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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-
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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
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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