Chapter 63

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 difficulties.

In the following pages, several ...

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