The Psychiatric Model of Treating Chronic Pain
A chronic pain patient returned from a period of treatment with another physician. He told me “it was different, it was different in what came across the desk.”
The literature and many patients’ personal reports strongly suggest the co-existence of both a medical model and a psychiatric model in the treatment of chronic pain. These two concepts—which often overlap but which are so psychodynamically different—have not been adequately defined. Most physicians, including some psychiatrists, primarily embrace the medical model. While many patients adequately benefit from just the medical model, others need at least some aspect of the psychiatric model.
The psychiatric model does not necessarily imply that a psychiatric problem exists. However, a concurrent psychiatric illness may exist, including quasi-psychiatric problems such as iatraddiction/pseudoaddiction or other Axis IV problems. The psychiatric model concept evolved following requests for psychiatric consultations because of fears that the pain was being malingered or exaggerated.
The psychiatric model is a style and philosophy of approach, with an intimacy that might be uncomfortable for many physicians. It usually begins following a failure of the typical multidisciplinary clinic approach to pain control. Being sensitive within the medical model to a patient’s psychological needs does not necessarily rise to the level of an active psychiatric treatment model.
The psychiatric model returns medicine to the Greek ideal of studia humananitatis: that of seeking a sound mind in a sound body. In doing so, this model is very eclectic, yields to result-driven interventions, and is notably marked by the continuous and direct physician teaching of skills to control the pain through the use of medications, reflection, mutual education and sharing of information, ego lending, and modeling. This is what the above patient meant about what “came across the desk.”
The Psychiatric Model
Typically, the psychiatric model starts with the assumption that prior treatments failed even with accurate medical diagnoses. As such, a de novo medical diagnoses is not needed.
The DSM-IV offers three pain disorder possibilities.1 The first is psychogenic pain, the second is pain from a mixture of physical and psychogenic etiologies, and the third category (which is coded as a medical condition) is pain with minimal or no psychological basis to its onset or maintenance. Work with the third category focuses on helping a psychiatrically normal person develop life strategies to function as a chronic pain patient, including any potential emotional decision making2 or reactive psychiatric problems resulting from under-treated pain. A distinguishing attribute of this third group is reflected in how they functioned in life before the chronic pain existed. These three groups can, at times, be managed within the multidisciplinary component of the medical model.
The psychiatric model starts as the multidisciplinary approach fails. One physician begins to singularly treat both the physical and emotional-situational issues of recalcitrant pain. The practice of referring a patient to a psychologist or social worker, appropriate under the multidisciplinary approach that follows Bonica’s innovative approach,3 reflects a psychiatric sensitivity but does not mean the psychiatric model is active. Such referrals reduce the first-hand experiential harmonics that so enrich the psychiatric model’s doctor-patient therapeutic relationship. Likewise, merely prescribing antidepressants or referring to a mental health professional to address, for example, a depression does not necessarily invoke the psychiatric model. Some multidisciplinary approaches fail because they are too fragmented, limited, or mechanical to meet the patient’s needs.
The psychiatric model often maintains hope after the medical and multidisciplinary model fails. It remains realistic but stalwartly supportive even in the face of complicated financial and clinical conditions. For a patient, the inability to find such adequate and dependable care can be as emotionally destructive as the pain itself. Keeping hope alive is itself a process which strengthens and heals. Indeed, prolonged positive emotional experiences of hope and support, above and beyond any possible placebo issues,4-6 can effectively reduce and modify the actual brainscape effects of chronic trauma (i.e., pain) or other negative experiences.7,8 Long term interventions, which calm the biological regulatory systems of both physical and emotional states, may be one of the mechanisms which allows medication doses to drop over time.9 The physician must be like the Wizard of Oz who offers a heart, a brain, courage, and hope. Many physicians draw on more of the psychiatric model’s techniques than they realize.
Pain treatment relationships, that begin with rigid written treatment contracts, act to police treatment unlike that in any other area of medicine. The psychiatric model, however, through its distinctive dialogue, uses the patient’s commitment to honesty as the “contract.” A simple and signed agreement to follow treatment recommendations ought to be sufficient. Any improper medication use must be therapeutically, but vigorously addressed in a manner identical to any improper behavior. The underlying reason, if possible, has to be treated. Addictionology consults are often inconclusive since good addicts can deceive even experienced forensic evaluators. A 45-year old teacher said “my doctor ought to spend time to know me…it shouldn’t come from another doctor who only saw me one time…why can’t he figure me out himself?”
The psychiatric model often lives in the zone just beyond the limits of hard clinical knowledge, and therefore commonly cares for those for whom no other standard diagnosis or treatment exists. Far too many patients report that doctors dismiss them once these doctors believe no more can be done for the them. The psychiatric model is historically steeped in the chronic management of such poorly responsive and difficult conditions. The patient may have to continue to live in pain, but he doesn’t have to feel alone.
Often the psychiatric model practitioner is clearly more comfortable and skilled with non-average medication doses and, as such, may be more aggressive with medications, even with opiates. Being comfortable enough to responsibly go to aggressive levels of care, or as one patient said, “having the courage to treat me,” should mean that the doctor is comfortable and very familiar with the patient’s biopsychosocial configuration.
The psychiatric model may also settle issues in the person’s life to the point that a return to the purely medical model is possible.
“Many pain patients speak of physicians who arbitrarily limit the upper dose of pain medications which adds to their hopelessness and suffering and which may produce a transfer into the psychiatric model.”
A patient felt that while his chart’s medical notes read like a “physiology manual,” his psychiatric notes captured how “the doctor himself and I dealt with the pain in my life…it was my biography.”