Chronic Pain and Psychiatric Illness: Managing Comorbid Conditions: Pay Close Attention to Risk and Benefit When Planning Pain Management

By Stayner, R. Scott; Ramezani, Amir et al. | Current Psychiatry, February 2016 | Go to article overview

Chronic Pain and Psychiatric Illness: Managing Comorbid Conditions: Pay Close Attention to Risk and Benefit When Planning Pain Management


Stayner, R. Scott, Ramezani, Amir, Prasad, Ravi, Mahajan, Gagan, Current Psychiatry


Pain is one of the most common symptoms for which patients seek medical care, with an associated estimated annual cost of $600 billion. (1) Using a multimodal approach to care--thorough evaluation, cognitive-behavioral and psychophysiological therapy, physical therapy, medications, and other interventions--can help patients effectively manage their condition and achieve healthier outcomes.

Evaluating a patient with pain

When developing a safe, comprehensive, and effective treatment plan for patients with chronic pain, first perform a thorough history and physical exam using the following elements:

Pain history. The PQRST mnemonic (Table 2, page 28) can help you obtain critical information and assist in determining the appropriate diagnosis and cause of the patient's pain complaints.

Psychiatric history. Document the mental health history of the patient and first-degree relatives.

Medical history. Knowing the medical history could reveal comorbidities contributing to a patient's pain complaint.

Treatment history. Listing past and current treatments for pain, including effectiveness, helps the clinician understand if an existing treatment plan should be modified.

Functional status. Document current level of daily activity, how life activities are affected by pain; strategies used to help cope with pain; level of physical and emotional support provided in home, work, and school environments; and active stressors (eg, financial, interpersonal).

Psychosocial history. Document historical information related to coping skills, trauma history, family of origin, abuse, interpersonal relationships, social support, and academic and vocational functioning.

Substance use or abuse. Assess for use of controlled substances (ie, early refills; lost medications; obtaining medications from multiple prescribers, friends, families, or strangers; use of prescribed and nonprescribed medications for non-medical and medical purposes), nicotine, alcohol, illicit substances, and caffeine. A thorough inventory can help to identify substances a patient is using that could affect daily functioning and pain level.

Behavioral observations. Assessing mental status (eg, insight, pain behavior, cooperation) can be useful. Paying attention to pain behaviors, such as complaints of pain, decreased activity, increased medication intake, or altered facial expressions or body posture, can help the clinician gain insight to the extent that pain affects the patient's quality of life.

The information gathered in the patient evaluation can be used to design a multimodal treatment plan to achieve maximum effectiveness.

Assessing psychiatric illness

Current approaches to pain evaluation and treatment recommend use of a biopsychosocial orientation because psychological, behavioral, and social factors can influence the experience and impact of pain, regardless of the primary cause. (2) A comprehensive psychiatric evaluation, diagnosis, and treatment plan should consider the broader context in which a patient's pain occurs.

Regarding psychiatric illness, past and current symptoms, treatment history, and risk assessment should all be included. Using the "AMPS approach" (Figure (3)--assessing Anxiety, Mood (depression and mania), Psychotic symptoms (paranoid ideation and hallucinations), and Substance use--helps screen for comorbid psychiatric conditions in patients with chronic pain.

Sleep assessment

Chronic pain patients often experience significant sleep disturbance that could be caused by physiological aspects of the pain condition, environmental factors (eg, uncomfortable bedding), a comorbid sleep disorder (eg, sleep apnea), a psychiatric disorder, or a combination of the above.

Obstructive and central sleep apnea are characterized by nighttime hypoxia, which leads to frequent disruption of the sleep-wake cycle and often manifests as daytime fatigue, irritability, depression, drowsiness, headaches, and increased pain sensitivity. …

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