PSYCHOLOGICAL ASPECTS OF CHRONIC PAIN
Depression: The patient presenting with pain must be closely observed for a flat affect, early morning wakening and emotional lability. Suicidal ideation trust should be asked about. If severe depression or suicidal ideation is present, referral to a psychiatrist must be sought immediately. Depression can mimic chronic pain or can be present secondarily to chronic pain. The difference is often difficult to determine even for a psychiatrist or psychologist.
Functional Disability: Questions regarding how the pain has affected the individual's function, both socially and at work, should be asked. A person who is not working because of pain, or is socially withdrawn because of pain, will often exhibit marked pain behaviors (see below) indicating poor coping skills. It is often not the pain that disables a person but how he or she decides to function with it.
Non-organic Signs: Waddell (a Scottish orthopedic surgeon) developed his "non-organic signs for low back pain" to identify those patients in whom physical treatment, such as surgery or physical therapy, was likely to have poor results. He identified axial rotation, twisting the patient's torso via the hips and not the back and axial pressure, pushing gently down on the patient's head to see if pain is recreated in the low back area as signs of exaggerated behavior. His other signs include: distraction causing an alteration in physical signs; a non-anatomical distribution of the pain; and exaggerated signs or pain behaviors. Three or more signs he described as being indicative of a "psychogenic cry for help." Surgery, even when "technically successful" in this group was often unsuccessful in decreasing pain. These signs should always be looked for when examining the low back. There are other non-organic signs which have been described for other body areas.
Pain Behaviors: Pain behaviors include grimacing, sighing, verbalizing, visibly guarding muscles and rubbing of the painful area. These are done on a frequent basis. While this is understandable with acute pain for the chronic pain individual it often indicates poor coping skills and, if not a conscious, it may be an unconscious request for compassion and secondary gain.
TREATMENT : PSYCHOLOGICAL ASPECTS
Antidepressants: The role of tricyclic antidepressants (amitriptyline, nortriptyline, imipramine) in chronic pain is well documented. By their action on the serotonin, norepinephrine, dopamine, and alpha-1 receptors, they appear to have more of an analgesic effect than the newer serotonergic specific re-uptake inhibitors. Amitriptyline or nortriptyline is useful as a sedative medication if the patient has sleep difficulty. It is given at 10 or 25 mg qhs, depending on the age of the individual. It can be titrated up every three days until adequate sleep is achieved. If the dry mouth is a significant problem, methyl cellulose mouth sprays can be prescribed, or the patient can be instructed to chew gum. Once a dose of 100 mg nortriptyline or amitriptyline has been reached, without sleep or pain improvement, a drug blood level should be taken. Based on this level the dose should be increased to antidepressant range and maintained for one month. The absorption pharmacodynamics of both drugs are linear making calculation of therapeutic levels easy so further drug levels are unnecessary. If after a month there is no improvement in the patient's pain, the medication should be stopped.
Amitriptyline may re-set the brain center that governs body size. If the patient starts putting on weight, the medication should be changed or a permanent weight gain may occur. Nortriptyline appears less likely to cause this problem The patient should be closely monitored if being treated for depression and a referral to a psychiatrist made if the patient has suicidal ideation or no improvement occurs in their mental status.
Coping Skills: There are many tapes of relaxation and stress management techniques available. If the individual can relax his or her muscles effectively, the pain is often reduced. A psychologist trained in pain management can be very effective in teaching coping skills training in dealing with environmental stressors. Biofeedback is useful in teaching the individual to relax if this is a problem.
Exercise: General exercise should always be encouraged. This can be walking, swimming or bicycling. Aerobic type exercise, as well as improving the patient's function and health, gives the individual an important coping mechanism for dealing with their pain. Specific stretching exercises for the individuals pain problem should be given. Advice on exercise can be as simple as parking at one end of the car park and walking further to the shop, or walking up two to three flights of stairs before taking the elevator higher. Taking on the responsibility of regular aerobic exercise has the added benefit of improving self-esteem.
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