Formulation: The Four Perspectives of a Patient in Chronic Pain
Patients with chronic pain are usually referred to a psychiatrist out of frustration. The patient is frustrated with their pain management. The physician is frustrated with the patient’s poor response to treatment. When no clear “medical” cause has been found, the cause of chronic pain is assumed to be psychogenic.
Unfortunately, what the patient requires at this point is generally a more comprehensive evaluation. Refractory chronic pain syndromes are best formulated through four perspectives (diseases, behaviors, dimensions, and life stories). In this approach to chronic pain, diseases are what people have; behaviors are what people do; dimensions are what people are; and life stories are what people encounter. This process of formulating the case should incorporate contributions from each perspective to the overall presentation and inform the prescription of a treatment plan that targets each component of the patient’s illness.1
The disease perspective is the easiest for most physicians to understand given traditional medical training. Diseases of the brain produce psychological manifestations in such faculties as consciousness, cognition, memory, language, affect, and executive functions. Abnormalities in the structure or function of the brain lead to mental diseases such as delirium, dementia, anxiety disorder, and major depression. However, the patient may describe deficits in these faculties with difficulty and rely on somatic symptoms (eg, pain) as incomplete proxies. These somatic symptoms are perceived as real and present as a broken part causing pathology. The treatments for diseases are cures that repair the broken part, prevent the initial damage from progressing, or enhance secondary systems to compensate for the pathology.
The perspective of behavior encompasses a wide range of actions and activities. The complex behaviors of humans are designed for the purpose of achieving goals. Internally, rhythmic alterations of attention and perception produce drives that increase a person’s motivation toward a particular action.1,2 Afterward, the drive is satisfied, and a state of satiety emerges. Over time, drives re-emerge, with subsequent effects on the individual’s perceptual attitude toward his or her setting. In concert, personal assumptions or external opportunities increase the likelihood of certain behaviors. Ultimately, choices determine which action to take, and consequences influence future actions. When aspects of choice and control over behavior become disrupted, physicians are asked to address the distorted goals, excessive demands, damaging consequences, and lack of responsiveness to negative feedback.3 Treatment of behavioral disorders begins with regaining temporary control of the situation by stopping the behavior.4,5 Restricting the patient’s actions and preventing these problematic behaviors limits the chaos of destructive choices. This stable foundation is required for the patient to gain insight into and increase motivation toward appropriate choices that result in less distress and more satisfaction.6
Many mental disorders arise not from a disease of the brain or some form of abnormal behavior but from a patient’s personal affective or cognitive constitution.1 Each individual possesses a set of personal dimensions, such as intelligence and temperament. These traits describe the person and are carried into the world as a set of innate capabilities within that person’s psychological makeup. These traits are not looked at categorically, but along a measurable spectrum. Which traits are relied on and how much of them a person possesses determine his or her potential to cope with different demands. Some circumstances overwhelm capacity and provoke a person’s vulnerability to distress. Treatment of disorders of the dimensional type focuses on acquiring new skills with remediation of specific deficiencies and guidance about overcoming potential vulnerabilities through adaptations such as education about, assistance with, or modification of the particular stressors.4,5
The life story perspective uses a narrative composed of a series of events that a person encounters and determines to be personally meaningful. 1,2 These self-relfections are the means by which a person judges the value of his or her life as a whole. They impart a sense of self, both as the agent of a life plan unfolding in a social setting and as the reflective subject experiencing and interpreting the outcome of plans and commitments. If events unfold as planned, the person feels satisfied with the success. However, if the sequence of events ends in a disappointing outcome, the person feels distress about this failure. Life story disorders emerge from the negative interpretations of life encounters (grief from loss, anxiety with expected threats). Treatment forges a new understanding of settings and sequences that highlight the role of the patient in his life and illuminate the troubled state of mind as the outcome of that role and course of events. Effective treatment requires reframing and reinterpretation to encourage the patient by transforming the story into one with potential for future success and fulfillment.