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Components of the chronic pain syndrome consist of anatomic changes, chronic anxiety and depression, anger, and changed lifestyle Usually, the anatomic problem is irreversible, since it has already been subjected to many interventions with increasingly unsatisfactory results An algorithm for assessing chronic pain and differentiating it from other psychiatric conditions is illustrated in Figure 25 1 Chronic anxiety and depression produce heightened irritability and overreaction to stimuli A marked decrease in pain threshold is apparent This pattern develops into a hypochondriacal preoccupation with the body and a constant need for reassurance The pressure on the clinician becomes wearing and often leads to covert rejection of the patient, such as not being available or making referrals to other clinicians This is perceived by the patient, who then intensifies the effort to find help, and the typical cycle is repeated Anxiety and depression are seldom discussed, almost as if there is a tacit agreement not to deal with these issues

Yes Is the motivation for the behavior apparent to the clinician Is the motivation for the behavior to assume the patient role

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Psychiatric evaluation for diagnosis of comorbid psychiatric disorders: Depression Panic or anxiety Posttraumatic stress disorder

Psychiatric treatment (concurrently with medical treatment)

Abnormal illness behaviors with symptoms produced unconsciously: Somatization disorder Hypochondriasis Pain disorder with psychological factors

Figure 25 1 Algorithm for assessing psychiatric component of chronic pain (Adapted and reproduced, with permission, from Eisendrath SJ Psychiatric aspects of chronic pain Neurology 1995 Dec;45(12 Suppl 9):S26 34)

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A single clinician in charge of the comprehensive treatment approach is the highest priority Consultations as indicated and technical procedures done by others are appropriate, but the care of the patient should remain in the hands of the primary clinician Referrals should not be allowed to raise the patient s hopes unrealistically or to become a way for the clinician to reject the case The attitude of the doctor should be one of honesty, interest, and hopefulness not for a cure but for control of pain and improved function If the patient manifests opioid addiction, detoxification may be an early treatment goal Nonsteroidal anti-inflammatory drugs are often the firstline of treatment for pain If opioid analgesics or sedatives are prescribed, they should not be given on an as-needed schedule (see 5) A fixed schedule lessens the conditioning effects of these drugs Tricyclic antidepressants (TCAs) (eg, nortriptyline) and venlafaxine in doses up to those used in depression may be helpful, particularly in neuropathic pain syndromes In other conditions, their effects

on pain may be less clear, but ameliorating depression is usually important nonetheless Gabapentin, an anticonvulsant with possible applications in the treatment of anxiety disorders, has been shown to be useful in postherpetic and diabetic neuropathy and somatoform disorders In addition to medications, a variety of alternative strategies may be offered, including physical therapy and acupuncture

Involvement of family members and other significant persons in the patient s life should be an early priority The best efforts of both patient and therapists can be unwittingly sabotaged by other persons who may feel that they are helping the patient They frequently tend to reinforce the negative aspects of the chronic pain disorder The patient becomes more dependent and less active, and the pain syndrome becomes an immutable way of life The more destructive pain behaviors described by many experts in chronic pain disorders are the results of well-meaning but

8:

misguided efforts of family members Ongoing therapy with the family can be helpful in the early identification and elimination of these behavior patterns

In addition to group therapy with family members and others, groups of patients can be helpful if properly led The major goal, whether of individual or group therapy, is to gain patient involvement A group can be a powerful instrument for achieving this goal, with the development of group loyalties and cooperation People will frequently make efforts with group encouragement that they would never make alone Individual therapy should be directed toward strengthening existing coping mechanisms and improving self-esteem For example, teaching patients to challenge expectations induced by chronic pain may lead to improved functioning As an illustration, many chronic pain patients, making assumptions more derived from acute injuries, incorrectly believe they will damage themselves by attempting to function The rapport between patient and clinician, as in all psychotherapeutic efforts, is the major factor in therapeutic success

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