ASSESSMENT AND DIAGNOSIS
Defining and assessing chronic pain involves taking a history. Somatizing patients typically present to primary care physicians who may become frustrated, if not angry, in the face of ongoing or proliferating symptoms and treatment failures. A concerned, supportive, and caring attitude will help the physician elicit important information. Careful listening to the exact words of the patient may reveal important dynamics fueling chronic pain. Dreams related by chronic pain patients frequently make relevant life themes clear symbolically. Questions about how the pain has changed the patient's life and about family members with similar problems usually uncover facts important to understanding the patient (S. Southwick MD, personal communication. May 1990). Insofar as possible, it is advisable to hear the patient out. Supportive comments or questions seeking clarification during the history will help to convey the physician's desire to understand and usually will pave the way toward establishing a measure of trust. More often than not, the diagnosis becomes evident following a thorough history.
Further assessment is accomplished through a mental status examination. Psychological tests of intelligence and personality are necessary. Sometimes projective measures and neuropsychological instruments are indicated. For optimal diagnostic accuracy, the testing psychologist should interpret the test within clinical context (ie, in the light of his or her own diagnostic interview).
Typically, patients who somatize are highly resistant to psychological interpretations of their symptoms. If the somatizing patient can acknowledge experiencing stress as part of his or her predicament, he or she will likely accept psychiatric evaluation focused on that stress. It is important not to confront the fragile defenses and self-esteem of the somatizing patient directly. Referral for psychiatric evaluation should never compel a patient to lose face.
The differential diagnosis of chronic pain includes several DSM-III-R entries, including somatofbrm pain disorder, hypochondriasis, somatization disorder, somatoform disorder not otherwise specified, undifferentiated somatoform disorder, factitious disorder with physical symptoms, substance abuse disorder, and malingering. Somatic preoccupation and somatization is frequently seen in association with mood or anxiety disorders.4 Somatoform pain may be the initial manifestation of an atypical or occult depression. Somatizing patients frequently perceive little, if any, mood abnormality. Serotonergic antidepressant medication as part of a comprehensive treatment approach may result in symptom amelioration in somatizing individuals. Lipowski suggests that whenever a somatoform disorder is diagnosed, the possibility of an associated mood or panic disorder should be considered.5 Such comorbidity is common. A comprehensive psychiatric and psychodiagnostic evaluation should establish the most probable diagnoses with reasonable accuracy.
Unfortunately, particularly in cases involving Workmen's Compensation claims, causation is the issue determining who will bear the cost of treatment. If, for example, a worker manifests depression in association with somatization, the compensation carrier will pay for treatment of the depression only if a causal relationship to on-the-job injury can be shown. On the other hand, when somatization is simply a manifestation of preexisting atypical or occult depression, securing payment for psychiatric treatment may be problematic at best. In some instances, the reported accident (or target incident) is simply a convenient focus onto which emotional symptoms (masquerading as physical symptoms) become grafted. Many, if not most, employee health plans outside of the workers' compensation system provide insufficient coverage for psychiatric illness. Small wonder that many treating psychiatrists collude with their patients in attributing the mood disorder (depression) to the somatoform pain. The conflict of interest is apparent. If the depression is industrial, the psychiatrist will be paid for treating it; if the depression is non industrial, the treating psychiatrist may not be paid.
Medical, psychological, and ethical issues are inextricable, and they involve all physicians who evaluate or treat injured workers. There is a conspiracy of silence about the crucial issue of causation and the conflict of interest involved in its determination. Ultimately, these problems reflect on and expose the inadequacies of the chaotic and, at times, arbitrary system of healthcare Jn the United States. It is undeniably in the best interest of the injured worker that diagnoses be accurate and that causation be understood by treating physicians. The situation becomes problematic, however, when an impoverished worker, out of work because of incapacitating chronic pain associated with a nonindustrial depression, cannot afford or otherwise obtain adequate psychiatric care. The present system affords little compassion and poses treatment dilemmas.
Certain adults, emotionally shortchanged during their formative years, are particularly vulnerable in the iace of stress (particularly object loss) to somatization. These individuals characteristically deny or minimize emotional distress, which becomes manifest in hypochondriacal or somatic concerns, including chronic pain. Not infrequently the compensation carrier and the employer are, at an unconscious level, placed by the patient in loco parentis. Financial or other recompense from the compensation carrier is sought for past wrongs by the individual who has been emotionally short-changed during the formative years. This common process usually occurs outside the patient's conscious awareness.
Engel and others have used the term psychogenic pain to describe pain grossly out of proportion to underlying organic pathology.6 The term is a particularly useful one because it suggests that the genesis of the pain is psychological. Unfortunately, the term was abandoned in the DSM-IU-R for the term somatoform pain. This newer term suggests that the pain has some characteristics of physical pain but neglects the question of etiology. Rumor has it that DSM-IV may introduce yet another term - idiopathic pain. The term psychogenic pain has been used more extensively than any other term and, from a dynamic standpoint, seems most appropriate. In this article, the reader may choose to substitute psychogenic pain wherever the term somatoform pain is used. It is important to remember that somatization frequently coexists with organic pathology. The pitfall of either/or thinking should be avoided. Somatic preoccupation and hypochondriacal concerns associated with depressive and anxiety spectrum illnesses represent somatization over and above any organic pathology that may be present.
Somatoform pain and depression frequently coexist. Although in some instances the concomitant mood disorder fully meets diagnostic criteria for depression, in many instances it does not. Engel, Blumer, Lipowski, and others point out that psychogenic pain can be a manifestation of depressive illness.5"7 In some cases the mood disorder, if present at all, is marked only by subtle indicators such as hypochondriacal concern, disturbed sleep, irritability, or diminished libido. It is well known that depression lowers the pain threshold. In effect, the depressed individual perceives the common aches and pains of daily living as incapacitating. Patients who experience somatoform pain and depression invariably believe that the somatoform pain caused the depression. The reasoning is post hoc ergo propter hoc (ie, the depression became apparent after the somatization therefore it was caused by the somatization). It must be underscored that chronic pain is more likely to be the initial manifestation of depression than the cause of depression.
Somatization may follow a relatively trivial injury after which the patient suffers ongoing and frequently proliferating symptoms. The patient may prove refractory to virtually every medication and treatment modality and may even feel worse with the passage of time. Somatizing patients become increasingly passive and dependent, and they may assume a victim role. They are prone to abuse alcohol and prescription narcotic analgesics. Many such patients had been particularly hard-working prior to injury. A careful developmental history usually reveals that in one way or another these patients were emotionally short-changed during their formative years. Parental fighting, absence, divorce, substance abuse, death, or other emotional abandonment is the norm for somatizhig patients. A history of childhood physical abuse or of sexual molestation is not unusual. Identification with a significant figure, especially a parent, spouse, or sibling who has suffered from chronic pain or hypochondriacal problems is an important underlying and often precipitating somatization (S. Southwick, MD, personal communication. May 1990).
The hard work and early achievement of these individuals (many of whom shouldered major family responsibilities as adolescents) is best understood as a reaction formation, defending against unmet, underlying, and unconscious dependency. A careful concurrent psychosocial history parallel to the history of work injury is necessary to uncover the psychosocial Stressors fueling the somatization. Individuals who somatize usually do not understand the role of psychosocial Stressors in the clinical picture and will often comment, "I don't see what my ( . . . divorce. . . children leaving the nest. . . parent's death) has to do with my back pain." Trivial physical injury becomes a focus onto which the (largely unconscious) emotional pain is grafted. Sometunes a patient will become tearful while describing extremely emotional material. The tears should be understood as a clue to understanding the underlying dynamics and ultimately to helping the patient.
Physicians must ever be mindful that a large subset of patients perceive and communicate emotional distress in somatic, rather than in psychological, terms. These individuals are minimally, if at all, aware of emotional distress. Constrained affect is a precursor to somatoform pain and depression. Individuals who are insensitive to, cannot acknowledge, or describe their feelings typically are convinced that their problems are totally physical. The conviction is of delusional proportion. Wellintentioned physicians, concerned lest they miss an important organic diagnosis, and often not suspecting that the pertinent diagnosis is a psychiatric one, frequently subject these patients to numerous, sometimes repetitive, and invariably costly diagnostic tests and medical treatments, including, at times, major surgery. Obscure, ill-defined or far-fetched diagnoses of frustration may lead the unwary on a wild goose chase (D. King, MD, personal communication. January 1985).
The very moment that the possibility of functional overlay is considered, the patient should be afforded the benefits of psychiatric and psychodiagnostic evaluation. The sooner this happens the better, for the longer the injured worker remains out of work, the less the likelihood that he or she will return to gainful employment. Prompt recognition and timely treatment of emotional disorders reflect good medical care, as well as being cost effective. An informed and wellreasoned opinion about causation should be possible following consideration of all available data and after comprehensive physical, psychiatric, and psychodiagnostic evaluations. Although serious physical illness may fuel depressive spectrum symptoms, it is important to recognize that a somatoform pain disorder is for more likely a manifestation of, rather than a cause of, depression. The somatizing patient may not recognize the depression because of repression and denial.
IMPAIRMENT OF FUNCTION AND DISABILITY
The assessment of impaired physical function in individuals with chronic pain but few, if any, medically documented findings to explain the pain on a physical basis is difficult. Such individuals do not qualiiy for disability under the present Social Security program. Workers' compensation varies from state to state. Impairment of function should be assessed when the patient has reached permanent and stationary status.
The functional impairment of patients with Axis I and Axis II diagnoses should be documented in terms of Enelow's eight work functions (see "Psychiatric Disorders and Work Function" by A. Enelow, MD, pp 27-35). The disability should not be described in terms of capacity for lifting, bending, stooping, pulling, climbing, or other activities involving comparable physical effort. It is irrational to attempt to describe physical impairment of function, much less disability, in the absence of objective physical dysfunction when concurrent somatization or some other psychological condition is responsible for physical complaints. Psychiatric disorders, when present, should be diagnosed. When such conditions have reached a permanent and stationary status, they should be rated in terms of Enelow's eight work functions.
The evaluation of pain in the injured worker involves determining a diagnosis, establishing causation, and describing impairment of function. Pain may be a manifestation of atypical or occult depression. Patient history, examination, and psychodiagnostic assessment are crucial in establishing accurate diagnoses and in determining causation. Some pitfalls in this process have been identified. Impairment of function in patients who have reached permanent and stationary status is best accomplished using Enelow's eight work functions.
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