A pain patient from our center recently left a series of phone
messages detailing his newly discovered powers of “dolphin-sonar,” and
added that Elliott Ness had possession of his car. He was wondering
if he could be provided with a skateboard with which to get around
town. His verbal style was characterized by a bombastic manner and
loose associations. Although previous conversations focused almost
exclusively on his painful lower back, in these messages there was
no mention of it.
This brief case sketch illustrates two important points regarding
the difficulties the practitioner has in dealing with chronic pain.
The first point is the high comorbidity of psychiatric diagnoses with
chronic pain diagnoses. Of course, only few chronic pain patients
have concomitant delusions as this patient did, but nearly all have
had their lives disrupted to such an extent that a psychiatric diagnosis
is highly possible. The second point has to do with the chronology
of these conditions. It is often difficult to determine whether
the pain caused the psychiatric diagnosis, the psychiatric condition
caused the pain, or they happen to occur somewhat simultaneously.
All of this suggests that a knowledge of psychopharmacology is important
for a pain practitioner not only because there is a large overlap
of psychiatric diagnoses with chronic pain conditions, but all of
the common psychopharmacologic medication groups are also used as
analgesics. Many of these agents have multiple mechanisms of action
that account for their dual effects. However, the dramatic overlap
of the analgesic and psychopharmacology drug arsenal suggests a
significant degree of clinical homology in patients with chronic
pain. Comprehensive pain management requires an understanding of
basic principles of psychopharmacology. From the perspective of
a non-mental health professional, it might seem fitting to ask, “Why
psychopharmacology for the pain specialist?” There are
several real answers to this important question:
- The majority of patients in chronic pain have comorbid
psychiatric conditions, ranging from mild (anxiety, adjustment,
depression) to severe (delusional, psychotic).
- Depression and anxiety are known to enhance perception of
pain and may be a predominating component of some pain syndromes.
- Some psychiatric conditions manifest as pain or pain-like
symptoms. For example, it has been suggested that complex regional
pain syndrome (CRPS) is a conversion-like disorder.1
- Many psychiatric conditions are caused by, or are accompanied
by, neurochemical abnormalities. These abnormalities may significantly
affect the pain medications prescribed and may affect the pain condition
in a significant manner. For example, serotonin is considered an
important factor in pain states, as well as mood states.
- There may be malpractice suits brought against pain practitioners
who do not adequately recognize or treat accompanying psychiatric
conditions that affect pain states.
- Patients may often choose not to seek mental health treatment,
even when instructed by the pain practitioner to do so. This may
have to do with a patient’s financial state, insurance
coverage, or the stigma associated with seeking help for emotional
In the following pages, several ...