With most chronic pain conditions, the exact pathology is uncertain. In such cases, psychiatrists may be called to assess for illness beyond medical diagnosis.
With most chronic pain conditions, the exact pathology is uncertain. In such cases, psychiatrists may be called to assess for illness beyond medical diagnosis. Scroll through the slides for 10 factors associated with pain when findings are inconclusive. For the Special Report on pain, see October 2020 issue of Psychiatric Times. (coming soon)
In general, pain resolves on its own with little need for intervention. However, when pain persists past the point of adaptive reaction to injury, it is important to note patients may experience an inability to engage in reinforcing activities that may contribute to increased isolation, feelings of worthlessness, and depressed mood. There may be a pathological explanation for a known physical complaint; but the intensity and duration of pain following such a clear pathological event may be well in excess of what is expected. Somatoform pain is not a discrete entity.
Chronic pain frequently leads to depression and anxiety. In some instances, the mood changes that result are a reaction to the alteration in function and life choices that can occur because of difficulties in coping with the disability. In other cases, the development of chronic pain is associated with reduced activity, which reinforces pain and introduces health hazards such as obesity. On the other hand, a psychiatric disorder in itself renders a person more prone to chronic pain.
While stress increases the perception of pain and people from psychosocially disadvantaged backgrounds are more prone to exhibit increased pain, this is not the only explanation for this finding. Psychiatric diagnoses are influenced considerably by the knowledge and attitude of the observer. A diagnosis of non-organic pain is more likely to be made in patients who have no evidence of a medical disorder but who have experienced severe psychosocial stress.
Pain is frightening and when experienced can be either confronted or avoided. Confrontation leads to resolution, whereas avoidance maintains the experience of pain. Pain avoidance arises in persons exposed to unpleasant events at the time of developing pain and is amplified by depression and anxiety sensitivity.Excessive attention to stimuli associated with pain, increased guarding, and reduced physical activity result.
There are many reasons for symptom amplification. Complaints of chest or abdominal pain are the most frequent symptoms in this group, but their nature depends on social and environmental factors. It is essential to collect as much information as possible about past illnesses, their nature, and the treatment sought and given. Previous medical records and observations by others are revealing.
Exaggeration on the part of patients who deliberately feign illness and who have an active wish to be treated as if they are ill are said to have factitious disorder.
Feigned symptoms, can be prompted by motivations to avoid responsibilities, such as military duty, work, and criminal prosecution, as well as to gain financial compensation or garner drugs. Both malingering and factitious disorders involve the person using conscious deceit to obtain a perceived benefit. However, the only clear dividing line between malingering and symptom exaggeration in situations in which there is an attractive goal is whether the exhibition of symptoms is conscious. Patients often try to deceive, and there is a continuum between exaggeration and malingering.
There are chronic pain syndromes in which the pathology appears to be insufficient to explain the symptoms. An example is complex regional pain syndrome, which is characterized by constant regional neuropathic pain. Diagnosis relies almost exclusively on clinical assessment, although in advanced cases trophic changes to the skin and loss of bone density occur. Most clinicians consider this syndrome to be caused by sensory nerve damage, in some cases arising from dysfunctional sympathetic nerve function; however, others believe that it results from inadequate assessment of psychosocial difficulties. This disagreement exemplifies the difficulty in making a confident diagnosis when there are only symptoms but no pathognomonic signs.
Pain rarely results from a conversion disorder in which a psychological conflict is converted into a physical symptom. Unlike malingering, these pain complaints are neither conscious nor intentional. This is regarded by many as true psychogenic pain. Pain that is amplified by anxiety or depression is not usually termed psychogenic pain, although sometimes this term is used in this context inaccurately.
Pain that arises as a result of psychotic beliefs has been recorded but is extremely rare. The classic example is of a patient who believed that he was Jesus Christ and was passing the 14 stations of the cross on the way to crucifixion. He complained of a headache that was situated over his scalp in a circular distribution, in the region where the crown of thorns would have been placed. Patients with auditory hallucinations very occasionally complain of ear pain. A number of patients with medically unexplained physical symptoms have minor pathological conditions, perceive illness differently, and sometimes have had distressing illnesses in the past.