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Clinical Manual of

Pain Management

in Psychiatry

This page intentionally left blank

Washington, DC

London, England

Clinical Manual of

Pain Management

in Psychiatry

Raphael J. Leo, M.D.

Associate Professor, State University of New York at Buffalo

School of Medicine and Biomedical Sciences;

Department of Psychiatry and

Center for Comprehensive Multidisciplinary Pain Management

Erie County Medical Center

Buffalo, New York

Note: The authors have worked to ensure that all information in this book is accurate

at the time of publication and consistent with general psychiatric and medical standards,

and that information concerning drug dosages, schedules, and routes of administration

is accurate at the time of publication and consistent with standards set by the U.S.

Food and Drug Administration and the general medical community. As medical

research and practice continue to advance, however, therapeutic standards may change.

Moreover, specific situations may require a specific therapeutic response not included

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Copyright © 2007 American Psychiatric Publishing, Inc.

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Library of Congress Cataloging-in-Publication Data

Leo, Raphael J., 1962–

Clinical manual of pain management in psychiatry / by Raphael J. Leo.—1st ed.

p. ; cm.

Includes bibliographical references and index.

ISBN 978-1-58562-275-7 (pbk. : alk. paper)

1. Pain—Treatment—Handbooks, manuals, etc. 2. Pain—Psychological aspects—

Handbooks, manuals, etc. 3. Psychotherapy—Handbooks, manuals, etc. 4. Chronic

pain—Handbooks, manuals, etc. I. Title.

[DNLM: 1. Pain—therapy. 2. Chronic Disease—psychology. 3. Pain—psychology.

WL 704 L576m 2007]

RB127.L3966 2007

616′.0472—dc22

2007018819

British Library Cataloguing in Publication Data

A CIP record is available from the British Library.

Contents

List of Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix

List of Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv

1Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Origins and Development of Pain Management . . . . . . .2

Interdisciplinary Pain Medicine . . . . . . . . . . . . . . . . . . . . .3

Traditional Medical Models of Pain Management

Versus the Current Biopsychosocial Paradigm . . . . . . .4

Role of Psychiatrists in Interdisciplinary

Pain Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

2Sensory Pathways of Pain and Acute

Versus Chronic Pain . . . . . . . . . . . . . . . . . . . . . . . 11

Pain-Relaying Pathways and Mechanisms . . . . . . . . . . .12

Role of the Autonomic Nervous System in Pain . . . . . .18

Pain-Modulating Processes

Within the Nervous System . . . . . . . . . . . . . . . . . . . . . .19

Acute Versus Chronic Pain. . . . . . . . . . . . . . . . . . . . . . . .25

Classifications of Acute and Chronic Pain . . . . . . . . . . .25

Categories of Chronic Pain. . . . . . . . . . . . . . . . . . . . . . . .27

“Patienthood” as a Psychosocial State:

The Patient With Simple Versus Chronic Pain . . . . . . .27

Multiaxial Pain Classification . . . . . . . . . . . . . . . . . . . . . .30

Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31

References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31

3Evaluation of the Pain Patient . . . . . . . . . . . . . . 35

Conducting an Interview . . . . . . . . . . . . . . . . . . . . . . . . .37

Obtaining the Pain History. . . . . . . . . . . . . . . . . . . . . . . .38

Evaluation of Treatment Suitability . . . . . . . . . . . . . . . . .47

Pain Assessment Instruments . . . . . . . . . . . . . . . . . . . . .47

Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60

References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60

4Common Psychiatric Comorbidities and

Psychiatric Differential Diagnosis

of the Pain Patient . . . . . . . . . . . . . . . . . . . . . . . . 63

Pain Disorder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .64

Depression. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70

Anxiety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .72

Sleep Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .74

Substance-Related Disorders. . . . . . . . . . . . . . . . . . . . . .75

Personality Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . .77

Schizophrenia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .78

Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .79

References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .80

5Pharmacology of Pain . . . . . . . . . . . . . . . . . . . . . 83

Opiate Analgesics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .83

Tramadol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .94

Nonopiate Analgesics. . . . . . . . . . . . . . . . . . . . . . . . . . . .95

Cyclooxygenase-2 Inhibitors . . . . . . . . . . . . . . . . . . . . . .96

Antidepressants. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .97

Anticonvulsant Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . .104

Considering Treatment Options: Antidepressant,

Anticonvulsant, or Both? . . . . . . . . . . . . . . . . . . . . . . .106

Antihistamines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .110

Benzodiazepines and Anxiolytics . . . . . . . . . . . . . . . . .111

Triptans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .112

Stimulants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .113

Neuroleptics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .114

Mexiletine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .114

Alpha2-Adrenergic Agonists . . . . . . . . . . . . . . . . . . . . . .115

N-Methyl-D-Aspartate Antagonists. . . . . . . . . . . . . . . . .115

Corticosteroids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .116

Muscle Antispasmodics . . . . . . . . . . . . . . . . . . . . . . . . .117

Topical Agents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .119

Herbal Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .120

Cannabinoids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .120

Placebo Effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .122

Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .122

References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .124

6Psychotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . 131

Resistance to Psychotherapy . . . . . . . . . . . . . . . . . . . . .133

Factors to Be Addressed in Psychotherapy . . . . . . . . .134

Behavior Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .140

Cognitive-Behavioral Therapy . . . . . . . . . . . . . . . . . . . .143

Supportive Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . .147

Marital, Couples, and Family Therapy. . . . . . . . . . . . . .148

Group Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .150

Adjunctive Interventions. . . . . . . . . . . . . . . . . . . . . . . . .151

Vocational Rehabilitation. . . . . . . . . . . . . . . . . . . . . . . .156

Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .157

References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .158

7Special Techniques in Pain Management . . . .161

Acupuncture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .162

Transcutaneous Electrical Nerve Stimulation. . . . . . . .164

Prolotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .164

Botulinum Toxin (Botox) Injection . . . . . . . . . . . . . . . .164

Anesthesia at the Level of the Spinal Cord . . . . . . . . .165

Regional Neural Blockade . . . . . . . . . . . . . . . . . . . . . . .166

Neurosurgical Techniques . . . . . . . . . . . . . . . . . . . . . . .170

Repetitive Transcranial Magnetic Stimulation . . . . . . .172

Role of the Psychiatrist in Pain Management

Related to Interventions. . . . . . . . . . . . . . . . . . . . . . . .173

Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .177

References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .177

8Common Pain Disorders . . . . . . . . . . . . . . . . . . 179

Headache. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .179

Back Pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .186

Nonarticular Pain Disorders. . . . . . . . . . . . . . . . . . . . . .188

Osteoarthritis and Rheumatoid Arthritis. . . . . . . . . . . .194

Neuropathic Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .197

Sympathetically Mediated Pain: Complex Regional

Pain Syndromes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .200

Phantom Limb Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . .202

Cancer and HIV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .204

Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .207

References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .208

9Special Populations . . . . . . . . . . . . . . . . . . . . . . 213

Pediatric Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .213

Geriatric Patients. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .216

Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .219

Cultural Issues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .220

Substance-Dependent and Substance-Abusing Patients. . .222

Patients With Terminal Conditions . . . . . . . . . . . . . . . .224

Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .229

References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .229

10 Forensic Issues Pertaining to Pain . . . . . . . . . . 233

Litigation and Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . .233

Medication Diversion . . . . . . . . . . . . . . . . . . . . . . . . . . .234

Opiate Adulteration and Misuse . . . . . . . . . . . . . . . . . .236

Legal Issues Related to Opioid Prescribing . . . . . . . . .237

Patient Contracts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .238

Drug Testing in Clinical Practice . . . . . . . . . . . . . . . . . .240

State and National Prescribing Data Banks . . . . . . . . .240

Confidentiality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .242

Disability Compensation . . . . . . . . . . . . . . . . . . . . . . . .244

Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .247

References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .248

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251

List of Tables

Table 1–1 Traditional versus biopsychosocial models of pain . . 6

Table 1–2 Role of psychiatrists in pain management

(biopsychosocial approach) . . . . . . . . . . . . . . . . . . . . 8

Table 2–1 Sensory neural fiber types of first-order neurons. . . 14

Table 2–2 Mediators of pain processing and transmission. . . . 20

Table 2–3 Monoamine neurotransmission involved in

descending pain inhibition . . . . . . . . . . . . . . . . . . . . 22

Table 2–4 Causes of chronic pain . . . . . . . . . . . . . . . . . . . . . . . 23

Table 2–5 Features distinguishing acute and chronic pain . . . . 26

Table 2–6 Categories of chronic pain. . . . . . . . . . . . . . . . . . . . . 28

Table 2–7 Common problems encountered by patients with

chronic pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Table 2–8 Simple versus complex chronic pain . . . . . . . . . . . . 30

Table 3–1 Obtaining a pain history. . . . . . . . . . . . . . . . . . . . . . . 38

Table 3–2 Psychiatric disorders accompanying acute and

chronic pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Table 3–3 Problematic cognitive patterns in pain . . . . . . . . . . . 43

Table 3–4 Factors that suggest poor surgical outcome for

pain disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

Table 3–5 Psychometric scales used in assessing chronic

pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Table 3–6 Pain assessment instruments for acute and

chronic pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

Table 3–7 Short form of the McGill Pain Questionnaire . . . . . . 55

Table 3–8 Uses of the Minnesota Multiphasic Personality

Inventory for patients with chronic pain . . . . . . . . . . 58

Table 4–1 DSM-IV-TR diagnostic criteria for pain disorder . . . . 65

Table 4–2 Limitations of the DSM-IV-TR nosology of

pain disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

Table 4–3 Psychiatric disorders in which pain can be a

prominent complaint . . . . . . . . . . . . . . . . . . . . . . . . . 68

Table 4–4 Factors that raise suspicion of malingering. . . . . . . . 69

Table 4–5 Physiologic substrates common to pain and

depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

Table 4–6 Distinguishing features of pseudoaddiction and

addiction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

Table 5–1 Opiate dosing and use . . . . . . . . . . . . . . . . . . . . . . . 84

Table 5–2 Medication suggestions for pain in the adult

patient. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86

Table 5–3 Opioid therapy guidelines for chronic

nonmalignant pain. . . . . . . . . . . . . . . . . . . . . . . . . . . 87

Table 5–4 Dosing guidelines. . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

Table 5–5 Analgesic effects of antidepressants . . . . . . . . . . . . 100

Table 5–6 Antidepressants used in chronic pain. . . . . . . . . . . 101

Table 5–7 Tricyclic antidepressant side effects . . . . . . . . . . . . 102

Table 5–8 Uses of anticonvulsants in various pain

conditions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104

Table 5–9 Anticonvulsant mechanisms of action

relevant to pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105

Table 5–10 Side effects of anticonvulsants . . . . . . . . . . . . . . . . 107

Table 5–11 Number-needed-to-treat (NNT) values obtained

from two meta-analyses assessing antidepressant

and anticonvulsant efficacy in neuropathy . . . . . . . 109

Table 5–12 Triptans available for abortive migraine

treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112

Table 5–13 Side effects of corticosteroid use in pain . . . . . . . . 117

Table 5–14 Dosing of muscle relaxants . . . . . . . . . . . . . . . . . . . 118

Table 5–15 Herbal agents used for pain . . . . . . . . . . . . . . . . . . 121

Table 6–1 Components of pain and associated

psychotherapeutic interventions . . . . . . . . . . . . . . . 132

Table 6–2 Psychotherapy interventions employed to

facilitate access of emotions . . . . . . . . . . . . . . . . . . 136

Table 6–3 Reasons why emotions are poorly identified

and regulated . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137

Table 6–4 Early psychodynamic conceptualizations of

pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137

Table 6–5 Steps of behavior therapy . . . . . . . . . . . . . . . . . . . . 141

Table 6–6 Script for deep breathing exercises. . . . . . . . . . . . . 154

Table 6–7 Techniques of hypnosis. . . . . . . . . . . . . . . . . . . . . . 156

Table 7–1 Treatment interventions for management of

acute and chronic pain conditions . . . . . . . . . . . . . 162

Table 7–2 Complications and contraindications of

subarachnoid and epidural analgesia . . . . . . . . . . . 167

Table 7–3 Risks of continuous epidural or subarachnoid

anesthetic infusions . . . . . . . . . . . . . . . . . . . . . . . . . 167

Table 7–4 Modalities of regional nerve blockade . . . . . . . . . . 169

Table 7–5 Types of and uses for autonomic nerve blocks . . . 170

Table 7–6 Neurosurgical interventions for use in pain

management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171

Table 7–7 Role of psychiatrists in the care of patients

undergoing interventional pain management . . . . 173

Table 7–8 Psychiatrists’ guide for assessing patient

decision-making capacity. . . . . . . . . . . . . . . . . . . . . 175

Table 8–1 Evaluation of the headache patient . . . . . . . . . . . . 180

Table 8–2 Treatment of headache . . . . . . . . . . . . . . . . . . . . . . 182

Table 8–3 Factors influencing likelihood of response to

psychotherapeutic measures in patients with

tension headache . . . . . . . . . . . . . . . . . . . . . . . . . . 183

Table 8–4 Common auras associated with migraine

headache . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184

Table 8–5 Common causes of back pain . . . . . . . . . . . . . . . . 187

Table 8–6 Treatment options for back pain. . . . . . . . . . . . . . . 189

Table 8–7 Diagnostic criteria for fibromyalgia . . . . . . . . . . . . . 190

Table 8–8 Features associated with fibromyalgia . . . . . . . . . . 191

Table 8–9 Summary of treatment approaches for

fibromyalgia based on strength of evidence

in the available literature . . . . . . . . . . . . . . . . . . . . . 193

Table 8–10 Pharmacologic treatment strategies for

comorbidities of fibromyalgia . . . . . . . . . . . . . . . . . 194

Table 8–11 Treatment options for patients with

osteoarthritis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195

Table 8–12 Treatment options for patients with

rheumatoid arthritis . . . . . . . . . . . . . . . . . . . . . . . . . 196

Table 8–13 Types of neuropathic pain. . . . . . . . . . . . . . . . . . . . 199

Table 8–14 Treatment strategies for patients with

neuropathic pain . . . . . . . . . . . . . . . . . . . . . . . . . . . 200

Table 8–15 Treatment of patients with complex

regional pain syndrome. . . . . . . . . . . . . . . . . . . . . . 202

Table 8–16 Common pain-related disorders associated

with HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205

Table 8–17 Management of cancer pain and pain

associated with HIV and AIDS, based on

pain ratings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206

Table 9–1 Behavior parameters warranting consideration

to assess discomfort . . . . . . . . . . . . . . . . . . . . . . . . 218

Table 9–2 Barriers to pain management in minority

patients. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221

Table 9–3 Pain management in patients with substance

abuse/dependence . . . . . . . . . . . . . . . . . . . . . . . . 223

Table 9–4 Medicare requirements for hospice care . . . . . . . . 227

Table 9–5 Approaches to dealing with spiritual issues . . . . . . 229

Table 10–1 Items to be factored into a patient contract

for use with controlled substances . . . . . . . . . . . . . 239

Table 10–2 Advantages of urine drug testing in

clinical pain management practice . . . . . . . . . . . . . 241

Table 10–3 Purposes of the National All Schedules

Prescription Electronic Reporting Act

database system . . . . . . . . . . . . . . . . . . . . . . . . . . . 242

Table 10–4 Limitations considered by Social Security

Administration adjudicators . . . . . . . . . . . . . . . . . . . 245

List of Figures

Figure 2–1 Dimensions of pain and the biopsychosocial

model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Figure 2–2 The affective-motivational pathway and

the sensory-discriminative pathway . . . . . . . . . . . . . 17

Figure 3–1 Components of the pain history . . . . . . . . . . . . . . . . 36

Figure 3–2 Single-dimension pain assessment instruments . . . 51

Figure 3–3 Example of a pain diary format . . . . . . . . . . . . . . . . . 54

Figure 3–4 Common Minnesota Multiphasic Personality

Inventory–2 profiles in chronic pain . . . . . . . . . . . . . 59

Figure 4–1 The anxiety–pain relationship . . . . . . . . . . . . . . . . . . 73

Figure 5–1 Influence of nonsteroidal anti-inflammatory drugs

(NSAIDs) and cyclooxygenase-2 (COX-2) inhibitors

on thromboxane and prostacyclin effects. . . . . . . . . 98

Figure 5–2 Equation for calculating number-needed-to-treat

(NNT) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108

Figure 6–1 Modalities involved in cognitive-behavioral

therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145

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xv

Preface

The text of this manual, an update of the Concise Guide to Pain Management

for Psychiatrists, was written in recognition of the significant advances in, and

dynamism within, the field of pain medicine. Frequently, references are made to

the importance of multidisciplinary, comprehensive treatment of the patient

with pain. Nonetheless, the role of the psychiatrist and mental health practi-

tioner in pain management continues to be the focus in this text. The con-

tributory role of the psychiatrist in evaluation and assessment, pharmacologic

management, psychotherapeutic interventions, and comprehensive treatment

planning is emphasized. While interventional approaches to pain manage-

ment are discussed herein, the importance of examining psychological variables

that can limit outcomes and that may preclude undertaking aggressive, inter-

ventional approaches is elaborated on.

Information has been evolving regarding the biological substrates underly-

ing both pain and psychiatric comorbidities (e.g., depression). Such knowledge

expands the care and management of patients afflicted with pain and common

psychiatric comorbidities. Particularly extensive revisions have been made in

the sections describing the use of psychiatric and other adjunctive medications

in pain management. While there is ample discussion of the role of opiates and

weak analgesics in pain management, concerns frequently arise pertaining to

long-term adverse effects, dependence, and behaviors resembling addiction (i.e.,

pseudoaddiction). Discussion of these issues has been expanded in the current

edition. Effort is directed at delineating the utility of adjunctive treatments,

including evolving data on the use of antidepressants and related medications,

in the care of patients with chronic pain.

xvi Clinical Manual of Pain Management in Psychiatry

An overview of chronic pain conditions is presented, with an update of

trends in treatment approaches that have been developed since publication of

the Concise Guide edition. Finally, emerging legal and forensic issues pertinent

to pain medicine have been updated in this text.

The positive comments that were received about the Concise Guide edi-

tion of the book were gratifying. It is this author’s hope that the manual is still

more useful to those psychiatrists and mental health practitioners who wish to

devote their skills and expertise to the care of patients with pain.

Disclosure of competing interests: The author has no competing interests or

conflicts to declare.

1

1

Introduction

Pain is one of the most ubiquitous health problems in the United States. Es-

timates suggest that 10%–20% of Americans have some form of chronic pain

condition (Gatchel and Okifuji 2006). The impact of pain is far-reaching, ad-

versely affecting vocational endeavors and contributing significantly to dis-

ability (Andersson 1999; White and Gordon 1982). The economic impact of

chronic pain is enormous when one considers health care costs (estimated at

over $70 billion annually) as well as the costs of absenteeism, reduced produc-

tivity, and disability compensation (estimated at over $150 billion annually)

(Gatchel and Okifuji 2006). In addition, pain interferes with individuals’ ac-

tivities, interests, and relationships and limits the enjoyment of life.

Significant losses can accompany chronic pain (e.g., losses of income and

autonomy). Patients may experience guilt, blaming themselves for their in-

ability to overcome or master pain. In the home, the patient’s role, and conse-

quently the roles of others, may require modification, leading perhaps to strained

relationships.

Pain is a common complaint among patients seeking medical attention.

Despite the pervasiveness of pain and its multiple ramifications, the manage-

ment of pain has often been elusive to clinicians. This is particularly true when

2Clinical Manual of Pain Management in Psychiatry

one considers the diversity of pain disorders that lack clear identifiable etiol-

ogies or when pain exceeds expectations given the underlying medical condi-

tion. Complex pain in a patient (i.e., pain that has not responded to common

pain medications and interventions) can present an enormous burden to med-

ical services.

Increasing attention has been directed to the issues of pain management,

mobilized in part by the efforts of organizations that educate the public about

pain management, such as the Compassion in Dying Federation, and by the stan-

dards of the Joint Commission on Accreditation of Healthcare Organizations

(JCAHO). In addition, pain management has received increased attention

from the medical community as a result of societal demands for more effective

and comprehensive treatment. JCAHO requires that physicians consider pain

as the fifth vital sign and that pain severity be documented by means of a stan-

dardized pain scale and be appropriately managed. Pain management also has

received greater political and legal attention. Congress passed a provision, sub-

sequently signed into law by President Clinton, declaring the decade 2001–

2010 the “decade of pain control and research.” From a medicolegal standpoint,

physicians have been disciplined by state regulatory boards after review of med-

ical records suggested negligence based on inadequate pain treatment (Albert

2001; Charatan 1999). Cumulatively, each of the aforementioned influences

increases the external pressure, ensuring that physicians become current in ef-

fective pain management.

Origins and Development of Pain Management

Pain management first emerged as a subspecialty of anesthesiology. The need

for the development of the science underlying pain and the skills for its treat-

ment prompted efforts to refine training strategies and provide specialized pain

clinics. Since the first pain clinic’s appearance in 1951, approximately 3,800

pain clinics, programs, and solo practices have been established in the United

States. This expansion points to the enormous need for specialized settings

and specialists to work toward the amelioration of pain.

However, it became readily apparent that the knowledge and skills re-

quired of pain practitioners far exceeded those skills available to traditional

anesthesiology training models. In addition to physical discomfort, patients

with pain experience marked emotional distress. Emotional factors (e.g., depres-

Introduction 3

sion and anxiety) not only emerge as a consequence of pain but also can con-

tribute to pain, thereby exacerbating and maintaining it. Psychological factors

can likewise interfere with treatment adherence and efficacy. Patients’ frustra-

tion caused by ongoing pain, the effects on functioning, and the impact on fam-

ilies and relationships can contribute significantly to psychiatric morbidity. As

a result of these factors, leaders in pain management training declared tradi-

tional medical models of pain to be too shortsighted and required a modifi-

cation in traditional training conceptualizations (Loeser 2001).

Interdisciplinary Pain Medicine

Pain medicine has emerged as a medical subspecialty in its own right. Although

not yet universally accepted, the term pain medicine is intended to encompass

the principles of pain management and embody an interdisciplinary approach.

Currently, specialists in pain medicine view pain as a distinct multifactorial ill-

ness (Gallagher 1999). Thus, no one discipline embodies the skills and mastery

required to address pain. Rather, management and treatment of pain require

the joint efforts of multiple clinical specialties, each of which can contribute to

the effective treatment of pain. Hence, the skills of the anesthesiology expert can

be complemented by the rehabilitation skills of the physiatrist and the psycho-

therapeutic and psychopharmacologic skills of the psychiatrist.

In 1998, the American Board of Psychiatry and Neurology (ABPN) and

the American Board of Physical Medicine and Rehabilitation joined the Amer-

ican Board of Anesthesiology in recognizing pain management as an interdis-

ciplinary subspecialty. Regardless of the primary discipline, pain medicine sub-

specialists need to understand the anatomy and physiology of pain perception,

the psychological factors modifying the pain experience, and the basic princi-

ples of pain management.

Eligibility for the certifying examination in pain medicine requires that

the applicant possess a medical license. The applicant must also be board certified

in one of the aforementioned disciplines and, as of 2006, must have completed

residency training in pain medicine approved by the Accreditation Council for

Graduate Medical Education (ACGME).

Currently, the ACGME is refining fellowship training in pain medicine to

reflect multiple disciplines. Toward this end, efforts are currently under way to

specify the training experiences, didactics, and rotations in anesthesiology as

4Clinical Manual of Pain Management in Psychiatry

well as psychiatry, neurology, and physical medicine and rehabilitation. Pa-

rameters for specialty tracks in pain medicine for each of these disciplines may

also become available.

ABPN diplomates were first eligible to sit for the subspecialty certification

examination in 2000. Subspecialty certification is appropriate for psychiatrists

whose practices are largely devoted to pain management. However, given the

pervasiveness of pain complaints, even the general psychiatrist will encounter

pain management issues among his or her patients, and the general psychia-

trist should also have the training and experience to recognize and treat basic

psychiatric issues associated with pain. This book provides a concise guide to

the psychiatric aspects of the management of pain.

Traditional Medical Models of Pain Management

Versus the Current Biopsychosocial Paradigm

In traditional medical models of pain management, pain is seen as a signal of

underlying disease or a pathophysiologic state. The physician is proactive in

undertaking pharmacologic and other treatment interventions to treat the un-

derlying disease state or relieve pain. The focus is on the disorder rather than

on the person with the disorder. Consequently, the physician enlisted to treat

the patient with pain first makes a determination as to the etiology of the pain.

In ambiguous cases, there is often an exhaustive search for biomedical causes

and treatment. When such efforts fail, the patient is dismissed as being “untreat-

able,” and he or she is often left to persist in pain, with no improvement in func-

tional adaptations.

In these traditional models there is a dualistic notion of pain, dividing it

by organic versus psychogenic causes. Thus, there is a tendency to attribute to

psychic factors any pain process in which the physical causes cannot be fully

delineated. Similarly, if the pain complaints seem disproportionate to the un-

derlying disease or if the pain fails to respond to treatment as expected, there

is a belief that psychological processes underlie the pain. For many patients

with chronic pain, such dualistic notions are inadequate (Boissevain and McCain

1991; Lynch 1992).

Frustrated by an inability to account for or to explain the cause of a pa-

tient’s pain or by a feeling of futility or defeat when faced with a patient who

persistently experiences pain despite the clinician’s best efforts, the clinician may

Introduction 5

cease to take the patient’s complaints seriously. For such patients, psychiatry

becomes the treatment of last resort, prompted by resignation that the pain is

psychic rather than somatic. Pain patients do not often think of themselves as

needing to see a psychiatrist. Physicians are accustomed to hearing such pa-

tients ask, “Why do I have to see a psychiatrist?” The implication that the pain

could be psychogenic can contribute to patients’ distress. They may perceive

that their doctors have given up on them, that their pain complaints are no

longer taken seriously, or that they are being blamed for their persistent pain de-

spite treatment (Gamsa 1994). (See Table 1–1 for a summary of the traditional

pain model.)

Current conceptualizations of pain medicine adopt a biopsychosocial per-

spective (Engel 1977) (see Table 1–1). This model contends that the health sta-

tus of individuals with chronic illnesses, the course of the illness, and the out-

come of treatment are influenced by the interaction of biological, psychological,

and social factors. The model provides a useful paradigm in which to view

chronic pain states. The focus is on the rehabilitation and reclamation of the pain

patient in the context of the pivotal doctor–patient relationship. Pain is viewed

not exclusively as a signal of disease but as an experience with biological, psycho-

logical, and social derivatives. The treatment hinges on patient participation, and

the physician serves as a guide, teacher, and interventionist to facilitate the reha-

bilitation process. The goal, therefore, is not necessarily a cure, because in many

cases pain can be a chronic or even lifelong process. The biopsychosocial para-

digm addresses relief from pain while addressing the impact of the pain condi-

tion on other aspects of one’s functioning, relationships, vocational adaptations,

and emotional well-being. The patient’s emotional experiences, beliefs, and ex-

pectations can determine the outcome of treatment and are fully emphasized as

the focus of treatment intervention. The biopsychosocial perspective pursues

and examines psychological and social facets of the patient’s pain experience

without discounting the pain based on the presence of such facets. The goal is to

identify and rectify any impediments to recovery and rehabilitation.

Role of Psychiatrists in Interdisciplinary

Pain Medicine

Comprehensive pain treatment programs involving interdisciplinary, multi-

modal treatment approaches are often required in treating complex and dis-

6Clinical Manual of Pain Management in Psychiatry

Table 1–1.

Traditional versus biopsychosocial models of pain

Traditional pain model Biopsychosocial model

View of pain As an illness As an experience

Determinants of pain Disease Biological, social, and psychological factors

Responsibility for

treatment

Physician Patient

Role of clinician Expert on pain relief Educator, motivator, physician-healer

Role of patient Passive Proactive

Goal(s) of treatment Cure or pain relief Increased function

Improved quality of life

Restored or improved relationships

Methods Pharmacologic Educational

Technical Motivational

Interpersonal

Psychological

Pharmacologic

Technical

Focus of attention Somatic complaints

Pain as corresponding to pathology;

if pain does not correspond, it is

not real

Reciprocal relationship between somatic complaints and emotion,

psychological processes, and interpersonal functions

Disregard for patient’s beliefs related to

pain

Regard for patient’s beliefs related to pain

Focus on cause of pain Focus on widespread impact of pain on life

Introduction 7

abling pain conditions. Encompassing specialists in the fields of anesthesiology,

neurology, psychiatry, psychology, and rehabilitation medicine, such programs

are directed at implementing measures whereby the patient gains mastery over

pain and refines cognitive styles and coping strategies (Jensen et al. 1994,

2001). Such comprehensive treatment programs are effective in producing

symptomatic pain relief, reducing affective distress, and improving adaptive

functioning and quality of life (Flor et al. 1992; Jensen et al. 2001; Skevington

et al. 2001). The duration of effects appears to be sustained over time, reducing

disability and health care utilization (Flor et al. 1992). Comprehensive pain treat-

ment programs have emerged as the most efficacious and cost-effective means of

addressing chronic pain, even among the most recalcitrant patients (Gatchel and

Okifuji 2006).

Unfortunately, attrition rates can be quite high (Jensen et al. 1994). Fac-

tors predisposing to attrition include a long history of pretreatment pain, de-

pendence on medications, multiple prior surgeries related to pain, and perceived

lack of social support for maintaining participation in treatment (King and

Snow 1989; Maruta et al. 1979).

Given that a significant number of psychosocial stressors and psycholog-

ical comorbidities complicate the experience of chronic pain, there is wide ac-

ceptance of the necessity of psychiatric and other mental health practitioners

in the comprehensive assessment and treatment of patients with pain. General

psychiatric training renders the psychiatrist particularly well suited for the treat-

ment of pain (Leo et al. 2003). Traditionally, psychiatrists view patients ho-

listically and adopt a biopsychosocial perspective. Psychiatrists are trained in

communication skills and are familiar with an array of pharmacologic agents

that can reduce pain.

The psychiatrist enlisted to care for the pain patient can perform a variety of

functions pivotal to the biopsychosocial approach (Table 1–2). Psychiatrists

may choose the roles they wish to assume in pain treatment as defined by their

skills, training, and expertise and by the collaborative efforts of other clinicians.

Thus, psychiatrists might serve a role in diagnosing and managing discrete psy-

chiatric disorders that accompany pain or interfere with treatment. Psychiatrists

might be involved in facilitating the patient’s adaptation after trauma or injury

resulting in pain (e.g., motor vehicle crashes, work-related injuries), in interven-

tions to treat pain (e.g., after an amputation), or in fostering improved quality of

life, including social and vocational factors. Naturally, the psychiatrist can be in-

8Clinical Manual of Pain Management in Psychiatry

volved in facilitating communication between the patient and clinicians with

whom the patient interacts. (In some circumstances, the patient’s perceptions of

how he or she is being treated, believed, or construed may adversely affect ther-

apeutic alliances and compromise the pain treatment team.)

Psychiatrists may be involved in the direct assessment and treatment of

pain, in coordinating referrals to other pain specialists, and in all facets of the

treatment plan. Conversely, they may respond to referrals from specialists in

other disciplines to complement existing treatment strategies in which psycho-

logical factors are thought to be complicating recovery.

Psychiatrists can offer pharmacologic interventions for pain. They also can

address emotional and cognitive sequelae of pain or its treatment and factors

interfering with treatment (e.g., treatment adherence). The patient with chronic

pain can become dependent on opiate analgesics, requiring psychiatric inter-

vention. In some cases, the care of the pain patient may be entirely delegated

to the psychiatrist.

Physicians seek psychiatric intervention to help in treating patients who

have acute pain or painful terminal disorders, especially to address the psy-

chological consequences and psychiatric comorbidities. More frequently, phy-

sicians seek consultation for patients with chronic pain with whom they are

frustrated by lack of treatment response. Often, such patients are pejoratively

labeled as noncompliant, uncooperative, attention seeking, medication seek-

ing, or malingering (Gallagher 1999). Deciphering the relative contribution

of biological and psychological variables to pain complaints requires evalua-

tion by a psychiatrist with skills in the biopsychosocial assessment of pain. The

Table 1–2.

Role of psychiatrists in pain management

(biopsychosocial approach)

Assess pain.

Assess intervening variables that affect pain.

Prognosticate (consider factors that might influence pain, treatment compliance, and

effects of treatment).

Determine problem areas for the patient.

Establish a treatment approach.

Delineate goals of treatment.

Reassess treatment efficacy.

Make modifications in the treatment plan as necessary.

Introduction 9

patient’s frustration caused by ongoing pain, the effects on functioning, and

the impact on relationships contributes to significant psychiatric morbidity. It

is not surprising, therefore, that the presence of chronic pain is a significant

risk factor for suicide (Fishbain 1999). Thus, there is a great demand for psy-

chiatrists to assist with pain management.

Key Points

• Pain is a ubiquitous health problem, the impact of which is far-reaching.

On a societal level, the economic burdens are enormous. For the individual,

pain adversely affects vocational endeavors, activities, interests, and rela-

tionships and limits enjoyment of life.

• From a biopsychosocial perspective, pain is viewed as an experience with bi-

ological, psychological, and social derivatives. This model provides a useful

paradigm in which the focus is on bringing about rehabilitation of the pain

patient and reclamation of his or her life, addressing symptomatic pain relief,

reducing affective distress, improving adaptive functioning and quality of life,

and thereby improving interpersonal and emotional well-being.

• Comprehensive pain treatment programs involving interdisciplinary, multi-

modal treatment approaches are often required for complex and disabling

pain conditions.

• Interdisciplinary treatment programs involve the coordination and collab-

orative endeavors of a number of health care providers, with the goals of al-

leviating symptoms, enhancing patient independence, improving functional

adaptation, addressing the psychological comorbidities accompanying pain,

and improving psychosocial functioning.

• Within the biopsychosocial perspective, there are several pivotal roles that

the psychiatrist can perform in the assessment, treatment, and ongoing man-

agement of the patient with pain.

References

Albert T: Doctor guilty of elder abuse for undertreating pain. Am Med News, July 23,

2001, pp 1, 4

Andersson GBJ: Epidemiological features of chronic low-back pain. Lancet 354:581–

585, 1999

10 Clinical Manual of Pain Management in Psychiatry

Boissevain MD, McCain GA: Toward an integrated understanding of fibromyalgia

syndrome, I: medical and pathophysiologic aspects. Pain 45:227–238, 1991

Charatan F: Doctor disciplined for “grossly undertreating” pain. BMJ 319:728, 1999

Engel GL: The need for a new medical model: a challenge for biomedicine. Science

196:129–136, 1977

Fishbain DA: The association of chronic pain and suicide. Semin Clin Neuropsychiatry

4:221–227, 1999

Flor H, Fydrich T, Turk DC: Efficacy of multidisciplinary pain treatment centers: a

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pain. J Pain 7:779–793, 2006

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Edition. Edited by Loeser JD, Butler SH, Chapman CR, et al. Philadelphia, PA,

Lippincott Williams & Wilkins, 2001, pp 255–264

Lynch M: Psychological aspects of reflex sympathetic dystrophy: a review of the adult

and pediatric literature. Pain 49:337–347, 1992

Maruta T, Swanson DW, Swenson WM: Chronic pain: which patients may a pain-

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7:141–149, 1982

11

2

Sensory Pathways of Pain and

Acute Versus Chronic Pain

Pain is a multidimensional concept (Loeser 1982), with biological, psycho-

logical, and social components (Figure 2–1). First, there is a sensory compo-

nent of the pain experience—an unpleasant sensation detected in the body

and processed in the central nervous system (CNS). This process, referred to

as nociception, relies on the transfer of information about the sensory experi-

ence from receptors in the periphery through nerves to the spinal cord and on

to the brain.

Second, there is an assessment of the unpleasant sensory experience. This as-

sessment involves a cognitive awareness of the sensation arising from the periph-

ery that the person labels as pain. Not all sensations are painful; some can be

construed as unusual, uncomfortable, or irritating but not painful. Thus, the

common pins-and-needles sensation in one’s foot might be described as the foot

“falling asleep” but not as pain. Similarly, one may experience an itch, a twitch,

or other noxious sensations (e.g., burning, throbbing) that are labeled as painful.

Third, there is a perception and cognitive appraisal that the discomfort is

associated with suffering. This subsumes not only the sensation and awareness

12 Clinical Manual of Pain Management in Psychiatry

of pain but also the reactions to the experience (e.g., distress, dysphoria, anx-

iety, hopelessness). The experience of pain may connote various experiences for

the individual, including many unpleasant emotional states.

The final dimension of pain consists of the pain behaviors displayed by

the patient in response to the unpleasant experience. Here the person conveys

to others how much distress he or she is experiencing. These behaviors can be

verbal (e.g., “Wow, this really hurts!”), paraverbal (e.g., moaning), or nonverbal

(e.g., guarding an affected limb, splinting, wearing a neck brace, taking med-

ication, reclining).

The neurophysiologic substrates of the pain experience are discussed in

this chapter. The first part of the chapter comprises a discussion of the sensory

pathways and mechanisms. The second part focuses on distinctions between

acute and chronic pain.

Pain-Relaying Pathways and Mechanisms

In their most basic aspects, the pain relay pathways involve three sets of

neurons. First-order neurons relay noxious information from the periphery or

Figure 2–1.

Dimensions of pain and the biopsychosocial model.

Biological

Nociception

Psychological

Cognitive appraisal

and suffering

Social

Pain behavior

Sensory Pathways of Pain and Acute Versus Chronic Pain 13

viscera to the spinal cord. Second-order neurons relay sensory information

from the spinal cord to the thalamus. Third-order neurons arising from the

thalamus send information to higher brain regions where complex processing

of the pain experience occurs.

First-Order Neurons: Relay to the Spinal Cord

The detection of pain requires that information regarding injury, trauma, and

noxious stimulation be detected by a transducer. Transducers serve the pur-

pose of taking information (e.g., changes in temperature, chemical irritation,

pressure) from some location on the body surface, muscles, or internal organs

and converting it into neurochemical information that is interpretable by the

brain. The transducers for pain include the free nerve endings of the first-order

neurons in the pain pathway (i.e., the Aδ and C neurons). These neurons have

long dendrites with fine terminal arborizations present in the skin, muscle,

connective tissue, joints, bone, and internal organs. When these neurons are

stimulated, action potentials extend from the dendrites to the cell body (in the

dorsal root ganglion) and from the axon to the spinal cord.

Information relayed about other nonnoxious sensory modalities (e.g.,

pressure, touch, proprioception) is detected by other types of sensory trans-

ducers. These include pacinian corpuscles, Meissner’s corpuscles, and other

transducers. When sufficiently stimulated, these receptors in turn pass infor-

mation along another set of first-order neurons, the Aβ neurons.

First-order neurons differ in their diameter, myelination, and, therefore,

electrical conduction rates (Table 2–1). Miscalculating the intended align-

ment of a hammer to the intended target (i.e., the head of the nail), one can

quickly appreciate the pain relay process once the swift blow of the hammer

makes inadvertent contact with the fingers of the hand holding the nail in

place. First, Aβ fibers, responding to low-threshold touch receptors, relay in-

formation about the blunt object making contact with the hand. Simultaneously

(when the stimulus is disconcertingly high, as in this example), high-threshold

mechanoreceptors and heat receptors are activated. This information is con-

ducted quickly and robustly, via Aδ fibers, immediately after the injury. Aδ fi-

ber information is well localized, sharp, pricking, and pulsating but very short-

lived. Shortly thereafter, C fibers relay information from the injured hand—

information that is less definitive or localized than that of the Aδ fibers (Bes-

son and Chaouch 1987). These C fibers mediate the slowly emerging, more

14 Clinical Manual of Pain Management in Psychiatry

persistent, dull, aching, and burning pain that is experienced. All three types

of fibers relay information to the dorsal horn of the spinal cord, where they

synapse directly, or indirectly through interneurons, on the second-order neu-

rons involved in the nociceptive pathway (Byers and Bonica 2001).

Viscera are also supplied by C fibers and Aδ fibers. These are activated by

inflammatory processes, ischemia, disease, rapid distention, and contraction.

These events trigger free nerve endings to transduce the noxious information

into electrical information that is eventually transmitted to the dorsal horn.

Pain from the face is relayed to the CNS through the fifth cranial (i.e., the

trigeminal) nerve. Noxious information from the face is relayed via dendrites of

one of the three branches of the trigeminal nerve, passes through to the trigem-

inal ganglion (containing the cell bodies of the trigeminal nerves), and passes

to the second-order neurons in the pons and medulla. In a pattern that par-

allels that of spinal cord pathways, information is ultimately relayed to the

thalamus and higher brain structures (Dubner and Bennett 1983). The face

and mouth have a high density of pain transducers and pain fibers and are thus

exquisitely sensitive to stimulation. Similarly, the representation of the face and

mouth in the somatosensory cortex of the brain is extensive, suggesting that

processing and encoding of sensory information from the face and mouth is

quite elaborate.

Dorsal Horn Anatomy

The gray matter of the spinal cord is classified by histological characteristics

into 10 layers or laminae (referred to as Rexed layers). The dorsal horn contains

6 of these. Those layers that are essential in the pain processing pathways in-

clude laminae I, II, and V, primarily where Aδ and C fibers terminate (Terman

and Bonica 2001). Cells within the dorsal horn include those that are nociceptive

Table 2–1.

Sensory neural fiber types of first-order neurons

AβAδC

Diameter Large (5–15 µm) Intermediate

(1–4 µm)

Thin (0.5–1.5 µm)

Myelination Yes Ye s No

Conduction rate Fast (30–70 m/s) Fast (12–30 m/s) Slow (0.5–2.0 m/s)

Sensory

information

Cutaneous touch

and pressure

Well localized

Sharp pain

Poorly localized

Dull, aching pain

Sensory Pathways of Pain and Acute Versus Chronic Pain 15

specific (i.e., respond to noxious stimulation). Other cells respond only to innoc-

uous stimuli, whereas still others, referred to as wide dynamic range (WDR) cells,

respond to noxious and innocuous stimuli but discharge at a higher frequency

to noxious stimuli.

The substantia gelatinosa, contained within lamina II, has a significant

role in modulating pain. This substance involves small interneurons that serve

as control switches or gates through which sensory information from the

periphery is either enhanced or depressed. Certain of these interneurons (i.e.,

islet cells) are inhibitory, whereas others (i.e., stalked cells) are excitatory. The

substantia gelatinosa receives extensive serotonergic and noradrenergic input

from nerve fibers emanating from higher brain centers, which likewise influ-

ences the gating process.

When one experiences pain from a joint, massage of the overlying skin

may reduce some of that discomfort. This phenomenon, referred to as counter-

irritation, is attributed to the gating mechanism of the substantia gelatinosa.

Massaging, by stimulating the tactile receptors of the skin, activates Aβ fibers.

These fibers in turn activate interneurons within the substantia gelatinosa that

serve to inhibit pain-mediating pathways (Melzack and Wall 1965; Wall

1980). Counterirritation has been offered as an explanation to account for why

certain therapeutic modalities can be effective in mitigating pain—for exam-

ple, use of liniment or transcutaneous electrical nerve stimulation units.

Lamina V contains WDR cells with large receptive fields (i.e., they receive

extensive inputs from multiple sources). For example, Aδ and C fibers arising

from visceral structures enter lamina V. The WDR cells receiving the neural

input from visceral organs simultaneously receive input from other sites. This

process is the basis for referred pain (i.e., the interpretation of unpleasant sen-

sory input arising from viscera as emanating from peripheral sites) (Pomeranz

et al. 1968). Thus, hypoxic injury to the heart is perceived as pain in the left

arm, because the afferents from the heart synapse on those lamina V cells of

the left lower cervical and upper thoracic segments. The brain interprets the

stimulation of those cells as pain originating in the left upper chest and arm.

Second-Order Neurons: The Spinothalamic Tract

The axons arising from neurons making up the spinothalamic tract emanate

from the entire gray matter of the spinal cord. Most of these fibers cross to the

other side of the spinal cord through the ventral commissure in the midline

16 Clinical Manual of Pain Management in Psychiatry

and ascend in the anterolateral aspect of the white matter (myelinated) portion

of the spinal column. These fibers ascend without interruption through the

spinal column and brain stem and terminate in the contralateral thalamus

(Besson and Chaouch 1987; Dennis and Melzack 1977). However, a small

number of fibers project to the ipsilateral thalamus. These pain relay pathways

diverge into the two pathways within the spinothalamic system: the neo-

spinothalamic (sensory-discriminative) and the paleospinothalamic (affective-

motivational) pathways (Figure 2–2). The latter is considered to be a phylo-

genetically older pathway.

Third-Order Neurons: The Thalamus and Beyond

The thalamus is the primary relay station for sensory information from the

spinal cord to the cortex (Chudler and Bonica 2001; Rome and Rome 2000).

The second-order neurons from the neospinothalamic tract terminate in the

lateral aspect of the ventral posterior nucleus (VPN). Third-order neurons

from the VPN relay information to the somatosensory cortex (parietal lobe).

Through this pathway, discriminative aspects of pain, localization of the pain,

and coordinated motor responses to the pain are possible (Rome and Rome

2000).

Information is relayed simultaneously from the paleospinothalamic path-

way through a parallel pathway to the reticular formation, medial thalamus,

hypothalamus, and prefrontal cortex (Giesler et al. 1994). The nociceptive

system thereby influences affect, attention, cognition, and memory that relate

to painful sensory information (Chudler and Bonica 2001). A stress reaction

develops to noxious sensation, involving the hypothalamic-pituitary axis and

autonomic nervous system (Giesler et al. 1994). Ultimately, this information

is relayed to both cortices. As a result, the affective quality and coloring of the

pain experience are possible. In addition, affective influences mediated by lim-

bic involvement are likely to modulate pain. Thus, one’s surprise (e.g., “I can’t

believe I hit my hand with the hammer!”), alarm (e.g., “I didn’t see that com-

ing!”), anger (e.g., “That was so stupid!”—along with use of expletives), and

fear (e.g., “My hand is damaged for good!”) are likely to shape the experience

of pain. Mood states (e.g., a predisposition to anxiety or depression) can shape

the cognitive strategies one employs to deal with the pain, one’s sense of effi-

cacy in dealing with the injury, and one’s expectations for the future. The relay

of pain information to the bilateral cortices adds a cognitive component to the

Sensory Pathways of Pain and Acute Versus Chronic Pain 17

Figure 2–2.

The affective-motivational pathway (left) and the sensory-

discriminative pathway (right).

Note. Dashed line=inhibitory pathways; solid line=pain-facilitating pathways.

Aδ and C fibers

Noxious

stimulation

Dorsal

horn

Medial

thalamus

Somatosensory

cortex

Autonomic

nervous

system

Ventral

posterior

thalamus

Reticular

formation

Limbic

system

Frontal

cortex

Spinothalamic

tract

18 Clinical Manual of Pain Management in Psychiatry

pain experience. Thus, the mutual influences of mood, cognition, expectation,

and pain are mediated.

The frontal cortex mediates the cognitive processes underlying pain. These

processes involve the identification and evaluation of, and decision making

pertaining to, the noxious sensory information input from the periphery. Hence,

immediate short-term problem solving can be undertaken (e.g., ignoring the

hammering, preferring instead to tend to the injured hand). Other cognitive

processes—such as one’s expectations along with the attributions, beliefs, and

meanings ascribed to the painful experience—are likewise derived from cortical

processes and influence both the pain experience and the decision making

around the pain. In addition, memory of the painful experience is established

and encoded for further referral and to guide subsequent behaviors—for ex-

ample, how (and whether) one tries carpentry again.

Role of the Autonomic Nervous System

in Pain

The autonomic nervous system plays a significant role in pain. Signals of

threat and danger are relayed to the hypothalamus. From there, specifically

the posterior portion, information is relayed to the spinal cord (i.e., the tho-

racic and lumbar regions) by sympathetic neural pathways (McMahon 1991).

Ultimately, fibers from the thoracolumbar regions innervate a number of end-

organs producing activation (i.e., a state of heightened arousal). Those end-

organ activities that are necessary for fight-or-flight responses are promoted,

whereas those that are not necessary are suppressed. Thus, the information

signaling threat or danger results in elevated heart rate and blood pressure, in-

creased oxygen use, sweating, dilation of pupils, and increased glycogen utili-

zation within muscles. Other organ functions (e.g., peristalsis) are inhibited.

The effects of sympathetic nervous system activity are relatively brief in

duration because of the rapid release and degradation of norepinephrine and

acetylcholine released in the mediation of the fight-or-flight response. More

sustained reactions to stressors or threat are mediated by neuroendocrine ef-

fects, a product of adrenal medulla activation. Sympathetic nervous system

activation of the adrenal gland results in release of norepinephrine and epi-

nephrine, mimicking sympathetic activity.

Sensory Pathways of Pain and Acute Versus Chronic Pain 19

Pain-Modulating Processes

Within the Nervous System

The pain transmission pathways that have been presented thus far are simplis-

tic. In reality, a number of processes can influence pain transmission from the

periphery through the entire CNS. These mechanisms involve complex and

dynamic interactions among various neurotransmitters, their receptors, and

other pain-reducing and pain-augmenting processes. These are discussed briefly

in the following sections.

Neurochemicals in Pain Processing

A number of neurotransmitters and chemical substrates are involved in pain

transmission; several are listed in Table 2–2. For example, in the periphery, tis-

sue injury results in the activation of a number of cellular processes that release

chemical compounds that can activate free nerve endings for pain transmis-

sion (Snyder 1980), such as acetylcholine, bradykinin, histamine, potassium

ion, and serotonin (Levine et al. 1993). Additional agents that are active within

the CNS are also listed in Table 2–2. Some of these substances have a pain-

promoting role, whereas others have a pain inhibitory role. Many of these sub-

stances are the targets of influence when analgesics are employed (e.g., anti-

inflammatory agents and antidepressants), as is described further in Chapter 5,

“Pharmacology of Pain,” of this book.

Endogenous Opiates

The endogenous opiates consist of β-endorphin, enkephalins, and dynor-

phins (Sewell and Lee 1980). These are abundantly distributed throughout

the CNS, thereby modulating pain transmission. Enkephalins are endoge-

nous opiates found in the interneurons of the substantia gelatinosa that me-

diate the effects of inhibitory interneurons within the dorsal horn. Binding to

opioid receptors, enkephalins can inhibit the release of substance P from noci-

ceptors. In fact, intraspinal application of opiates (e.g., morphine) is thought

to influence the enkephalin receptors, thereby mitigating pain transmission

from the spinal cord. Cells producing β-endorphin arise from the hypothalamus

and are thought to exert their influence within the limbic system and mid-

brain.

20 Clinical Manual of Pain Management in Psychiatry

Pain-Reducing Pathways

Several structures serve to diminish the pain sensory information coming into

the CNS. Intuitively, pain-modulating mechanisms prevent the organism

from being overcome by unbridled pain, thereby allowing the organism an

opportunity to “escape” and tend to the injury. The four regions in the CNS

that can function to reduce pain sensation and control pain awareness are

1) the cortex and limbic structures, 2) the midbrain (the periaqueductal gray

[PAG]), 3) the rostral ventromedial medulla (RVM), and 4) the spinal dorsal

horn (Besson and Chaouch 1987; Terman and Bonica 2001). The gating

mechanism of the substantia gelatinosa within the dorsal horn was described

earlier in this chapter. The cortex and reticular formation can influence atten-

tion, arousal, expectations of pain, and psychological factors that can in turn

influence pain experiences. The specific mechanisms by which these structures

influence pain have yet to be clarified.

Table 2–2.

Mediators of pain processing and transmission

Pain promoting Pain inhibiting

Peripheral nervous system Acetylcholine

Adenosine

Bradykinin

Cytokines

Glutamate

Histamine

K+

Prostaglandins (E series)

Serotonin

Substance P

Endogenous opiates

Central nervous system Cholecystokinin

Glutamate

Serotonin

Norepinephrine

Substance P

Endogenous opiates

β-Endorphin

Endorphins

Dynorphins

Serotonin

Norepinephrine

Neurotensin

Source. Adapted from Terman GW, Bonica JJ: “Spinal Mechanisms and Their Modulation,” in

Bonica’s Management of Pain, 3rd Edition. Edited by Loeser JD, Butler SH, Chapman CR, et al.

Philadelphia, PA, Lippincott Williams & Wilkins, 2001, pp. 73–152.

Sensory Pathways of Pain and Acute Versus Chronic Pain 21

The PAG is a midbrain structure with an abundance of opiate receptors.

Neural connections extend from the PAG to neighboring serotonergic structures

(e.g., the RVM) and noradrenergic structures (e.g., the dorsolateral ponto-

mesencephalic tegmentum [DLPT]). The pain-modulating influences of the

PAG are conducted predominately, if not exclusively, through the RVM. The

RVM in turn projects onto the cells of the dorsal horn in laminae I, II, and V

(Terman and Bonica 2001). Analgesia results if morphine is injected into the

PAG, RVM, or amygdala. In µ-opiate receptor–deficient mice, morphine in-

jection into the PAG, RVM, and amygdala is completely ineffective in mitigat-

ing pain. The µ-receptor, therefore, is responsible for the supraspinal analgesia

produced by opiates, mediated through the PAG and RVM.

Additionally, axons of supraspinal nuclei extend down the spinal cord,

synapse within the dorsal horn, and release monoamines that influence pain

transmission (see Table 2–3). Essentially all of the serotonin-containing neu-

rons in the dorsal horn originate from the RVM and the raphe nuclei. Thus,

for example, stimulation of the RVM evokes serotonin release with resultant

analgesia, an effect that can be blocked by concomitant serotonin antagonist

(e.g., methysergide) administration. The analgesic effects of serotonin are

thought to be mediated largely by 5-HT1A receptors (Terman and Bonica

2001).

As with serotonin, norepinephrine released by axons extending from the

locus coeruleus and DLPT and terminating within the dorsal horn can inhibit

pain transmission (see Table 2–3). The analgesic effect of norepinephrine is

thought to be mediated by activity at the α2-receptor. Support for this is

suggested by the fact that α2-receptor agonists (e.g., clonidine) can produce

analgesia. In addition, norepinephrine appears to be essential for opioid-

induced analgesia; blockade of norepinephrine (e.g., by phentolamine) re-

duces the effects of systemically applied opioids. However, serotonin and

norepinephrine have both nociceptive and antinociceptive effects depend-

ing on the specific receptor subtypes and the neural circuitry activated (see

Table 2–3).

Opiate Receptors and Descending Inhibition of

Pain Pathways

There are four classes of opiate receptors recognized to date (Terenius 1985).

The µ-receptor is responsible for supraspinal analgesia. It also produces eu-

22 Clinical Manual of Pain Management in Psychiatry

phoria from opiate use and is responsible for physical dependence. Physical

effects of opiates (e.g., hypotension, decreased respirations, hypothermia, pru-

ritus, and decreased gastrointestinal motility) are all attributed to µ-receptor ac-

tivation from opiate use.

Analgesia on a spinal level is a result of the opiate activation of the κ-recep-

tor. Activation results in pupil constriction and sedation. The δ-receptors also

produce analgesia and are activated by endogenous opiates. The role of the σ-

receptor is more controversial. It produces no analgesia but is responsible for

the dysphoria, and possibly hallucinations, associated with opiate use. Because

of these disparate effects, compared with other opiate receptors, there is con-

troversy about whether the σ-receptor is actually an opiate receptor.

The µ-receptor produces more analgesia than the other types of receptors.

It is also responsible for changes in respiratory activity, gastrointestinal motility,

and sphincter tone produced by opiates. The µ-receptor is abundantly present

in the dorsal horn, medulla, and the PAG. It is also responsible for pain mod-

ulation at peripheral nerve endings. Its abundance in the myenteric plexus is

likely responsible for the effects of the opiates on gastrointestinal motility and

sphincter tone.

Table 2–3.

Monoamine neurotransmission involved in

descending pain inhibition

Effect on pain transmission

Neurotransmitter and sources Receptors Inhibitory Promoting

Serotonin

Rostral ventromedial medulla

Raphe nuclei

5-HT1A

5-HT2

5-HT1B

5-HT3

+

+

+

+

+

+

Norepinephrine

Locus coeruleus

DLPT

α2

α1

+

+

Note. Serotonin and norepinephrine have both nociceptive (pain promoting) and antinocicep-

tive (pain inhibiting) effects depending on the specific receptor subtypes and the neural circuitry

activated. DLPT =dorsolateral pontomesencephalic tegmentum.

Source. Adapted from Terman GW, Bonica JJ: “Spinal Mechanisms and Their Modulation,” in

Bonica’s Management of Pain, 3rd Edition. Edited by Loeser JD, Butler SH, Chapman CR, et al.

Philadelphia, PA, Lippincott Williams & Wilkins, 2001, pp. 73–152.

Sensory Pathways of Pain and Acute Versus Chronic Pain 23

Pain-Augmenting Mechanisms and the

Emergence of Chronic Pain

When acute pain is inadequately treated, there is an increased risk of emer-

gence of chronic pain. Several mechanisms are postulated to play a role in the

development of chronic and enduring pain (see Table 2–4).

Ongoing abnormalities in peripheral tissues, with resultant inflammation,

can result in activation of nociceptive pathways, rendering pain chronic. In

such cases, treatment is best directed at the inflammatory mechanisms (e.g.,

aspirin or nonsteroidal anti-inflammatory agents). Peripheral nerves may be-

come dysfunctional due to injury or disease (e.g., diabetes, infection, toxin

exposure). Damaged neurons may fire spontaneously. Nociceptive fibers fir-

ing in this way are perceived in the CNS as signaling pain, yet in the peripheral

tissues there may be no current injury. In such cases, antidepressants and anti-

convulsants might be the most helpful treatment.

Trauma and injury can produce reflex motor activity in the vicinity of the

injury, producing spasm. This process may initially serve a protective function

in acute pain states, but in chronic pain states it can lead to aggravated muscle

tension that exacerbates painful states (Zimmerman 1979).

The dorsal horn can become sensitized by a number of mechanisms that

can potentiate chronic pain. Changes that occur within the dorsal horn may

account for the maintenance of pain sensation that loses its relevance in its

ability to signal danger. This sensitization appears to be related to changes me-

diated by CNS neurotransmitters, especially the excitatory neurotransmitter

glutamate. With repeated stimulation (e.g., in poorly treated acute pain or in

Table 2–4.

Causes of chronic pain

Ongoing activation of pain pathways from the periphery can cause pain

to become chronic.

Peripheral nerves may be dysfunctional.

Motor reflexes may potentiate pain.

Dorsal horn can become sensitized.

Sympathetic nervous system can become a major contributor to

ongoing pain.

Cortical and limbic activity can contribute to pain.

24 Clinical Manual of Pain Management in Psychiatry

re-injury), glutamate activity can expand to include other receptors, including

N-methyl-D-aspartate (NMDA) receptors. With expansion of glutamate

activity, a series of intracellular processes occur that result in the heightened

activation of dorsal horn cells, referred to as wind up. Such processes become

difficult to interrupt from a therapeutic standpoint; however, NMDA recep-

tor blockers (e.g., ketamine) can be helpful.

Ongoing NMDA activation can result in cell death. Death of neurons leaves

areas of deafferentation in the spinal cord pathways. As a result, nearby sen-

sory neurons often sprout collaterals into the deafferentated area to replace the

synaptic connections lost after cell death. This replacement results in an inner-

vation of pain pathways that correspond to the injured areas stimulated or ac-

tivated by nearby undamaged areas.

The sympathetic nervous system can become a major contributor to on-

going pain (Zimmerman 1979). Trauma and injury trigger a sympathetic re-

sponse that can effectively alter the neurochemical milieu of nociceptors in the

periphery, along with causing changes in the microcirculation. This situation

can alter the sensitivity of peripheral pain receptors, thereby augmenting pain

sensitivity.

Pain can be maintained—despite lack of injury or even after effective heal-

ing—by the actions of the sympathetic nervous system. In such cases, pro-

tracted painful conditions can arise, such as reflex sympathetic dystrophy and

complex regional pain disorder. Some of these disorders can be alleviated by

blockade of sympathetic activity (i.e., sympatholysis); however, not all re-

spond to sympatholytic techniques. Treatment for such disorders can include

nerve blocks, sympathetic nerve blocks, and psychotropic medications (e.g.,

antidepressants and anticonvulsants).

Commensurate alterations in the thalamus and somatosensory cortex can

occur after peripheral nerve injury. Thus, even after an amputation, the area of

the somatosensory cortex corresponding to the amputated limb increases.

Other cortical and limbic events can contribute to pain. The experience of pain

can be shaped and influenced by the diffuse interconnections of the pain path-

ways with limbic and cortical pathways. In such cases, psychoactive medica-

tions, psychotherapy, and adjunctive therapeutic approaches such as relaxation

training may be helpful modes of treatment.

Sensory Pathways of Pain and Acute Versus Chronic Pain 25

Acute Versus Chronic Pain

The sensation of pain serves an adaptive function. Specifically, nociceptive

pathways serve to alarm the organism that some damage or injury has been

sustained and that efforts may need to be directed at tending to the injury and

avoiding further injury. Consider a disorder such as Hansen’s disease, also known

as leprosy, which is characterized by dysfunction in pain-mediating pathways.

Persons infected with Mycobacterium leprae, the agent that causes the disease,

have deficits in pain perception. On the surface, this seems quite desirable;

however, over the course of the illness, these patients sustain marked deficits in

self-care and are exposed to hazards brought on by physical injury and infec-

tion. Death can result from the lack of appropriate awareness of the bodily

warning mechanisms that would otherwise motivate treatment.

Problems arise when pain takes on a life of its own. Certainly, in medical

conditions in which there is ongoing tissue damage—arthritis, for example—

pain may likewise be ongoing. One might question the utility of such pain, be-

cause one certainly is aware of the trauma that warrants medical attention. On the

other hand, and perhaps more troubling, there are situations in which pain

persists despite healing (e.g., postherpetic neuralgia) or situations in which

pathologic processes emerge within the CNS or the peripheral nervous system

(or both) to produce aberrant activity that is interpreted and experienced as

pain, as in Dejerine-Roussy syndrome (a pain syndrome related to thalamic

stroke).

Classifications of Acute and Chronic Pain

Pain is classified in several ways, including the familiar categories of acute and

chronic. For example, pain can be classified based on its temporal aspects, its

etiology and its associated features from differing sources, and its functional

significance (see Table 2–5). Acute pain has been customarily defined as pain

that is less than 6 months in duration. Chronic pain is defined as pain persist-

ing beyond 6 months (Crue 1983). There are always problems with arbitrary

definitions such as these. For example, it becomes difficult to classify some

painful conditions (e.g., migraine or osteoarthritis) based on temporal aspects.

Migraine is a recurrent painful disorder that can persist for years, but the spe-

cific episodes of pain are relatively short-lived. Osteoarthritis, on the other hand,

26 Clinical Manual of Pain Management in Psychiatry

is a chronic, progressive medical condition that is accompanied by a mixture

of acute and chronic pain components. Acute pain can be precipitated by new

injury, whereas chronic pain features can arise from prior injuries and sensitiza-

tion of peripheral nervous system involvement.

Generally, acute pain is considered to be pain that serves self-protective

functions. The value of the alarm functions of pain brought on by the inad-

vertent slamming of one’s thumb with a hammer is obvious. Such pain, it is

hoped, is discrete and mobilizes the person to take measures to minimize pain

and prevent further injury. Conversely, chronic pain is considered to have lost

such meaningful aspects. One is hard-pressed to arrive at any adaptive func-

tion gleaned from chronic neuropathic pains or fibromyalgia.

Acute pain arises from tissue injury, trauma, or inflammation. Chronic pain

extends beyond the period of healing and can be brought on by pathophysi-

ologic processes within the nervous system. Some pain states can be mediated

by the ongoing barrage of peripheral pain sensors (i.e., nociceptors). The patho-

logic firing of peripheral or CNS pathways that mediate pain can also trigger

chronic pain.

Another distinction between acute and chronic pain states is based on the

presence of psychological and psychiatric conditions that accompany or ag-

gravate the pain. The pain brought on by fracture or another traumatic injury

is not necessarily accompanied by the personality changes and psychiatric dis-

turbances that can accompany chronic pain states. Psychological sequelae of

acute pain are likely to be discrete and obvious.

Table 2–5.

Features distinguishing acute and chronic pain

Acute pain Chronic pain

Duration <6 months >6 months

Cause Tissue damage, injury,

inflammation

Pathophysiologic processes

in the peripheral or

CNS pathways

Psychogenic factors

Biological utility Yes No

Psychological factors

contributing

No Yes

Note. CNS=central nervous system.

Sensory Pathways of Pain and Acute Versus Chronic Pain 27

The long duration and pervasive effects of chronic pain states likely have an

impact on a person’s functioning. Naturally, pain can have profound effects on

social, interpersonal, and emotional functioning. By virtue of the long-term

course, there may be changes in mood, thought patterns, perceptions, and per-

sonality that accompany the pain. One’s life experiences and ability to adapt to

ongoing demands and stress are affected. Therefore, it is incomprehensible to

address chronic pain without considering psychological and social functioning.

Categories of Chronic Pain

Chronic pain has been categorized as nociceptive, neuropathic, or psycho-

genic (Table 2–6). These classifications differ with respect to their character-

istics and responsiveness to varying types of treatment interventions (Leo and

Singh 2002; Portenoy 1989). For example, nociceptive pain responds to anti-

inflammatory agents and opiate analgesics, whereas neuropathic pain responds

to antidepressants, anticonvulsants, and opiates.

“Patienthood” as a Psychosocial State:

The Patient With Simple Versus Chronic Pain

An array of factors can become central to the life experiences of the patient with

chronic pain (Table 2–7). As a result of these factors, a number of emotional and

psychological sequelae are associated with the chronic pain state. Physicians have

long noted a puzzling discrepancy between physical disease status and progres-

sion and the patient’s subjective experiences (Weisberg and Clavel 1999). Some

patients with severe disease present few complaints and report less disability and

emotional distress. Yet some others with little documented disease report severe

symptoms and experience marked distress and disability.

Despite the pervasiveness of chronic pain, most individuals with chronic

pain can nonetheless maintain basic functioning, work, and interests. They

are able to work with their clinicians and other care providers and can respond

with some relief to medications or interventions. At times, psychotherapeutic

interventions may be required to address mood disturbances, stress, and cop-

ing. This cluster of patients is sometimes referred to as having simple chronic

pain. Small proportions of patients with chronic pain are entirely debilitated

by the pain and are sometimes referred to as having complex chronic pain (see

28 Clinical Manual of Pain Management in Psychiatry

Table 2–6.

Categories of chronic pain

Source Localization Features Examples Effective medication

Nociceptive: somatic Damage to tissue,

soft tissue, or bone;

inflammation;

trauma

Well localized Aching, sharp Pain of arthritis,

cancer

Aspirin, NSAIDs,

COX-2 inhibitors,

opiates

Nociceptive: visceral Injury or damage to

visceral structures,

organs

Referred pain, fairly

well localized

Aching, sharp Pain of angina, kidney

stones, appendicitis

Opiates, other

analgesics

Neuropathic Damage to nerve

tissue, either

peripheral or CNS

Nerve distributions,

poorly localized

with CNS sources

Paresthetic, numb,

burning, pins-

and-needles

Postherpetic neuralgia,

trigeminal neuralgia

Antidepressants,

anticonvulsants

Psychogenic No clear underlying

cause; psycho-

logical distress

Poorly localized Vague, sweeping Somatization disorder Psychotropic

medications,

psychotherapy

Note. CNS=central nervous system; COX-2= cyclooxygenase-2; NSAID= nonsteroidal anti-inflammatory drug.

Source. Reprinted from Leo RJ, Singh A: “Pain Management in the Elderly: Use of Psychopharmacologic Agents.” Annals of Long-Term Care: Clinical

Care and Aging 10:37–45, 2002. Used with permission.

Sensory Pathways of Pain and Acute Versus Chronic Pain 29

Table 2–8 for a comparison of the two categories). In this subset, patients have

a notable preoccupation with pain. For these persons, life revolves around the

pain. Activities are forestalled, and work is not pursued. The patients may be

thrust into positions of marked dependency on others. Several, perhaps all, as-

pects of their lives are made contingent on pain experiences or are put off be-

cause the patients fear their pain might get worse (Sternbach 1974). For such

persons, being a patient is a primary psychosocial state. Life experiences be-

come centered on doctors’ visits. If these visits are unsatisfying, patients may

develop a history of “doctor shopping.” They may seek invasive and diagnos-

tic procedures to confirm the existence of the pain or alleviate their distress.

Such patients may display increasing preoccupation with medication use and,

possibly, abuse. Numerous psychological factors beset the patient with complex

pain, many of which can exacerbate and maintain pain (Weisberg and Clavel

1999).

Table 2–7.

Common problems encountered by patients with

chronic pain

Medical Problems with access to appropriate care

Difficulties in establishing a working relationship with

practitioner skilled in pain management

Psychological Comorbid mood disturbances

Physical The pain itself

Deconditioning resulting from inactivity

Medical complications from use of multiple medications

Vocatio nal Job loss

Restrictions from usual types of job activities

Financial Financial problems arising from job loss, loss of medical coverage,

or the cost of medical care

Legal Litigation related to injuries, workers’ compensation, or disability

issues

Family Pain’s interference with customary role of the patient, causing

others within the family to adopt new roles

Limited reserves of energy and time left for other family members’

needs (e.g., children’s needs, their activities, their schoolwork,

etc.) because so much is taken up with pain and the pain patient

Sociocultural Pain’s interference with patient’s ability to engage in customary

activities and maintain social ties, resulting in significant losses

in the patient’s social support network

30 Clinical Manual of Pain Management in Psychiatry

Patients with simple chronic pain may do well with a single pain specialist,

with referral as needed to services provided by practitioners in other specialties

(e.g., psychiatrists, therapists). Patients with complex pain, on the other hand,

can overwhelm a single practitioner. Clearly, such patients need a multidisci-

plinary approach to their pain, involving the coordinated joint efforts of prac-

titioners in medical, surgical, physical, neurologic, or psychiatric services.

Multiaxial Pain Classification

The International Association for the Study of Pain (1986) has advocated a

multiaxial classification of chronic pain, comparable to that used in psychiat-

ric diagnosis. The intention behind the classification system is to standardize

diagnosis and facilitate research endeavors in pain treatment. Axis I refers to

the body region that is the source of pain (e.g., lower back); Axis II refers to the

systemic source whose abnormal functioning produces pain (e.g., neurologic

system); Axis III characterizes the pattern of the pain and its temporal char-

acteristics (e.g., 6 months of continuous pain that radiates to the lower ex-

tremity); Axis IV refers to the patient’s rating of pain intensity and pain

duration (e.g., severe); and Axis V refers to the etiology (e.g., intervertebral

disk rupture). This classification approach may be useful if it is systematized

Table 2–8.

Simple versus complex chronic pain

Simple pain Complex pain

Pain is clearly defined. Multiple pain complaints are present.

Patient is easily enlisted into treatment. Difficulty can be encountered enlisting

patient into treatment.

Patient’s support systems are stable. Patient has unstable social systems.

Comorbid psychological factors are

easily defined.

Severe complicating psychological factors

can be present.

Patient’s pain shows some response to

medications and treatment.

Patient’s pain shows poor response to

medications and treatment.

Patient may require short-term

psychotherapy or psychological

interventions.

Patient may require multidisciplinary

treatment approaches, including

psychiatric treatment.

Litigation is not central to the patient’s

presentation.

Litigation is apt to be central to the patient’s

presentation.

Sensory Pathways of Pain and Acute Versus Chronic Pain 31

and employed uniformly. However, the multiaxial system has not yet been re-

quired by insurers or universally accepted in clinical circles.

Key Points

• Consistent with a biopsychosocial perspective, pain is multidimensional,

with biological (nociceptive and sensory), psychological (cognitive ap-

praisal and suffering), and social (overt behaviors and communicated dis-

tress) components.

• The neurophysiologic substrates of the pain experience can be broken down

into those elements of pain transmission emanating from peripheral, spi-

nal, and supraspinal processes.

• The mechanisms involved in pain processing within the central nervous sys-

tem are complex, influenced by the dynamic interaction of neurotransmitters,

their receptors, and pain-augmenting and pain-inhibiting neural circuits.

• Awareness of the diverse array of neurophysiologic processes underlying

the experience of pain can form the basis for appreciating various modes of

intervention for pain treatment. Overlap between neurophysiologic pro-

cesses underlying pain and related conditions (e.g., depression) may account

for the high rates of comorbidity between them.

• Differences between acute and chronic pain have largely been based on the

duration of pain. It may be more pertinent to distinguish patients with pain

by the extent to which their lives are adversely affected by their symptoms.

Thus, in the case of patients with complex pain, one’s life becomes centered

on pain and disability; being a patient becomes a primary psychosocial state.

Multidisciplinary treatment approaches become essential not only to ad-

dress symptom relief but also to mitigate related mood disturbances, im-

prove adaptive functioning, and reduce the life dissatisfaction that accompa-

nies such complex pain states.

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pp 3–32

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35

3

Evaluation of the Pain Patient

Comprehensive assessment of the pain patient involves judicious use of his-

tory, physical examination, pain assessments, diagnostic testing, and psy-

chological testing. In this chapter I focus on the elements of comprehensive

history gathering. Given that pain is a subjective experience, a number of mea-

surement indices have been employed as part of the assessment that allow for

grading the quantity, extent, or severity of the pain. The elements of the his-

tory are the focus of the first portion of this chapter, and pain assessments are

discussed in the second portion.

The neural processing of pain is quite complex, involving more than just

sensory processes. In fact, pain processing involves neurologic substrates com-

mon to emotion and cognition (i.e., limbic and cortical systems). The experi-

ence of pain and the appreciation of, and reactions to, pain information involve

cognitive and emotional factors. The behaviors displayed by the pain patient

can likewise have an impact on social and adaptive functioning. It follows,

then, that pain assessment can be quite complex, involving somatic and psy-

chological factors (cognitive, emotional, and motivational), as well as adaptive

and social functioning (Figure 3–1).

36 Clinical Manual of Pain Management in Psychiatry

Figure 3–1.

Components of the pain history.

Psychological

Mood and affect

Cognitive content

and processes

Coping repertoire

Psychiatric illness

Lethality

assessment

Social

Impact on relationships

Capacity for intimacy,

mutuality, sexuality

Activities of daily living

Vocational

Somatic

Onset/Duration

Location

Quality

Intensity

Associated features

Aggravating factors

Alleviating factors

PAIN

Evaluation of the Pain Patient 37

Conducting an Interview

During the course of verbal evaluation, the patient should be encouraged to

speak freely. Open-ended lines of inquiry should be employed to prompt the

patient to elaborate (e.g., “Tell me more about the pain” or “How has the pain

affected your lifestyle?”). Very specific lines of inquiry (e.g., “Is the pain ag-

gravated by movement?”) often restrict the free elaboration of the patient, can

prematurely limit the patient’s willingness to provide information, and can

confine the patient’s reporting of history to the examiner’s persuasion and bi-

ases. Open-ended lines of inquiry communicate that the patient is listened to,

whereas a litany of questions can suggest that the patient’s impressions and ex-

periences of pain are of less importance.

Occasional paraphrased recapitulation of the patient’s report allows the

interviewer to clarify what was conveyed. If aspects of the history are missing,

the practitioner can quickly insert clarifying inquiries (e.g., “Let me see if I got

this right. You indicated that you have been experiencing dull, aching pain in

your lower back. It seems to radiate down your right leg, and it makes you feel

unsteady when you walk. Is that right?”). If the paraphrasing is confirmed, the

practitioner might consider redirecting and clarifying questions (e.g., “I am

still unclear about something. What seems to bring on the pain?”). With pa-

tients who have difficulty articulating characteristics of the pain, encouraging

the use of metaphor could facilitate capturing the features of the pain experience

(Fishman and Loscalzo 1987).

Patients appear for psychiatric evaluation with varying agendas. For ex-

ample, a patient might seek out psychiatric assessment at the recommendation

of a clinician who is concerned about the patient’s adherence to treatment or

about psychological issues that might be contributing to or exacerbating pain.

On the other hand, the patient might have an agenda that is quite different

from the clinician’s agenda (e.g., the impact of pain on relationships, employ-

ment, and quality of life). The open-ended line of inquiry allows for exposure

and examination of the more covert aspects of the patient’s reasons for seeking

evaluation or treatment. Ascertaining the patient’s agenda can be helpful in

guiding the interview and arriving at a reasonable treatment plan that reflects

the patient’s needs. An example: A patient sought help on the recommenda-

tion of her physician, who presumed that depression was complicating her

chronic back pain. During the evaluation, it became apparent that she had con-

38 Clinical Manual of Pain Management in Psychiatry

cerns about marital issues arising from role modifications within the home as

a result of her pain (e.g., “My husband doesn’t understand my pain”). It seemed

that more direct attention to facilitating effective patterns of communication,

problem solving, and coping within the marriage would be required in order

to mitigate both the depression and the back pain.

Obtaining the Pain History

Somatic Component

Essential to the diagnosis of pain disorders is information about the somatic

components of the pain: its duration, course, intensity, and precipitating and

mitigating factors. The more detailed this history, the more likely it is that the

psychiatrist will arrive at an understanding of the pain features amenable to

treatment. In addition, clarity of these features allows the clinician to determine

whether the interventions and treatments used are effective, because one

should be able to detect changes and improvements in some or all of these pa-

rameters. Table 3–1 summarizes the somatic components to be obtained in

the pain history (Morgan and Engel 1969).

Table 3–1.

Obtaining a pain history

Onset When did the pain begin?

Location Where is the pain located? Does it radiate? If so, where?

What factors influence the radiation?

Quality What is the pain like?

Quantity How intense is the pain?

Duration and

chronology

How long has the pain been going on? What has the course

of your pain been like? Is it getting better? Worse?

Setting Under what circumstances does the pain occur?

Aggravating and

alleviating factors

What factors aggravate the pain? What brings about relief

or attenuation of pain?

Associated features What other symptoms are associated with the pain?

How does it affect your sleep? Your appetite?

Your energy level?

Source. Adapted from Morgan ML, Engel GL: The Clinical Approach to the Patient. Philadelphia,

PA, WB Saunders, 1969.

Evaluation of the Pain Patient 39

Chronic disorders of any sort, by virtue of their occurrence over time, will

produce changes in a person’s emotional and psychological state, influence

adaptive functioning, and affect social roles and relationships. Thus, evalua-

tion of such patients naturally prompts inquiry into the factors that predispose,

activate, and perpetuate the pain and disability. These factors may possibly in-

volve psychosocial stressors. Examination of the factors that render treatment

ineffective is also warranted. Once all of these factors are evaluated and ad-

dressed, appropriate treatment, rehabilitation, and reclamation of the patient

will be possible (Aronoff et al. 2000). Having established the history of pain

complaints, the physician can direct attention to the psychological and social

correlates of the pain.

Psychological Component

Certainly, any focus on somatic concerns should prompt the psychiatrist to

consider psychiatric comorbidities in which pain or other related somatic

concerns might be a feature or focus (Fishbain 1999a). Careful inquiry will

need to be made into common psychiatric comorbidities associated with pain

(Table 3–2).

The psychiatrist should inquire into the relationship of emotional and psy-

chological states to subjective pain complaints and exacerbations. Inquiry

should be conducted in a manner that does not trigger defensiveness on the part

of the patient. Often, patients have become accustomed to being rejected by

Table 3–2.

Psychiatric disorders accompanying acute and

chronic pain

Anxiety disorders

Delirium

Depression

Sexual dysfunction

Sleep disorders

Somatoform disorders

Conversion disorder

Hypochondriasis

Pain disorder

Somatization disorder

Substance abuse or dependence

40 Clinical Manual of Pain Management in Psychiatry

physicians who use traditional medical approaches and have felt as though their

pain complaints have been dismissed as being all in their head. Consequently,

patients with chronic pain can be exquisitely sensitive to inquiry that suggests

even the most remote aspects of psychological and emotional dysfunction. They

may well fear that attention could be directed away from the physical aspects of

treatment. Nonetheless, they could respond favorably to the comprehensiveness

of an assessment—including the possible emotional and psychological effects of

chronic pain—and the prospect that treatment directed at the psychological fac-

tors accompanying pain might also have pain-mitigating effects.

The essential components of the psychological variables related to pain are

summarized in Figure 3–1. These items are interrelated, so there is consider-

able overlap in a person’s moods, cognitive appraisals, and coping strategies.

Thus, flexibility is required in assessment of each of these components.

Mood and Affect

Careful examination of mood states can begin with inquiry into the patient’s

pervasive mood over recent weeks and whether this represents a change from

his or her baseline mood. Concerned primarily about illness, disability, func-

tioning, and treatment, the patient may well dismiss his or her own mood or

affective states as being natural reactions to the pain state. Consequently, inquiry

might be directed at how other people in the patient’s life have commented on

the patient’s recent mood and whether they have construed the recent mood as

a distinct change from the patient’s usual mood.

Inquiry into mood and affective states is likely to reveal the emotional fac-

tors related to the pain experiences among patients with chronic pain. Among

inpatients with chronic pain, pain ratings were linearly correlated with anger,

fear (or anxiety), and depression. On the other hand, the presence of joy, in-

terest, and surprise were predictive of lower pain states. Other emotional states

(e.g., shame, disgust, contempt) were only weakly correlated with pain com-

plaints (Fernandez and Milburn 1994).

It might be possible to determine in the interview that certain affective

states are temporally related to pain levels. Discrete, situational emotions are

important determinants of pain ratings (Gaskin et al. 1992). Thus, for exam-

ple, it could become apparent that certain emotional states precede pain,

whereas other emotional states arise after the experience of pain. Exacerbations

of pain could possibly predispose a person to certain affective states (e.g., dys-

Evaluation of the Pain Patient 41

phoria, anxiety, anger) (Huyser and Parker 1999). On the other hand, the

presence of affective states (e.g., anger) could possibly result in exacerbations

of pain. Thus, dysphoria can arise as a reaction to the pain experience, as a re-

sult of the lack of satisfactory treatment, in response to the sequelae of pain, or

as an independent disorder (i.e., depression) warranting treatment. It might

be helpful to discern whether such relationships exist, because these relation-

ships can have implications for possible treatment interventions.

Anger can be an important component of the experience of the patient

with chronic pain (Wade et al. 1990). The presence of anger in and of itself is

not a problem. Rather, problems arise when there is a conflict around the ex-

pression of anger, there is difficulty around the expression of anger, or there are

high levels of hostility. In these circumstances, there is likely to be activation of

the autonomic nervous system and endocrine systems (e.g., increased cortisol

levels) and other physiologic effects of anger (Fernandez and Turk 1995). Pa-

tients incapable of diffusing anger or channeling it into appropriate avenues

are prone to resentment, suspicion, mistrust, and heightened levels of arousal.

Likewise, inability to modulate unpleasant emotional states is likely to heighten

levels of pain (Kinder and Curtiss 1988).

Anxiety disorders are accompanied by an increased incidence of somatic

symptoms and pain complaints (Beidel et al. 1991). Anxiety can lower pain

thresholds and predispose one to heightened somatic concerns (Barsky et al.

1988).

More important than the mere presence of a particular affective state are the

ways in which unpleasant emotional states are managed. Thus, inquiry into

coping strategies would be warranted (see also section “Coping Strategies” later

in this chapter). Naturally, the repertoire of strategies one employs to comfort

oneself and the effectiveness of those strategies would be of interest.

Cognitive Patterns

The psychiatrist needs to examine the patient’s cognitions about pain—that

is, the beliefs held by the patient about the meaning of the pain, expectations

about future pain, and interpretation of the impact the pain has on his or her

life, functioning, and relationships. Cognitive appraisal of pain depends on

the individual’s perspective on the consequences of pain on his or her well-

being, the importance he or she assigns to the pain, and his or her view of the

measures available to cope with the pain and its ramifications.

42 Clinical Manual of Pain Management in Psychiatry

Questions arise as to the role the pain plays in the patient’s life. This aspect

of inquiry might naturally follow from discussions of the medical conditions

underlying the pain. The topic can be introduced by asking patients what they

were told about the cause of the pain and what their reactions were to these ex-

planations. For example, for some patients the explanations offered by clini-

cians are reassuring; for others, they are met with incredulity. This line of in-

quiry can reveal the sorts of preoccupations and concerns about the pain that

might not have been overtly expressed to other clinicians. For example, in pa-

tients with cancer, this line of inquiry might unveil thoughts the patients have

about fears that the cancer is spreading or that it now renders them “terminal.”

It also can reveal misconceptions about the pain or distortions of what has

been disclosed to them and, therefore, a need for clarification and education.

When there is no clear etiology for the pain, the interviewer can gain insight

into the patient’s disease conviction. Disease conviction refers to the extent to

which patients maintain that they are ill, how much they are bothered by symp-

toms, and the extent to which they would accept the reassurances of the physi-

cian. Disease conviction is notably present among depressed patients with so-

matic concerns (Pilowsky 1975).

Attention needs to be directed to listening for the distorted cognitive pat-

terns and styles that can be manifested by the patient with pain (Table 3–3).

These patterns and styles may be influenced by one’s prevailing emotional

state. On the other hand, such cognitive patterns can influence one’s emo-

tional state. Thus, the relationships are likely to be reciprocal. Such cognitive

styles are likely to reduce self-efficacy, hamper development of effective cop-

ing, drain one’s support systems, accentuate unpleasant emotional states (e.g.,

anger, anxiety, depression), and exacerbate pain. The presence of such pat-

terns, therefore, could signal the need for psychotherapeutic interventions.

In a recent interview, a distressed patient reported, “The pain—it’s always

there. It ruins my entire life. There is absolutely nothing that gives me relief.”

The patterns reflected in these statements signal the presence of catastrophizing

(“It ruins my entire life”), overgeneralizing (“It’s always there”), and helplessness

(“Absolutely nothing that gives me relief”). Recognition of these features might

prompt further inquiry into similar beliefs about other aspects of the patient’s

life. Using this line of inquiry, the evaluator can determine how pervasive these

patterns of beliefs are, how rigidly they are maintained, and how malleable the

person is in terms of alternative ways of looking at his or her condition.

Evaluation of the Pain Patient 43

Coping Strategies

Identification of problematic emotions and cognitive patterns should signal a

need for inquiry into the coping strategies used by the individual to self-

soothe, self-comfort, reduce distress, and modulate unpleasant states. Inquiry

should again be open-ended (e.g., “When you get to feeling [or thinking] this

way, how do you cope?”). Attentive listening to active and passive strategies is

required. Some patients have a propensity to retreat and withdraw from other

Table 3–3.

Problematic cognitive patterns in pain

Catastrophizing Tendency to view and expect the worst (e.g., “I am doomed

to have pain and misery forever!”)

Helplessness Belief that nothing that one does matters, that there is no

benefit despite one’s best efforts (e.g., “My doctor says that

I should exercise to improve my osteoarthritis. I know it

won’t help!”)

Help-rejecting Rejection of the efforts of well-meaning others as a means

of expressing anger, securing ongoing support or attention,

or even manipulating others (e.g., “I had problems with

the last four medicines you gave me.”)

Labeling Ascribing a behavior of a person to a characteristic or

nature of the person; the patient who is disappointed

about the ineffectiveness of a medication might need

to discount the qualifications of the clinician

(e.g., “The medication the doctor gave me didn’t

help. What a quack!”)

Magnification Exaggeration of the significance of a negative event (e.g.,

“My pain got worse at work yesterday. I had to leave an

hour early. I might as well come to grips with the fact that

I am totally disabled!”)

Overgeneralization Expanding one adverse event or setback to many or all

aspects of one’s life (e.g., “If this medication doesn’t help

me, nothing will!”)

Personalization Interpretation that an event or situation is indicative of

something about oneself (e.g., “Because of the pain,

I am a worthless failure!”)

Selective abstraction Propensity to attend selectively to negative aspects of

one’s life while ignoring satisfying and rewarding aspects

(e.g., “Everything that happens in my life is bad!”)

44 Clinical Manual of Pain Management in Psychiatry

people (thus affecting social functioning). Other patients might have a need

to enlist and secure the support of others (an approach that can be adaptive or

maladaptive). Still other patients have a tendency to engage in passive coping

strategies (e.g., hoping for relief, praying, sleeping). For still others, there might

be a tendency to distract themselves with other activities, engage in self-state-

ments that can produce relief, and so forth (Rosenstiel and Keefe 1983).

Some patients are apt to focus on somatic complaints and pain, as op-

posed to dealing with the distress and emotional responses incurred by having

a painful condition. In addition, somatic amplification might be invoked when

emotionally laden distress is difficult for patients to tolerate or to address di-

rectly. Thus, some patients tend instead to focus on, embellish, or magnify so-

matic complaints and concerns so as to enlist the support of others and to com-

municate to others their level of distress. Others might cope with unpleasant

emotions and cognitive patterns by self-medicating with analgesics or even by

abusing substances.

Coping strategies that involve the support of other people may be healthy

or they may be overdemanding and exasperating to members of the patient’s

social support network. Patients’ cognitive processes can serve to put up bar-

riers to addressing and dealing with problem areas in their lives. Statements

such as “This pain will be the ruin of me! It will never get better, no matter

what they tell me to do!” might actually serve to foster passivity and buffer the

patient from taking any responsibility in the rehabilitation process.

It is critical to assess lethality. Patients with chronic pain and unremitting

or terminal illnesses are particularly prone to despair. The risk of suicide is in-

creased among persons with medical illnesses in which there is distress over

disfigurement (Work Group on Suicidal Behaviors 2003), pain (Chochinov et

al. 1995; Fishbain 1999b; Fishbain et al. 1991), comorbid mood disorders

(Work Group on Suicidal Behaviors 2003), substance abuse (Borges et al. 2000),

severe functional impairments (Waern et al. 2002), or increased perceived lev-

els of disability. It is imperative to carefully inquire into thoughts of despair,

hopelessness, suicidal ideas and suicide intent, and whether plans are present.

In ascertaining the severity of these issues, it is important to determine the fol-

lowing: Is there a history of prior suicide attempt? If so, did the attempt occur

within recent months? Is there a family history of suicide? What support sys-

tems are in place to ensure the patient’s safety? Does the patient make use of

those available supports?

Evaluation of the Pain Patient 45

Social and Adaptational Component

The patient’s social history can be especially important in understanding the

profound impact of pain (see Figure 3–1). Another important feature to con-

sider is the patient’s adaptive functioning. Inquiry should be focused on what

the patient is able to do and what activities are avoided because of the pain. A

thorough evaluation of the following factors is indicated: the patient’s day-to-

day activities and interests, loss of (or decline in) activities due to the pain, the

patient’s occupation, how work is affected, how the patient is supported (if

not by work), concerns over the accessibility and cost of medical care, whether

litigation related to the cause of pain is pending, and whether applications for

disability are under review. Inquiry into the patient’s general life satisfaction is

critical (e.g., how free time is spent, pursuit of interests, how the patient comforts

himself or herself, how the patient manages pleasant and unpleasant emotions).

The interviewer needs to listen for elements that suggest the patient assumes

an invalid role in all or most aspects of his or her life and assess the function

that role serves for the patient.

Especially pertinent is the identification of significant persons in the patient’s

life and how the pain has influenced relationships with those persons. For exam-

ple, pain patients and their significant others can experience loss in intimacy and

sexual dissatisfaction because of the impact of pain on sexual functioning.

Inquiry into how pain is communicated to others, the expected responses,

the responses generated and from whom, and how the patient perceives those

responses is germane. Inquiry should be directed to how the patient’s pain in-

fluences the behaviors of others. To avoid defensiveness on the part of the pa-

tient, the examiner should avoid implying that such influence on others is

intentional or manipulative. However, the interviewer should recognize the

possibility that such influences may be unconsciously driven. Given that in-

terpersonal relationships are bidirectional, it is equally important to ascertain

the extent to which the patient’s adaptation in the context of pain may be

shaped or reinforced by the responses of others in his or her life (Turk and

Okifuji 2002).

Careful histories of alcohol and drug use are imperative. Abused agents

can include medications prescribed for the patient’s use (e.g., opiate analge-

sics), and patients may become defensive if they fear that analgesics provided

to them—even if not fully effective in eradicating pain—might be withdrawn

or withheld. Patients might require assurance that this line of inquiry is part of

46 Clinical Manual of Pain Management in Psychiatry

a comprehensive approach. This inquiry is also important in determining what

types of medical and pharmacologic approaches best suit the patients’ needs.

Longitudinal Approach

A historical perspective on the pain history can be quite helpful in under-

standing the evolution of the present pain experience. Thus, it can be useful to

evaluate the patient’s early pain complaints, history of medical interventions,

and response to treatment. There can be indications of the quality of previous

doctor–patient interactions; how proactive or passive a role the patient took;

and the patient’s history of adherence to medical treatment, including physical

or occupational therapy, medications, diet, exercise, and other components.

Earlier history can constitute a backdrop against which the current pain ex-

periences can be evaluated. Previous experiences can influence the patient’s

expectations of current treatment, his or her current doctor–patient relation-

ships, and the patient’s participation and follow-through with treatment.

Other longitudinal aspects include developmental life experiences. The

presence of early childhood illnesses (e.g., diabetes) can have a profound im-

pact on family interactions and the shaping of early relationships. These ex-

periences can shape current relationships as well. Family history of medical ill-

nesses, particularly those involving pain, and how these were experienced by

the family—and by the patient in particular—can reveal patterns of pain be-

haviors with which the patient grew up and that influence current experiences

(Fishman and Loscalzo 1987). These patterns may have an impact on how the

patient currently manages his or her pain. Degree of impairment and disability

arising from painful medical or surgical conditions can also have been “learned”

by the patient in such early experiences. Responses of family members to treat-

ment endeavors might have shaped the patient’s expectations and beliefs about

the utility and effectiveness of pain interventions, whether or not those early

experiences bore directly on the type of pain (or the source of pain) the patient

experiences in his or her own current medical condition.

Other developmental factors may have an impact on a person’s current so-

cial and adaptive functioning. For example, a history of sexual abuse is present

in a number of patients with chronic pelvic pain, abdominal pain, and even

disorders such as fibromyalgia (Gross et al. 1980). Accessing this information

can relay significant history about the dynamics within the home, how crises

were managed, what support systems were available to the patient while grow-

Evaluation of the Pain Patient 47

ing up, and whether the patient has a support system in place to actually sup-

port, nurture, and protect him or her. This inquiry should be conducted in a

sensitive and respectful manner. Patients may well be reluctant to confide such

information, fearing that it could reflect adversely on them. They may feel a

need or a desire to protect family members despite the abuse itself or the family’s

failure to intervene on their behalf even in the face of evidence or suggestion of

abuse. Patients may need to be informed that such experiences can influence

how they approach their world, can affect the patients’ expectations regarding

the reliability and goodwill of treating sources (authority figures), and have

been related to certain chronic pain disorders.

Evaluation of Treatment Suitability

At times, psychiatric evaluation is requested to assess the factors that contrib-

ute barriers to effective pain treatment. Evaluation can determine whether

psychopharmacologic treatment, psychotherapeutic modalities, or both should

be employed. Sometimes psychiatric evaluation is requested when psycholog-

ical factors are mediating the pain experience or when psychiatric disorders

more completely explain the origin of the pain. Psychiatric evaluation can be

conducted to assess the patient’s suitability for other interventions (e.g., sur-

gery). Table 3–4 lists the factors that predict a poor surgical outcome for pain

disorders. Once such factors are addressed in psychiatric treatment, however,

a patient could possibly be considered for surgical interventions (see also sec-

tion “Role of the Psychiatrist in Pain Management Related to Interventions”

in Chapter 7, “Special Techniques in Pain Management,” of this book).

Pain Assessment Instruments

Pain assessment tests and scales are useful adjuncts to the evaluation of the

pain patient. These instruments allow the examiner to ascertain the severity

and intensity of the pain experience. A number of scales are available, and the

selection of the assessment instrument to be used is determined in part by the

characteristics of the pain and the elements gleaned from the interview (see

Table 3–5 for a list of psychometric scales used in assessing chronic pain). In

acute pain states, certain types of assessments are desirable that are of limited

utility in assessing chronic pain states (see Table 3–6 for a summary of the

48 Clinical Manual of Pain Management in Psychiatry

instruments used in acute vs. chronic pain). On the other hand, multidimen-

sional pain assessments and complex behavioral assessments can be invoked

when complex interactions between pain states and psychosocial factors are

implicated in mediating pain.

Patients with acute pain (e.g., postoperative pain) are preoccupied with the

situational characteristics of the pain. The pain is expected to be time limited.

Conversely, for those with chronic pain, their day-to-day, interpersonal, aca-

demic, and vocational functioning are overshadowed by the pain experience.

Therefore, assessments used in acute pain settings will be fundamentally dif-

ferent from those used in chronic pain. Measures for acute pain, summarized in

Table 3–6, focus on the experience and intensity of pain and assess responsive-

ness to treatment interventions. Chronic pain assessments focus on broader as-

pects of patients’ pain experiences, functioning, and psychological adaptation.

The pain assessments described in the following subsections serve a num-

ber of functions, including assessment of pain intensity, quality, and duration.

In addition, such scales can assist the physician in making treatment selections

and assessing the efficacy of treatment.

Table 3–4.

Factors that suggest poor surgical outcome for

pain disorders

Emotional factors

Anger

Anxiety

Depression

Cognitive factors

Catastrophizing

Perception of loss of control

Vocational factors

Financial settlement or pending litigation

Job dissatisfaction

Workers’ compensation

Social factors

Marital dissatisfaction

Historical factors

History of physical abuse

History of sexual abuse

Prior psychological treatment

Substance abuse or dependence

Evaluation of the Pain Patient 49

Single-Dimension Scales

The most commonly used pain scales involve single-dimension ratings of pain

intensity. Such scales are appealing because of their ease of administration and

interpretation. Patients also find them easy to complete (e.g., requiring little

in the way of time commitment or concentration). However, single-dimension

scales have been criticized for oversimplifying pain ratings and for ignoring

factors that contribute to or exacerbate the pain experience (e.g., emotional

and cognitive factors).

Verbal Descriptor Scale

A verbal descriptor scale (VDS) requires that a patient rate the pain experienced

according to one of five to seven verbal descriptors. Only limited types of re-

sponses are permitted. Such scales can be used in clinical and experimental set-

tings. Of course, use of a VDS assumes that the patient has intact verbal skills

(i.e., reading and comprehension). Thus, these measures may not be useful for

patients who have significant language barriers or cognitive impairments or for

Table 3–5.

Psychometric scales used in assessing chronic pain

Coping Strategies

Questionnaire

Assesses the coping strategies in patient’s repertoire

to deal with chronic pain. May predict the level of

activity, physical impairment, and psychological

functioning associated with pain.

Fear-Avoidance Beliefs

Questionnaire

Assesses beliefs characterized by danger, threat, or

harm associated with pain. The degree to which

patients assign threat to activities can limit their

participation in, and lead to avoidance of,

activities related to work.

McGill Pain Questionnaire Assesses the features of pain severity and intensity.

Allows patients to qualify pain in emotional,

cognitive-evaluative, and sensory terms.

Minnesota Multiphasic

Personality Inventory

Provides personality profile and pathologic

assessment of patient with chronic pain.

Pain Interference Indices Assess the impact of chronic pain states on various

aspects of a person’s activity, functioning, and role

responsibilities.

Multidimensional Pain

Inventory

Assesses patient’s appraisal of pain, its impact on his

or her functioning, and the patient’s perceived

responses of others to his or her pain.

50 Clinical Manual of Pain Management in Psychiatry

young children. The scoring of a VDS correlates with pain ratings of other scales

(e.g., a visual analog scale [VAS]). The VDS, included in Figure 3–2, ignores the

emotional, cognitive, and behavioral components of pain.

Numeric Rating Scale

A numeric rating scale (NRS) is often used to measure pain experience and in-

tensity. Patients are asked to rate their pain on an 11-point scale, from 0 (no

pain) to 10 (worst pain). A variation of this scale shows a rating of pain from

0 to 100, with similar anchors (Jensen et al. 1986). These scales are reliable and

correlate with other simple assessment measures. Use of an NRS requires that

the patient have intact language and cognitive skills. One drawback of NRSs

is that the patient’s rating of pain (i.e., the number selected) has no intrinsic

meaning. Thus, if a patient rates his pain as a 5, this rating cannot be assumed

to be one-half that of another patient who rates her pain as a 10. Furthermore,

the transition from one rating (e.g., from 5 to 4) might not mean the same,

even within the same patient, as a transition at another point in the scale (e.g.,

from 9 to 8).

Visual Analog Scale

An extension of NRSs, the Visual Analogue Scale consists of a 10-cm line with

anchors at 0 and 10 or verbal anchors (see Figure 3–2). The patient is asked to

draw an X along the line that best denotes his or her level of pain. The VAS has

been used in clinical as well as experimental settings. The denoted pain levels for

an individual can be compared over time to quantify levels of pain worsening or

improving. These serial comparisons, unlike those employed with repeated use

of NRSs, are proportional. However, the use of the VAS for clinical compari-

Table 3–6.

Pain assessment instruments for acute and chronic pain

Acute pain Recurrent/chronic pain

Visual analog scale or numeric

rating scale

Visual analog scale, McGill Pain

Questionnaire

Medication use Medication use

Observer rating Observer rating

Pain diary

Multidimensional Pain Inventory

Psychological measures

Evaluation of the Pain Patient 51

Figure 3–2.

Single-dimension pain assessment instruments.

No

pain Mild

pain Moderate

pain Severe

pain Very

severe

pain

Worst

pain

possible

Verbal descriptor scale

012 345678910

No

pain

Moderate

pain

Worst

pain

Numeric rating scale

Visual analog scale

No

pain

Pain as

bad as it

could be

Pain as

bad as

it could be

Faces scale

Faces scale

52 Clinical Manual of Pain Management in Psychiatry

sons has been questioned (Carlsson 1983). A VAS might not be suitable for el-

derly patients or patients who have difficulty understanding its abstract

concept. In such cases, pain can be erroneously denoted, and the faulty values

can impede the appropriate characterization of the pain and its treatment.

Faces Scale

With the faces scale, the patient is asked to rate pain intensity according to

printed facial expressions conveying varying amounts of distress (see Figure 3–2).

This is an easily understood rating instrument and one that has appeal for chil-

dren. The faces scale allows the examiner to bypass issues related to language

barriers (Frank et al. 1982).

Behavioral Measures

Behavioral measures are instruments that assess pain in a manner vastly dif-

ferent from the simple rating scales. Although some professionals in the field

have questioned the utility and reliability of observer ratings of pain behavior,

these ratings are often used by clinicians and nursing staff. Thus, when some-

one complains of distress, the clinician often examines the overt behavior of

the patient to look for corroborating behaviors that substantiate the allegation

of pain. The clinician might look for evidence of distress, facial grimacing,

wincing or frowning, guarding of an affected area, limping, splinting, muscle

tension, and similar behaviors. The problem with observer ratings is that the

results are contingent upon the skill of the observer in detecting pain symp-

toms. However, observer ratings are also subject to a great deal of bias. For in-

stance, observing a patient with chronic pain who is able to smile or make puns

periodically might lead one to dismiss the patient’s allegations of pain because

of the bias that such behaviors would be entirely inconsistent with pain.

Medication Use

Reviews of the patient’s use of medications can be an indicator of the patient’s

pain experience and severity. It is useful to assess the patient’s adherence to

treatment, appropriateness of medication use, and excess medication use. Pain

patients can be unreliable about medication use and can significantly under-

estimate the extent of their opioid use (Ready et al. 1982). Thus, the support

of collateral informants (e.g., from a spouse or other family member) to pro-

vide information about the use of medications can be helpful.

Evaluation of the Pain Patient 53

Pain Diary

A pain diary can be as simple or as detailed as the clinician deems necessary

(see Figure 3–3 for an example). Categories that might be included in a pain

diary include the date and time; the pain rating; the situation; the patient’s

emotions, behavior, and thoughts; and the response of others to the patient’s

pain. Pain diaries can be very useful, revealing patterns of pain intensity, ex-

acerbations of pain, and mitigating factors. They can likewise uncover varying

psychological states temporally related to episodes of pain or pain relief. This

information can be particularly useful when patients are resistant to the idea

that psychological states could be related to the pain experience. Also, diaries can

be a source of information about the extent to which patients engage in activ-

ities (e.g., reclining, pursuing their interests).

Completion of pain diaries can be quite time-consuming for patients. For

the diary to be maximally effective, the patient must be committed to main-

taining it. Completion of the entire diary for a week in the hour preceding the

doctor’s appointment limits the utility of the diary, because the entries will be

based on the patient’s memory and recollections. Instead, the utility of the diary

is best derived when the patient maintains the diary reliably and consistently

during the periods of study. However, the more complex the diary, the less in-

clined the patient might be to reliably make entries, because the task can seem

overwhelming. In addition, clinicians need to devote some time to review the

diary contents to look for trends in the pain ratings and associated temporal

features.

Multidimensional Pain Scales

McGill Pain Questionnaire

In the McGill Pain Questionnaire (MPQ; Melzack 1975), a verbal rating scale

commonly used to characterize pain, subjects are asked to select verbal de-

scriptors for their pain among sets of categories of descriptors. A long form

and short form are available for use. The long form contains 20 sets of cate-

gories. The first 10 sets of descriptors refer to the sensory-discriminative aspects

of the pain. Sets 11–15 contain items that characterize the affective-emotional

components of the pain. Set 16 contains descriptors that correspond to the

evaluative components of pain, and the remaining sets (17–20) contain mis-

cellaneous items. The short form of the MPQ (see Table 3–7) contains 15 items.

54 Clinical Manual of Pain Management in Psychiatry

Date/Time

Pain

rating Situation Mood/Affect Activity Thoughts

Response

of others

Figure 3–3.

Example of a pain diary format.

Evaluation of the Pain Patient 55

The patient is asked to rank the extent to which each item corresponds to the

intensity of his or her pain (Melzack 1987). The short form offers the advantage

of being easier to complete, and the scoring correlates with results obtained in

the longer form. The MPQ has been translated into a number of different lan-

guages for patients for whom language barriers impede the reading or under-

standing of the English version.

Pain Interference

Any assessment of pain level—or of pain relief resulting from treatment—is

less meaningful without a consideration of the patient’s perception of the ex-

tent to which pain impairs activity and social functioning. Thus, any reduc-

tions in pain ratings that suggest an intervention is successful mean little

without commensurate changes in the patient’s psychological and social well-

being and changes in adaptive functions. Examples of such instruments include

the Pain Disability Index (Pollard 1984) and the Oswestry Disability Question-

Table 3–7.

Short form of the McGill Pain Questionnaire

None Mild Moderate Severe

Throbbing 0)_____ 1)_____ 2)_____ 3)_____

Shooting 0)_____ 1)_____ 2)_____ 3)_____

Stabbing 0)_____ 1)_____ 2)_____ 3)_____

Sharp 0)_____ 1)_____ 2)_____ 3)_____

Cramping 0)_____ 1)_____ 2)_____ 3)_____

Gnawing 0)_____ 1)_____ 2)_____ 3)_____

Hot–burning 0)_____ 1)_____ 2)_____ 3)_____

Aching 0)_____ 1)_____ 2)_____ 3)_____

Heavy 0)_____ 1)_____ 2)_____ 3)_____

Ten der 0)_____ 1)_____ 2)_____ 3)_____

Splitting 0)_____ 1)_____ 2)_____ 3)_____

Tiring–exhausting 0)_____ 1)_____ 2)_____ 3)_____

Sickening 0)_____ 1)_____ 2)_____ 3)_____

Fearful 0)_____ 1)_____ 2)_____ 3)_____

Punishing–cruel 0)_____ 1)_____ 2)_____ 3)_____

Source. Reprinted from Pain, Volume 30, Melzack R: “The Short-Form McGill Pain Question-

naire,” pp. 191–197, 1987. Copyright 1984, with permission from Dr. R. Melzack, McGill Uni-

versity and the International Association for the Study of Pain.

56 Clinical Manual of Pain Management in Psychiatry

naire (Fairbank et al. 1980). Factors included in such indices include ratings of

ability to perform activities of daily living and other customary role responsi-

bilities. These issues can be the basis for modifications in pain treatment and

can also be the focus of psychotherapeutic endeavors.

Psychological Assessments

Multidimensional Pain Inventory

The Multidimensional Pain Inventory (MPI) (formerly referred to as the West

Haven–Yale Multidimensional Pain Inventory; Kerns et al. 1985) is a 52-item

inventory developed for the assessment of a patient’s idiosyncratic appraisals

of chronic pain. The instrument relies on components of the cognitive-behav-

ioral approach to help understand and conceptualize pain. The instrument is

used to examine a person’s perceptions, appraisals, and emotions and behav-

iors associated with pain. Coping strategies used by the individual patient are

also assessed, as are the patient’s reactions to the responses of others to pain

complaints. Not only does the MPI enable the examiner to understand the pa-

tient’s view of his or her own pain, but it can also serve as a basis for the de-

velopment of treatment interventions (e.g., to be used in psychotherapy).

Response patterns can reveal patient profiles that might become a focus of

clinical attention. A dysfunctional profile reveals high levels of perceived pain,

life interference from the pain, low levels of perceived life control, and subjective

distress. An interpersonally distressed profile is likewise characterized by high

levels of perceived pain and life interference, and patients with this profile per-

ceive themselves as having low levels of social support. Last, an adaptive pro-

file is one in which the patient perceives high levels of self-control, along with

low levels of perceived pain and perceived life interference from the pain. The

profiles summarized here can have predictive value in terms of treatment ap-

proaches and treatment outcomes (Bradley and McKendree-Smith 2001).

Fear-Avoidance Beliefs Questionnaire

The Fear-Avoidance Beliefs Questionnaire (FABQ; Waddell et al. 1993) is a

16-item instrument that assesses the beliefs and fears a patient associates with

back pain. Each item is ranked along a 7-point Likert scale that ranges from

“strongly agree” to “strongly disagree.” The patient’s beliefs and fears can have

an impact on his or her range and extent of activity. The FABQ assesses fears

the patient has about eliciting pain through behaviors required at work and in

Evaluation of the Pain Patient 57

general activity. The higher the level of fear, the higher the level of the patient’s

perceived disability.

Coping Strategies Questionnaire

The Coping Strategies Questionnaire (Rosenstiel and Keefe 1983) is useful in

assessing active (e.g., diverting one’s attention, increasing the level of activity)

and passive (e.g., praying, hoping, ignoring pain) coping strategies used by

patients dealing with chronic pain. The instrument measures the extent to

which maladaptive strategies (e.g., catastrophizing) or more adaptive strate-

gies (e.g., reinterpreting the meaning of the pain and using coping self-state-

ments) are employed. Thus, the scale can illustrate those strategies that are

effective and that, therefore, should be maximized when dealing with pain. In

addition, those strategies that are ineffective and maladaptive can be the focus

of therapeutic interventions to foster modification of those strategies.

Minnesota Multiphasic Personality Inventory

The Minnesota Multiphasic Personality Inventory (MMPI; Hathaway et al.

1989) has been used extensively as an assessment tool for a variety of psycho-

logical disturbances. It is also among the most widely used assessment instru-

ments in pain syndromes. The MMPI consists of 566 statements requiring

true or false responses. The MMPI comprises 10 standard clinical scales as-

sessing psychopathologic states, 3 validity scales, and 4 additional scales eval-

uating ego strength and other factors. Consultation with a psychologist trained

in the administration and interpretation of the MMPI can be very helpful in

the use of this instrument.

The MMPI’s strength is its usefulness in identifying psychological factors

that warrant clinical attention (e.g., drawing attention to those characteristics

that might present barriers to treatment and that ultimately could require psy-

chotherapeutic intervention) (see Table 3–8). The three scales that have the

most relevance to patients with pain are Hypochondriasis (Scale 1), Depres-

sion (Scale 2), and Hysteria (Scale 3). High scores on Scale 1 suggest that patients,

when emotionally distressed, symptomatically channel the distress into somatic

complaints. Scale 2 may be an indicator of general distress, but elevated ratings

on this scale can suggest a possible depressive disorder. Elevations on Scale 2 may

suggest one is unhappy, pessimistic, and self-deprecating. Patients who score

high on Scale 3 are characterologically prone to react by developing physical

58 Clinical Manual of Pain Management in Psychiatry

symptoms when confronted with stress or uncomfortable emotions. Scales 1

and 3 are often related (Trimboli and Kilgore 1983).

The two most common patterns noted among patients with chronic pain

are the conversion V and the neurotic triad (see Figure 3–4). In the conversion V

pattern, elevated ratings on Scales 1 and 3, relative to that on Scale 2, form a val-

ley or Vshape when represented on an MMPI graphic profile. Despite use of

the term conversion, it was never maintained that the pain complaints character-

ized features of a conversion disorder. Rather, persons with this profile endorse

somatic concerns, develop physical complaints in the face of stress, often deny

depressive symptoms, and often lack insight into their emotional states (Trim-

boli and Kilgore 1983). By contrast, those with the neurotic triad pattern (i.e.,

with elevations on each of the three scales) have somatic preoccupations and neu-

rovegetative symptoms of depression and are often demanding and complaining.

MMPI profiles may change as a patient makes the transition from acute to

chronic pain, suggesting commensurate changes in the p