As a psychiatrist working in the field of pain, it is commonly assumed that
I devote most of my attention to people who have pain as a result of stress or
psychological difficulties. Indeed, 24 years ago when I first started seeing
individuals in chronic pain who had been referred to me in a pain clinic
because it was thought that organic factors were insufficient to explain the
complaint of pain, I looked carefully for psychiatric and psychological
explanations. Despite the fact that one-third of people attending our clinic
had evidence of psychiatric illness (Tyrer
et al, 1989), it has become clear to me from those I see
that such psychiatric morbidity is largely a result of chronic pain and is not
a forerunner of a painful state. The vast majority of people I see in a
multidisciplinary pain clinic have a clear organic cause for pain either in
the present or past, and it is rare to have a patient with pain arising purely
from emotional causes. There is evidence of environmental and social factors
affecting the exhibition of pain. Psychiatric illness is more common in people
with pain referred to psychiatric out-patient clinics
(Merskey, 1965;
Merskey et al, 1987),
but in total the evidence for organic factors leading to distress in
vulnerable individuals is overwhelming.
A sizeable number of people in distress from chronic pain do not have
enough signs of illness to persuade doctors that organic factors are
sufficient to explain their symptoms. These individuals usually show intense
conviction of disease, strong adherence to mechanistic explanations of their
illness and considerable functional disability arising from the painful
complaint. They are undoubtedly in distress and they score highly on symptoms
of depression and, to a lesser extent, other psychiatric illnesses. Why these
people present in the way they do cannot be deduced solely through application
of the medical model.
***
The word pain comes from the Latin poena, which means punishment
or penalty, after the Roman goddess of punishment. The term was originally
used for the punishment of an offence against the law. Over time the word was
increasingly used to denote suffering, particularly if this had resulted from
a blameworthy act.
Early writers equated emotional suffering with pain and the words were used
interchangeably. This psychological dimension to the experience of pain was
largely forgotten following Descartes' observations illustrating pain as a
signal of physical pathology:
‘quand je ressens de la douleur au pied, la physique m'apprend que ce sentiment se communique par le moyen des nerfs dispersés dans le pied, le pied, qui se trouvant tendus comme des cordes depuis là jusqu'au cerveau, lorsqu'ils sont tiré dans le pied, tirent aussi en même temps l'endroitdu cerveau d'ou ils viennent et auquel ils aboutissent, et y excitent un certain mouvementque la nature a institué pour faire sentir de la douleur à l'esprit, comme si cette douleur était dans le pied’ (Descartes, 1647).
Although not anatomically precise this work convinced scientists of the
relationship between the integrity of sensory nerve conduction and the
experience of pain. The experimental work then conducted supported the views
of doctors that pain was due to tissue damage, so in those complaining of pain
there must be a source of injury. The concept of non-organic pain was not
considered important at this time. It was not until Breuer & Freud
(edition 1957), in detailed
case histories originally published in their studies on hysteria in 1895,
suggested that pain could be a manifestation of a psychological problem, that
the contribution of psychological factors to pain was reconsidered. The
profound influence of Freud shaped the belief in psychological and psychiatric
circles that persistent pain associated with emotional distress in the absence
of organic findings is primarily due to a psychiatric illness. This was not
generally acknowledged by physicians although a number of pain specialists
have realised the importance of psychosocial factors in the presentation of
patients with chronic pain (Fields &
Price, 1994; Livingston,
1998). Dr Livingston, a surgeon writing in the middle of the past
century, disagreed with the concept supported by many doctors at the time that
pain, without physical findings, is hysterical or due to malingering.
***
PSYCHIATRISTS AND PAIN
The concept of ‘emotional pain’ occupied a select group of
British psychiatrists in the 1960s and Erwin Stengel proposed a variety of
mechanisms to explain this phenomenon. Stengel was born in Vienna as an
identical twin and came to England in 1938 following the occupation of Austria
by Hitler. He was intrigued by those who seem to be impervious to pain and
described case studies of this phenomenon. More than most, he understood that
mechanistic models were inadequate to explain the gamut of experiences
described by people with pain. The controversy between Stengel and Eliot
Slater about this issue, published in the British Journal of
Psychiatry 40 years ago (Stengel,
1965), neatly encapsulates the mind-body dualism that was adopted
by most practitioners in a more convergent explanation of the origin of pain
(Slater, 1966).
Stengel's work in this area led to a sprouting of interest in Sheffield,
where he was the first head of the university's Department of Psychiatry at
this time. Three junior psychiatrists in his Department have since become
prominent researchers in this area - Harold Merskey, Izzy Pilowsky and Sir
Michael Bond. All have contributed massively to the contribution of
psychiatric and physical features to the perception of pain, an area into
which, sadly, psychiatrists in the UK nowadays rarely venture.
At the same time that Stengel was articulating his views in England,
psychiatrists in the USA developed psychological theories to assist in the
management of pain in the New World. The established physician and truncated
phonemic associate George Engel believed that, although pain may originally
develop from an external source, it often becomes a psychological phenomenon
(Engel, 1959). He described
risk factors for developing chronic pain, including a history of defeat,
significant guilt, unsatisfied aggressive impulses and a history of real or
imagined loss. Later, Blumer & Heilbronn
(1982) described a group of
patients who developed chronic pain who had a strong work ethic and were
preoccupied with their pain. As these individuals later developed many of the
vegetative symptoms of depression, these authors unwisely generalised that
chronic pain in such people is a manifestation of depression.
***
EFFECTS OF PAIN ON PERSONALITY
Although Engel (1959) and
Blumer & Heilbronn (1982)
correctly described factors predisposing to the genesis of chronic painful
syndromes in a selected group of patients, the generalisations they made
dissuaded colleagues working in this field that the biopsychosocial model
espoused by these psychiatrists was necessarily relevant
(Engel, 1977). Later studies
showed that the development of psychiatric illness more usually follows the
development of the chronic painful condition, and ‘pain-proneness’
is not demonstrable in most patients
(Gamsa, 1990). The reason why
most people in pain complain of distressing symptoms is because of the
debilitating and demoralising effects of the pain itself. This contention was
supported by an intriguing study carried out 20 years ago. At that time the
Minnesota Multiphasic Personality Inventory (MMPI) was a widely used tool in
the investigation of those with chronic pain. The typical profile of an
individual who had developed chronic pain and had the psychological
disposition to do so was a component of high scores on the neurotic triad, the
depression, hypochondriasis and hysteria sub-scales, of this instrument. This
picture was found in a large proportion of a group of patients being assessed
for backpain surgery. By chance, a number of the individuals concerned had
previously been tested with this instrument in an earlier epidemiological
study. In these people it was found that their premorbid profiles were within
normal limits, strongly suggesting that the painful condition from which they
were suffering was responsible for the apparent change in the personality
picture (Hagedorn et al,
1985). Love & Peck
(1987) later showed that this
particular MMPI profile found in patients with chronic pain did not represent
previous personality functioning but was a consequence of disability.
***
SOMATOFORM DISORDERS
A minority of patients with chronic pain do fulfil the criteria for the
diagnosis of a somatoform disorder. In such conditions there is continued
presentation of physical symptoms together with persistent requests for
medical investigations despite negative findings of organic illness and
reassurance by doctors that the symptoms have no physical basis. The diagnosis
par excellence of a somatoform disorder is somatisation disorder,
where pain is just one of many symptoms exhibited by the (usually) female
patient. This diagnosis is not common, ranging from 0.2% of patients referred
to a liaison psychiatry service (Smith
et al, 2000) to 5% of medical patients
(Fink et al, 2004).
This figure is higher than the previous figure of Smith et al
(2000) because Fink et
al (2004) used ICD-10
criteria. The ICD-10 diagnosis of persistent somatoform pain disorder was 1.5%
in this same population (Fink et
al, 2004). This low figure is not too surprising, as the
latter diagnosis can be made only if the pain described by the patient ‘
occurs in association with emotional conflict or psychosocial problems
that are sufficient to allow the conclusion that they are the main causative
influences’ (World Health
Organization, 1992: p. 168). Contrast this with the diagnosis of
pain disorder listed in the somatoform disorders section in DSM-IV
(American Psychiatric Association,
1994). For this diagnosis to be made, ‘psychological factors
are judged to have an important role in the onset, severity, exacerbation, or
maintenance of the pain’ (p. 461).
Although cases largely due to physical illness are excluded, as also are cases
where the pain is ‘better accounted for by a mood, anxiety or psychotic
disorder’, more cases with pain and emotional sequelae achieve this
level of diagnosis on the DSM-IV schedule than on ICD-10.
The differentiation of the somatoform disorders has been questioned
(Wessely et al,
1999). The problem with the diagnosis of somatoform disorders in
general and of somatoform pain disorders in particular is the judgement
required that the symptoms manifest are due to psychological factors. It is
not easy to determine this objectively and most psychiatrists working in the
area are aware that physical and psychological factors both contribute
significantly to the presentation (Mayou,
1991; Merskey,
2000). The evidence of psychological causation cannot be assumed
from a history of previous risk factors. The reporting of unexplained pain
symptoms as due to previously experienced psychological trauma has been found
to be an artefact of retrospective self-report rather than a consequence of
actual events (Raphael et al,
2001). This being said, there is evidence that some non-organic
pains arising in adolescence have a psychogenic basis
(Hotopf et al,
1999).
The value of the present classifications of these syndromes has been
brought into question because of the imprecise categorisation of such
disorders and the fact that many patients fall into the category of
undifferentiated somatoform disorder, a watered-down version of somatisation
disorder (Bass et al,
2001; Sharpe & Mayou,
2004). Dimensional assessment of pain on the axes of nociception,
evaluation of pain, mood consequences of the pain and pain behaviour
(Karoly & Jensen, 1987;
James, 1992) may be of greater
clinical relevance.
***
BOOKS ON PSYCHOSOMATIC PAIN
Edward Shorter, the prominent medical historian, has shown how the symptoms
of psychosomatic illness have changed over the years. He believes that these
symptoms are presented according to the prevailing culture. In the early
1800s, for example, a current concept to explain back pain was spinal
irritation, caused by pressure at specific spinal tender spots, leading to
nerve and muscle pains. Shorter's contention is that psychosomatic symptoms
are selected carefully from a culturally determined symptom pool to give the
impression of origin from an underlying organic disease, thus avoiding
ridicule (Shorter, 1992). This
assumption is supported by the changing terminology of diagnostic labels such
as hysteria and neurasthenia.
A recently published book argues that fear of pain explains the high
prevalence of psychological distress in patients with chronic pain
(Asmundson et al,
2004). There are two schools of thought to explain why a minority
of people behaves in this way; these are interrelated. One claims that a
catastrophic meaning is placed on the experience of pain because of the fear
of injury or re-injury. The other suggests that fear of pain is due to fear of
anxiety-related sensations associated with painful episodes. This hypothesis
has led to treatment by graded exposure to such situations to enable
individuals to learn to manage both anxiety and pain together
(Vlaeyen et al,
2002). For more general reading on psychosomatic disorders, books
by Chris Bass (1990) and Peter Manu (2004) are recommended.
As is usually the case with a medical condition that is imperfectly
understood and has no established cure, there is a plethora of books for
sufferers from pain. One that has received considerable plaudits from patients
is The Mindbody Prescription, on treatment for back pain
(Sarno, 1998). Dr John Sarno
believes that tension is the underlying cause of many back problems. He states ‘
Pain serves to smother the emotions so they don't break through to the
conscious mind. The brain produces these symptoms as... a distraction to make
sure your internal rage does not come out’ (p.
39). Although treated
with scepticism by his medical colleagues Dr Sarno is clearly appreciated by
many pain sufferers in North America. A useful part of the therapy process is
educational, in the form of a lecture presentation in which the temporal
relationship between emotional feelings and pain is recognised.
***
THE FUTURE
The specialty of pain has grown considerably over the past 25 years and the
influence of the psyche on painful symptoms and vice versa has become much
more widely recognised. The difficulty in disentangling the mechanisms
involved in this relationship will be clear to those who have read to the end
of this piece. Those wishing to obtain more information are recommended to
contact the International Association for the Study of Pain (IASP;
http://www.iasp-pain.org).
It is in many ways paradoxical that in the UK the vast majority of doctors
working in the pain field are anaesthetists, with only a scattering of
pharmacologists, neurologists, orthopaedic surgeons and psychiatrists. The
value of psychological assistance is more widely recognised. The IASP
recommends that all first-class pain clinics should have at least four
healthcare professionals on the staff. This is a rare situation in Britain.
Until the field of chronic pain is recognised in liaison psychiatry job plans,
there is unlikely to be major input from psychiatrists in the UK into chronic
painful conditions. If a Faculty of Pain Medicine or similar organisation were
to be designated, this might change.
- © 2006 Royal College of Psychiatrists
***
References
all found here:
http://m.bjp.rcpsych.org/content/188/1/91.full
***Psychosomatic pain by Stephen Tyrer***Department of Psychiatry, University of Newcastle upon Tyne, Leazes Wing,
Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP,UK. E-mail:
s.p.tyrer@ncl.ac.uk
(EDITED BY SIDNEY CROWN, FEMI OYEBODE and ROSALIND RAMSAY)
(EDITED BY SIDNEY CROWN, FEMI OYEBODE and ROSALIND RAMSAY)
