Indian Write-Ups

Psychotropic Medication

Approximately 60 to 80 percent of patients with chronic pain benefit to some degree from treatment with tricyclic antidepressant medication (imipramine, dothiepin, amitryptiline). Different studies report benefit in pain unrelated to antidepressant effect. Antidepressant medication is effective as an analgesic and also potential the effects of other analgesics.

Psychological Interventions

Psychological interventions are necessary to influence the patients perception or tolerance of pain.

Contigency Management / Operant Methods

Whatever the underlying cause of the pain problem, Fordyce (1976) considers that pain-behaviors such as complaining of pain, inactivity or taking medication may be maintained by their reinforcing consequences.

The aim of operant programmes is to increase the frequency of well-behaviour and decrease that of pain-behaviours. The family members give no attention to pain behaviour but provide considerable social reinforcement for targeting well behaviours. Every day the quota of physical activity is increased. The progress as part of physical therapy programme, is charted graphically. Reducing the level of medication is also an important aim of operant programmes.

Cognitive Therapies

Cognitive therapy techniques comprise various methods by which individuals learn to distract or distance themselves from their pain. Relaxation techniques and visual imagery are used to redefine the experience of pain or replace it with more pleasant thoughts or sensations.

Relaxation Techniques

Relaxation training (meditation, yoga, Jabobson’s techniques, hypnosis etc) has been widely used in the treatment of chronic pain. It has produced encouraging results in tension headache, migraine, low backpain etc.

Biofeedback

A range of biofeedback techniques (EMG, skin-temperature EEG) have been applied to chronic-pain patients with good results (Gada 1984).

Assertive Training

Patients with chronic pain often lack the ability to assert themselves to get their needs met.

Assertive training and role playing are methods used to help patients express their needs more directly. Then also need training in developing communication skills. (As in the above case)

Role of Family Members

Family members will need to change their reactions to the patient’s pain complaints and this is likely to require considerable attention in the home environment and change in patterns of interaction. Family members require the simultaneous avoidance of excessive caretaking or overdirection with the promotion of autonomy by firmly and consistently placing responsibility on the patient for effort, persistence and progress towards treatment goals. This must be accomplished in a manner that recognizes and respects the subjective reality of the patient’s suffering but that resists the natural tendency of family members to assume control or cure the problem. Spouse and family members should help the patient to resume increasingly the previous level of functioning in spite of the pain. With attitudinal change in the spouse and family members the secondary gain is ‘avoided’ and the progress in the therapy is achieved rapidly.

All the above therapies are tailored to the need of the individual patient. The type of the therapy is also decided depending upon the need of the patient. More than one type of therapy may also be needed.

Conclusion

• Chronic pain is clearly a major problem in terms of incidence and cost. Headache, low back pain and pain secondary to arthritis or cancer are among the leading medical disorders in terms of cost for hospitalization and visits to the physician’s office
• In evaluating and treating persistent pain, the physician should realize that pain is not a simple stimulus response reaction. Rather, the perception that pain is multifactorial, combining many bio-psychosocial variables.
• Multiple aetological factors (especially biological, behavioural and psychological aspects) need to be considered routinely. Medical and surgical specialists and primary care physicians increasingly recognize the importance of behavioural and psychiatric approaches in the routine management of chronic-pain patients. There is a growing consensus that psychiatrists (and behavioural specialists) need to be involved from the start of treatment even in those patients who have clear tissue pathology basis for their pain.