Pain Management

Pain takes many forms

Differential Diagnosis of Pain Complaints:

• Physical Disorder with no psychological overlay or causation
• Somatic Symptom Disorder
• Factitious Disorder
• Malingering
• Drug Dependence

Somatoform Disorders are closely related to anxiety disorders. The person has poor insight; does not recognize that concerns are excessive or unreasonable. Reassurance of normal functioning from others, including physicians is not helpful.

Their symptoms cannot be fully explained by a physical cause. Medical test results are either normal or don’ not explain the person’s symptoms. People who have somatoform disorder often become very worried about their health because they don’t know what is causing their health problems. The symptoms of somatoform disorder are similar to the symptoms of other illnesses. People with this disorder may have several medical evaluations and tests to be sure that they do not have a specific illness, injury or disorder.

Symptoms of somatoform disorder may include frequent headaches, back pain, abdominal cramping and pelvic pain. Other symptoms include pain in the joints, legs and arms, and chest or abdominal pain. Somatoform disorder may also cause gastrointestinal problems, such as nausea, bloating, vomiting, diarrhea and food intolerance. Sometimes somatoform disorder makes it painful for a person to urinate, even if he or she doesn’t have an infection. It can also cause problems with sexual function for both men and women, such as erectile failures and anorgasmia.

When faced with determining the source of inexplicable pain, many physicians choose the route of Diagnosis-by-exclusion (vs. inclusion) – excluding all physical causes before beginning to look for a psychological basis for the physical complaint.

HISTORY OF SOMATOFORM DISORDER

Concept dates back at least 4000 years

Formerly known as hysteria, a term first used by Hippocrates

Egyptian treatment approaches followed a medical path

In the Middle Ages, though to be related to demon possession

A focus of Charcot and Freud РBriquet’s Syndrome 100 yrs ago: More perplexing…are those patients who manifest symptoms resulting from a local bodily lesion, but in whom the severity of the complaints and the magnitude of the disability are far greater than would be expected from the nature and extent of the local lesion alone.”

CONCERNS

• Unnecessary surgical procedures
• Drug dependence
• Suicide attempts in the future
• Improper treatment
• Invasive work-ups & high costs of care

CURRENT TREATMENT

• Explore psychosocial problems
• Consider SSRI
• Cognitive Behavioral Therapy
• Explanatory Therapy

THE MEDICAL APPROACH

The American Society of Anesthesiologists Task Force on Chronic Pain Management has updated its chronic pain guidelines. The objectives are to optimize pain control, enhance physical and psychological well-being, and minimize adverse outcomes. The recommendations apply to patients with chronic non-cancer, neuropathic, somatic, or visceral pain. The task force focused on interventional diagnostic procedures including diagnostic joint block, nerve block, and neuraxial opioid trials.

The team agreed that findings from the patient history, physical examination, and diagnostic evaluation should be combined to provide an individualized treatment plan focused on optimizing the risk-to-benefit ratio. Treatment should progress from a lesser to greater degree of invasiveness. “Whenever possible,” the task force reports, “direct and ongoing contact should be made and maintained with the other physicians caring for the patient to ensure optimal care.”

The new guidelines detail:

• ablative techniques
• acupuncture
• blocks
• botulinum toxin
• electrical nerve stimulation
• epidural steroids
• intrathecal drug therapies
• minimally invasive spinal procedures
• pharmacologic management
• physical therapy
• psychological treatment
• trigger point injectionsDrugs for chronic pain include anticonvulsants, antidepressants, benzodiazepines, N-methyl-D-aspartate receptor antagonists, nonsteroidal anti-inflammatory, opioid therapy, skeletal muscle relaxants, and topical agents. The task force discusses each in detail and recommends strategies for monitoring and managing adverse effects and patient compliance. Anesthesiology. 2010;112:810-833.

SOME STATISTICS & COMMONALITIES

• Female to male ratio 10:1-20:1Found in 10-20% first degree female relatives
• Depression 2.8 times more frequentGeneralized Anxiety Disorder 2.5 times more frequent
• Higher rates of childhood illness or family member with chronic illness
• Suggestion of medical condition but absence of completely explanatory physical findings
• Symptoms fluctuate with stress
• Course is chronic
• Relationship problems
• Symptoms represent emotional communication rather than evidence of disease
• Psychological factors present but unrecognized
• Dependency a core issue
• Conditions are unconscious
• Limited insight
• Not psychologically-minded
• Vague, Dramatic, Exaggerated presentation, 12-14 sxs
• Pain described vivid, colorful, discursive, circumstantial‚Ķeffect rather than nature
• Hx of mx MDs, numerous (unnecessary) procedures

ADDICTION & SECONDARY GAIN

Family physicians and internists are taught that when faced with unexplained complaints, the first rule-out is always narcotic seeking for the sake of addiction rather than pain relief. The following features are red flags:

• Narcissistic, emotional, dependent, manipulative personality
• Seeks out solely or predominately a physician who will prescribe narcotics
• Has drugs of choice which others may not willingly prescribe
• Discontinues ( lost to follow-up‚Äù) care frequently
• Self-selects own 2nd, 3rd opinions
• Secondary gain – removes self from educational, sexual, and/or occupational competition as a means to deal with interpersonal inadequacies

Most patients with inexplicable chronic pain are resistant to psychological interpretation and intervention for their complaints.

DEFINITIONS & FINE DISTINCTIONS (BASED UPON DSM-IV GUIDELINES)

HYPOCHONDRIASIS

Preoccupation with fears of having, or ideas that one has, a serious disease based on the person’s misinterpretations of bodily symptoms. The preoccupation persists despite appropriate medical evaluation and reassurance. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. The duration of the disturbance is at least 6 months.

SOMATIZATION DISORDER

History of many physical complaints beginning before age 30 that occur over a period of several years and result in treatment being sought repeatedly. Significant impairment in social, occupational, or other important areas of functioning:

Four pain symptoms: A history of pair related to at least four different sites or functions (such as head, abdomen, back, joints, extremities, chest, rectum, during sexual intercourse, during menstruation, or during urination.

Two gastrointestinal symptoms: A history of at least two gastrointestinal symptoms other than pain (such as nausea, diarrhea, bloating, vomiting other than during pregnancy, or intolerance of several different foods).

One sexual symptom: A history of at least one sexual or reproductive symptom other than pain (such as sexual indifference, erectile or ejaculatory dysfunction, irregular menses, excessive menstrual bleeding, vomiting throughout pregnancy.

One pseudo neurologic symptom: A history of at least one symptom or deficit suggesting a neurological disorder not limited to pain (conversion symptoms such as blindness, double vision, deafness, loss of touch or pain sensation, hallucinations, aphonia, impaired coordination or balance, paralysis or localized weakness, difficulty swallowing, difficulty breathing, urinary retention, seizures; dissociative symptoms such as amnesia; or loss of consciousness other than fainting)

PAIN DISORDER

Pain in one or more anatomical sites is the predominant focus of the clinical presentation and is of sufficient severity to warrant clinical attention. The pain causes clinically significant distress or impairment i social, occupational, or other important areas of functioning. Psychological factors are judged to have an important role in the onset, severity, exacerbation, or maintenance of the pain. The symptom or deficit is not intentionally produced or feigned (as in factitious disorder or malingering). The pain is not better accounted for by a mood, anxiety, or psychotic disorder and does not meet criteria for dyspareunia.

BODY DYSMORPHIC DISORDER

Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person’s concern is markedly excessive. The preoccupation causes significant distress or impairment in social, occupational, or other important areas of functioning. The preoccupation is not better accounted for by another mental disorder (e.g. dissatisfaction with body shape and size in anorexia nervosa).

CONVERSION DISORDER

One or more symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological or general medical condition. Psychological factors are judged to be associated with the symptom or *deficit because the initiation or exacerbation of the symptom or deficit is preceded by conflicts or other stressors.

The symptom or deficit is not intentionally produced or feigned (as in factitious disorder or malingering); cannot, after appropriate investigation, be fully explained by a general medical condition, or by the direct effects of a substance, or as a culturally sanctioned behavior or experience.

The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation and is not limited to pain or sexual dysfunction, does not occur exclusively during the course of somatization disorder, and is not better accounted for by another mental disorder.

COMPLEX REGIONAL PAIN SYNDROME (CRPS) is a controversial clinical diagnosis. In a study of 25 patients with possible CRPS, one out of four CRPS experts disagreed with the diagnosis when it was diagnosed by a colleague. CRPS could not be diagnosed with much certainty and idiopathic and somatoform pain syndromes were important differential diagnoses.Van De Vusse et al. The Pain Clinic, June 1, 2003, vol. 15, no. 2, pp. 143-149.

The most important role for testing is to help rule out other conditions: a somatoform disorder, a factitious disorder, malingering or narcotic seeking and/or narcotic dependence. *

Although CPRS differs from somatoform pain disorder specifically because of the objective evidence of disturbed peripheral blood flow, it has many similarities. Patients with CPRS often have significant psychological problems, typically, but not always, pre-existing the specific injury. These factors must always be identified, whether causally related to the specific injury or not.

• The term “complex regional pain syndrome” was introduced to replace the term “reflex sympathetic dystrophy.”
• CRPS Type I used to be called RSD,‚Äù absence of causative nerve injury
• CRPS Type II used to be called causalgia,‚Äù a definable peripheral nerve injury

The terminology was changed because the pathophysiology of CRPS is not known with certainty. The terms CRPS Type I and CRPS Type II are meant as descriptors of certain chronic pain syndromes. They do not embody any assumptions about pathophysiology. For the most part the clinical characteristics of CRPS Type I are the same as seen in CRPS Type II.

Pain that can be abolished or greatly reduced by sympathetic blockade (for example, a stellate ganglion block) is called sympathetically maintained pain.

Pain that is not affected by sympathetic blockade is called sympathetically independent pain. The pain in some CRPS patients is sympathetically maintained; in others, the pain is sympathetically independent.

KEY ISSUES IN DIAGNOSIS

At least four of the following must be present in order for a diagnosis of CRPS to be made.

• “burning” pain
• increased skin sensitivity
• changes in skin temperature: warmer or cooler compared to the opposite extremity
• changes in skin color: often blotchy, purple, pale, or red
• changes in skin texture: shiny and thin, and sometimes excessively sweaty
• changes in nail and hair growth patterns
• swelling and stiffness in affected joints
• motor disability, with decreased ability to move the affected body part
• atrophy over limbs over time

Some experts believe there are three stages associated with CRPS, marked by progressive changes in the skin, muscles, joints, ligaments, and bones of the affected area, although this progression has not yet been validated by clinical research studies.

Stage one is thought to last from 1 to 3 months and is characterized by severe, burning pain, along with muscle spasm, joint stiffness, rapid hair growth, and alterations in the blood vessels that cause the skin to change color and temperature.

Stage two lasts from 3 to 6 months and is characterized by intensifying pain, swelling, decreased hair growth, cracked, brittle, grooved, or spotty nails, softened bones, stiff joints, and weak muscle tone.

Stage three the syndrome progresses to the point where changes in the skin and bone are no longer reversible. Pain becomes unyielding and may involve the entire limb or affected area. There may be marked muscle loss (atrophy), severely limited mobility, and involuntary contractions of the muscles and tendons that flex the joints. Limbs may become contorted.

Doctors are not sure what causes CRPS. In some cases the sympathetic nervous system plays an important role in sustaining the pain. The most recent theories suggest that pain receptors in the affected part of the body become responsive to a family of nervous system messengers (catecholamines). Animal studies indicate that norepinephrine, a catecholamine released from sympathetic nerves, acquires the capacity to activate pain pathways after tissue or nerve injury. The incidence of sympathetically maintained pain in CRPS is not known.

Some experts believe that the importance of the sympathetic nervous system depends on the stage of the disease.

Another theory is that post-injury CRPS (CRPS II) is caused by a triggering of the immune response, which leads to the characteristic inflammatory symptoms of redness, warmth, and swelling in the affected area. CRPS may therefore represent a disruption of the healing process. In all likelihood, CRPS does not have a single cause, but is rather the result of multiple causes that produce similar symptoms.

HOW IS CRPS DIAGNOSED?

Differential Diagnosis

The differential diagnosis of this disorder includes peripheral neuropathy, myofascial pain, somatoform pain disorder and malingering. Opinions should always been obtained, ideally from a neurologist with experience with these disorders, specifically to objectively document skin and/or temperature changes and to consider alternative diagnoses. Most experts agree that it is more common in young women. Sedative or analgesic dependence (drug abuse and dependence) can develop.

CRPS TREATMENT

• Physical therapy
• Psychotherapy
• Sympathetic nerve block
• Medications
• Surgical sympathectomy
• Spinal cord stimulation
• Intrathecal drug pumps

*National Guidelines Clearing House (Dept. Labor, August, 2002)*The Pain Clinic June 1, 2003. pp 143-149

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