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. . . Chronic P A favorite buzzword in rehabilitation medicine is “Chronic Pain Syndrome.” I call it a buzzword because it is not really a diagnosis, either in medicine’s ICD-9-CM or in psychiatry’s DSM-III. When many patients dispIay a similar pattern of symptoms, it is fashionable for a doctor to publish an article “discovering” the pattern, describing it and affixing a name to it, preferably his own. Well versed in Syndromese, doctors understand one another well enough when talking of chronic pain. They do not always make themselves clear to others. What they mean by “Chronic Pain Syndrome" is how their patients behave when healing does not progress at the expected rate. “What is meant by ‘Chronic Pain Syndrome' is how patients behave when healing does not progress at the expected rate.” Pain is best understood as a warning to its sufferer, and as a complaint from them. The warning is to guard the afflicted anatomy, to restrict its use and to guard against further trauma. When pain is brought to the attention of others, the process is called complaint, couched in verbal as well as body language. The complaint is meant to alter the situation of the afflicted person, to attract remedial attention, and in some cultures, to restrict obligations. In our culture, pain is recognized as a legitimate reason to limit activities, and is therefore accepted as disabling. Physical pain is perhaps neurologically connected with our sense of time, so that we automatically expect change and eventual relief. Not so with the emotions? When we are in love or depressed, it is always forever. (No wonder that we are so predisposed to impulsive marriage or suicide.) Perhaps this is why unremitting pain so often leads to depression, demoralization and apathy. Usually, when referring to chronic Pain Syndrome, we mean simply that one has come to regard themselves as disabled because of chronic pain, which becomes the central focus of their life. They usually becomes quite depressed as well, giving up many activities and becoming more dependent upon others. The syndrome includes all official diagnostic categories, with or without anatomical injury. When an individual who is unaccustomed to emotional ex- pression becomes depressed, he may not have the words in his lexicon of complaint to express himself properly. Instead, he will seek relief or attention through complaining about his physical pain. This is the plight of many patients with Chronic Pain Syndrome said to be showing “func- "Psychogenic Pain disorders are like buzzsaw wounds, in which one tooth of the saw is injured" tional overlay.” Once anatomically healed, they retain their welllearned physical complaints, attempting to remedy a painful emotion or affect. Emotional response may be due just as much to loss of function, money or relationships as to exhaustion with physical pain. Unfortunately, the complaint is usually misread. One is reminded of the drunk found on his knees under the street lamp, looking for his keys, which he dropped in the bushes. It is easier to look where the light is better. It is the “alexithymic” (literally, “no words for feelings’) in- . dividual who is supposed to be most as risk for somatization or chronic pain. When chronic pain lacks an anatomic or physiologic basis, we sometimes invoke the diagnosis of Psychogenic Pain Disorder. This is one of psychiatry’s Somatizing Disorders. It is an absolute stickler for insurors because of the peculiar nature of its "casuality". In order for a condition to be called Psychogenic Pain Disorder, (the physical pain version of Conversion Disorder) there must be a precipitating stress, such as an injury. There must also be an internal conflict, expressed in the symptom. The latter is always a personal or biographical issue, usually with no connection at all to the stressor, except temporal coincidence. Psychogenic Pain disorders are like buzzsaw wounds, in which one tooth of the saw is injured. There is probably no single strategy for getting a chronic pain patient back to work. Most studies indicate that the only significant variable is time; the longer off work, the less the liklihood of return. Financial incentives may not make too much difference. Most pain patients point to their financial losses as their most depressing problem, but the hardship does not motivate them to endure more pain. Usually, careful inquiry will reveal that they have no hope of returning to their former earning capacity. I suspect that this factor may be most crucial for motivation, so that a patient’s hopelessness must be carefully explored for its basis in reality. One approach to the treatment of chronic pain is the Pain Clinic, which actually combines . I all treatments into an intensive course, the goal of which is to terminate treatment. The idea is that by teaching the patient enough about tolerating pain through relaxation, pacing, stress reduction and anger management, the need for further medical palliation may be lessened. This works well for those who actually want less treatment, but poorly for those whose hidden agendas include being taken care of by family and physician, or who secretly expect that the clinic will actually end their pain. Some clinics emphasize recognition and acceptance of limits, pacing of activities and reordering of lifestyle. Others try to divert attention away from pain, by ignoring complaints and rewarding other behavior. This is sometimes referred to as "stepover therapy”, as one might causally step over someone who has dramatically flung himself upon the floor in agony It is sometimes the only effective intervention with dependent individuals, who then return to work complaining about how useless the program was. Joseph Dubey, M.D. Psychiatrist @ 1989 DUBEY OBJECTIVE MEDICAL ASSESSMENTS