Psychiatry and Chronic Pain Patterns

Clinical Psychiatry News, June 2008 | Go to article overview

Psychiatry and Chronic Pain Patterns


As a psychiatrist known for using behavioral techniques as well as a variety of relaxation therapies, I was not surprised when, a number of years ago, orthopedic surgeons and neurosurgeons started referring their chronic pain patients to me. These surgeons had been consulted for chronic pain problems and were unable, in many cases, to offer either a surgical or medical approach to treatment.

My observations led me to write a paper for an orthopedic journal addressing some of the chronic pain problems experienced by our patients (Foot Ankle 1986;7:133-7).

Many of the patients referred to me had chronic pain patterns that were musculoskeletal--the pain apparently stemmed from soft tissue and muscle fibers. Today, we refer to these pain patterns as fibromyalgia.

Current research relates fibromyalgia more to stress dysregulation within the central nervous system, involving the hypothalamic-pituitary-adrenal axis as it affects autonomic regulation. The American College of Rheumatology (ACR) is actively involved in understanding and treating this disorder. Plus, it developed diagnostic criteria for fibromyalgia in 1990 (Arthritis Rheum. 1990;33:160-72).

In my 1986 paper, I divided patients suffering from chronic pain patterns into three categories:

* Those patients whose complaints were psychological, and their musculoskeletal system was responding to some emotional stress.

* Those whose complaints were psychological/physiological and had an injury or illness providing a focus for an emotional stressor to localize a pain pattern as an Achilles heel phenomenon.

* Those whose complaints were physiological, and the pain pattern was injury/illness related with no intervening emotional factors.

This construct still provides a valid way of thinking about musculoskeletal pain patients who appear to be in search of relief from their suffering. Years ago, orthopedic surgeons and neurosurgeons said that these patients had some form or other of fibromyositis--which often tended to be linked to some emotional stress, as they put it. Some would say that "it's all in the head."

I don't know if that's the case or not, but there did seem to be an emotional overlay in many of these patients. Does that suggest that these syndromes are psychogenic in origin and need psychological intervention?

Whether there is an emotional connection and a possible need for psychological intervention are good questions. Certainly, the use of antidepressants, especially the tricyclics, have a beneficial effect on the chronic pain patterns. Anticonvulsants have been used off label to achieve the same results, and last year, the Food and Drug Administration approved pregabalin (Lyrica) as the first drug for treating fibromyalgia. Lyrica is a medication not too different from gabapentin (Neurontin), an anticonvulsant often used to control mood, anxiety, and pain.

Should these patients undergo Freudian analysis to control their pain, or would cognitive-behavioral therapy do the trick?

Although fibromyalgia is not a psychiatric illness, it does not preclude using psychiatric/psychological techniques to alleviate some of the pain and suffering these patients experience. Numerous approaches exist to treating patients with mind/body problems, including chronic pain. For me, the two that worked best after medicinal therapy failed or was only partly effective were the use of relaxation/desensitization and rapid learning based interpretive psychotherapy to help connect the dots in the genesis of the stress-related physical problem. …

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