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An introduction to the issue of pain an acute mental or emotional discomfort

  • Additionally, if reinforcement of pain behavior is in place for example, financial compensation for continuing disability, an overly solicitous spouse, abuse of addictive drugs , remission is less likely;
  • Factitious Disorder Individuals with this disorder create the appearance of a physical illness e;
  • TCAs are particularly effective for neuropathic pain, headache, facial pain, fibromyalgia, and arthritis.

Furthermore, many criticize the somatoform disorder group which includes pain disorder as being an aggregate of disorders that are not truly distinct from one another. This lack of distinctiveness suggests to some researchers that a more appropriate system of classification should be dimensional rather than categorical.

In other words, if shared dimensions or characteristics of the several somatoform disorders exist, differences among disorders should be a matter of degree along the possible dimensions. The critics of the DSM categorical approach would prefer a dimensional or multiaxial system because when classification systems are improved, the reliability and validity of measures assessing disorder improve, and better estimates of rates are possible.

Currently, there are no good estimates for rates of pain disorder in the general population. Diagnosis A psychiatrist or mental health professional arrives at the diagnosis of pain disorder after considering several questions.

An important preliminary question is whether the pain is entirely accounted for by a general medical condition. If so, the diagnosis of pain disorder is ruled out; and if not, the psychiatrist considers whether the pain is feigned. If the psychiatrist believes the patient is pretending to be in pain, the patient is diagnosed as malingering for external rewards, such as seeking mood-altering drugs, or as having a factitious disorder that reflects the patient's need to adopt a sick role.

Neither malingering nor factitious disorder is in the somatoform group. The psychiatrist may employ a variety of methods to assess the severity of pain and the contribution of psychological factors to the experience of pain.

Description

These include structured interviews where the questions asked are standardizedopen or unstructured interviews, numerical rating scales, visual analog scales where the patient makes a mark along a line to indicate severity of pain, or if the patient is a child, or is illiterate, selects a face to represent the degree of painand instruments such as the McGill Pain Questionnaire or the West Haven-Yale Multidimensional Pain Inventory.

There are several conditions that rule out a diagnosis of pain disorder: The patient's primary complaint relates to the experience of painful sexual intercourse. The patient has a long history of pain that began prior to age 30 and involves the gastrointestinal, reproductive, and nervous systems. In addition to pain, there are other symptoms associated with motor or sensory dysfunction.

Mood, anxiety, or psychotic disorder. Any one of these more fully accounts for the pain. This last exclusion rests upon a very subjective opinion. Subjectivity reduces inter-rater reliability and is one of the points raised by critics of the DSM category for pain disorder. A final consideration is whether the pain is acute or chronic. Treatments Depending on whether the pain is acute or chronic, management may involve one or more of the following: If the pain is acute, the primary goal is to relieve the pain.

Customary agents are acetaminophen or nonsteroidal anti-inflammatory drugs NSAIDs ; if opioid analgesics are prescribed, they often are combined with NSAIDs so that the dosage of opioids may be reduced.

Psychotherapy is less important for the treatment of acute pain as compared to chronic pain disorder. In comparison, treatment of chronic pain disorder usually requires some sort of psychotherapy in combination with medication.

Antidepressants Tricyclic antidepressants TCAs reduce pain, improve sleep, and strengthen the effects of opioids such as codeine and oxycodoneas well as moderate depression.

Relief of pain may occur in a few days while lessening of depression may take several weeks. TCAs are particularly effective for neuropathic pain, headache, facial pain, fibromyalgia, and arthritis. Treatment of sleep dysfunction Pain and depression diminish the restorative quality of sleep. When the cycle of pain, depression, insomnia, and fatigue is established, it tends to be self-perpetuating. Treatment may include antidepressants, relaxation training, and education regarding good sleep hygiene.

Cognitive-behavioral therapy Many people who suffer chronic pain experience isolation, distress, frustration, and a loss of confidence regarding their ability to cope; subsequently, they may adopt a passive, helpless style of problem solving. The goal of cognitive-behavioral therapy CBT is to restore a sense of self-efficacy by educating patients about the pain-and-tension cycle, by teaching them how to actively manage pain and distress, and by informing them about the therapeutic effects of their medications.

CBT is time-limited, structured, and goal-oriented. Some tension-reducing techniques include progressive muscle relaxation, visual imagery, hypnosis, and biofeedback. Pain diaries are useful for describing daily patterns of pain and for helping the patient identify activities, emotions, and thoughts that alleviate or worsen pain.

Diaries also are useful in evaluating the effectiveness of medication. Patients may be taught pacing techniques or scheduling strategies to restore and maintain meaningful activities. The cognitive aspect of CBT is based on cognitive-social learning theory.

The focus is on helping the patient to restructure his or her ideas about the nature of pain and the possibility of effective self-management. In particular, the patient is taught to identify and then modify negative or distorted thought patterns of helplessness and hopelessness. Operant conditioning The principles of operant conditioning are taught to the patient and family members so that activity and non-pain behaviors are reinforced or encouraged. The goal is to eliminate pain behaviors, such as passivity, inactivity, and over-reliance on medication.

Other Treatments Other treatments effective in the management of pain include acupuncturetranscutaneous electrical nerve stimulation TENStrigger point injections, massage, nerve blocks, surgical ablation removal of a part or pathwaymeditationexercise, yogamusic and art therapy.

Pain disorder

Prognosis The prognosis for total remission of symptoms is good for acute pain disorder and not as promising for chronic pain disorder. The typical pattern for chronic pain entails occasional flare-ups alternating with periods of low to moderate pain.

  • Cognitive-behavioral therapy Many people who suffer chronic pain experience isolation, distress, frustration, and a loss of confidence regarding their ability to cope; subsequently, they may adopt a passive, helpless style of problem solving;
  • Most patients in pain first contact their primary care physician who may make a referral to a mental health professional or pain clinic;
  • Psychological symptoms of stress include anxiety and tension, uncontrollable worrying, irritability, distractibility, and difficulty in learning new things;
  • Mania A period of time usually a week to a month long in which the person is and feels very excited, talkative, active, and impulsive;
  • Pain diaries are useful for describing daily patterns of pain and for helping the patient identify activities, emotions, and thoughts that alleviate or worsen pain;
  • One of the best known examples of dementia is Alzheimer's disease, which typically begins after age 55.

The prognosis for remission of symptoms is better when patients are able to continue working; conversely, unemployment and the attendant isolation, resentment, and inactivity are correlates of a continuing pain disorder. Additionally, if reinforcement of pain behavior is in place for example, financial compensation for continuing disability, an overly solicitous spouse, abuse of addictive drugsremission is less likely.

  • Many individuals with these disorders return to a somewhat normal state between episodes, and there is a statistical association with creativity and even artistic genius;
  • Treatment may include antidepressants, relaxation training, and education regarding good sleep hygiene.

The results of outcome studies comparing pain disorder treatments point to cognitive-behavioral therapy in conjunction with antidepressants as the most continually effective regimen. However, people in chronic pain may respond better to other treatments and it is in keeping with the goal of active self-management for the patient and health professional s to find an individualized mix of effective coping strategies.

Prevention Pain disorder may be prevented by early interventioni. When pain becomes chronic, it is especially important to find help or learn about and implement strategies to manage the distress before inactivity and hopelessness develop.

Most patients in pain first contact their primary care physician who may make a referral to a mental health professional or pain clinic.

Many physicians will reassure the patient that a referral for psychological help is not stigmatizing, does not in any way minimize the experience of pain or the medical condition, and does not imply that the physician believes the pain is imaginary.

On the contrary, the accepted IASP definition of pain fully recognizes that all pain is, in part, an emotional response to actual damage or to the threat of damage. Diagnostic and Statistical Manual of Mental Disorders.

Definition

Nathan and Jack M. Oxford University Press, 1998. Sunil, Verma, and Rollin M. Lake, Glenview, IL 60025. The American Chronic Pain Association. Other articles you might like: