Indian Write-Ups

Chronic pain is an ancient and puzzling phenomenon. Considerable advances have been made in the pharmacological management of acute pain but it remains the case that many patients with long-term painful disorders are helped only minimally by current medical and surgical methods.

The world pain is derived from the Latin word “poena” meaning “penalty” or “punishment”. In the past, pain was viewed as a punishment inflicted by God for the sins committed by the sufferer. The International Association for the Study of Pain (IASP) has adopted the following definition. “ Pain is an unpleasant sensory and emotional experience which we associate with tissue damage or describe in terms of tissue damage” (France & Keefe 1985)

The “Gate –Control Theory” (Melzack and Wall 1965, Melzack 1983) suggests that the cells in the substantia gelatinosa have a capacity to modulate the transmission of painful stimuli, either heightening or inhibiting them. Where a tissue lesion gives evidence for ascending painful stimuli, the presence of anxiety or depression can cause descending impulses to “widen” the gate, disinhibiting transmission that is then experienced as an increased sensation of pain. This provides a model of pain in which psychological factors such as attention, distraction, mood, expectation, memory and personality are given a credible role.

Chronic Pain and Psychiatry

Varma et al (1983) from Chandigarh have studied 2,000 consecutive new cases with chronic intractable pain. One fifth of the cases reported pain in the extremities and another 13 per cent pain all over the body as their main presenting symptom. In 50 percent of the patients, no physical illness could be detected by treating physicians (non-physchiatric consultants); in another 21 percent of cases physical illnesses (arthopathies, arthritis or spondylosis) were not considered to be sufficient to explain the pain by treating specialists doctors. 72 per cent of these cases had identifiable psychiatric illnesses, the most common being depressive disorders and anxiety disorders.

The psychiactric problems in association with chronic pain are numerous. The commonest association is with depressive disorders where pain has been reported as a frequent symptom (Gada 1980). Various authors have reported pain as a symptoms in 56 to 70 per cent of patients with depressive disorders. Large (1980) reported that the majority of his pain-clinic patients, had depressive disorders.

Gada (1987), has reported generalized bodyache to be a part of depressive disorder. 84 percent of his cases reported bodyache, 75 percent had backache and 79 percent had sensations of tingling and numbness in the extremities. Vijay et al. (1988) from Bangalore, have reported that 40 per cent of patients attending the orthopaedic outpatient department of a general hospital had recognizable psychiatric disorders requiring psychiatric treatment.

Vicious Circle

Pain leads to anxiety in patients. The anxiety is associated with the release of stress hormones and other biochemical changes. This leads to spasm of muscles which increases the pain. Thus a vicious circle of pain – anxiety – spasm – pain is established.

Clinical Observations

In certain patients, the influence of psycho-social factors is profound and treatment aimed at modifying their influence is likely to be of greatest benefit.

Many patients learn to adopt a chronic pain life-style because they find it highly reinforcing psychologically. Spouse and family members become quite anxious and take over many responsibilities for these patients. Some patients find the increased attention, and avoidance of unwanted home and work responsibilities and family/marital conflicts highly reinforcing. These patients may enter a chronic pain stage in which their pain complaints are controlled primarily by their positive social and environmental consequences.

Typically, patients with chronic pain have a history of multiple contacts with physicians for diagnosis and treatment, a long serious of treatment failures, significant social and economic problems and an altered life-style

The patients are asked to rate their pain at regular intervals using a six-point scale as given above.

Patients are also asked to note the psychological events which precede pain. The events which are psychologically disturbing to the patients act as precipitating and/or aggravating factors. Some of such psychologically disturbing negative events are material and/or social conflicts, loss in business, children not doing well, expectations not being fulfilled, negative remarks by other etc.

Case Study

A middle-aged patient working in a nationalized bank has had headaches during the course the last seven years. The pain initially was intermittent, coming in episodes, usually in the evening and was relieved with analgesics. Later, she developed pain in the neck and the back, mainly in the shoulder region and in and around the breasts. Of late the pain was continuous and was not relieved by analgesics. During this period, she had consulted many physicians, neurologists and orthopaedic surgeons. She was investigated thoroughly, including CAT Scan and Magnetic Resonance Imaging (M.R.I). Due to the pain and suffering, she had taken leave from work for about six months in the last three years (one can imagine the cost of investigations and suffering to the patient and her family). Lastly the neurologist referred the patient for psychiatric evaluation.

Initially she wondered why she had been referred to a psychiatrist as she had no “tensions” in life. She reported that she was happily married, with a husband who was working and had no bad habits and had three children who were doing well in their studies. There was no financial worries as she, in addition to her husband, was working. The detailed history and psychotherapeutic sessions revealed the following factors.

She was not able to decide whether to continue working in the bank as she was finding the work too much for her. The pain would increase whenever the work-load in the bank would increase. By resigning from her job, the family would lose the income. Unconsciously she had solved the problem by developing pain and then not attending work. Due to the disease (pain) she would even get sympathy from her husband and colleagues in the bank (secondary gain). She was always worried about others’ opinions about her. Due to this aspect of personality, in many instance she would avoid taking decisions, particularly decisions which would displease others. Such neurotic conflicts were solved by pain and then saying “no” by body language, while simultaneously gaining sympathy.

She would not go out on Sundays and other holidays on the pretext that her widowed mother-in-law would be alone at home. On her working days the mother-in-law was always alone as her husband would go to work and the children would be at school. She herself had volunteered the information that her mother-in-law had told to her ‘enjoy life’. Other relatives would relatives would praise her for looking after the house and mother-in-law on Sundays. This had resulted in yet another neurotic conflict.

During psychotherapy, the above conflicts were discussed with her and her husband. Initial resistance gave way and she slowly changed her attitude. Her husband helped her to take decisions in a proper perspective and unpleasant decisions were expressed properly. She started going out to enjoy and to relax herself. With drug therapy she became symptom-free within six weeks. By six months, she had changed her attitude and the medicine could be stopped without any recurrence of pain.

Treatment

General Principles

Engel has emphasized that the key to success lay in investigating the manner in which pain disrupted the patient’s personal, social, family and occupational life thus avoiding an artificial separation between what are regarded as organic, psychological and social factors. An interview with a spouse or relative should provide information about interpersonal pain behavior and the social-reward system. A central task in evaluation and pretreatment planning is to help patients redefine their problem in a manner that ends the investigation without challenging the reality of the pain and that shifts the emphasis from a curative to a rehabilitative approach. Implicit in this change is a transfer of responsibility from physician to patient.