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10 Articles in Volume 9, Issue #8
Adjunctive Psychiatric Pain Management Treatment
Deep Cervical Muscle Dysfunction and Head/Neck/Face Pain–Part 2
Hackett-Hemwall Dextrose Prolotherapy for Unresolved Elbow Pain
Intradermal BTX-A Reduces Frequency and Severity of Pain for MMD
Keeping Prescribers on Board if Certification Becomes Part of REMS
Magneto-Laser Therapy of Pulpitis and Vertebra Column Osteochondrosis
Pain and Self-regulation
Pain Care of Severely Neurally-Compromised Patients
Simultaneous Use of Opioid and Electromagnetic Treatments
The Experience of Pain

Adjunctive Psychiatric Pain Management Treatment

The psychiatric/psychological modality is a crucial component of comprehensive treatment for chronic pain.

Research has shown that comprehensive pain treatment is most effective in reducing pain and increasing functioning in our patients with chronic pain.1,2 When patients see a team of providers—which might include a pain medicine physician, a psychiatrist/psychologist, a physical therapist, and an alternative medicine practitioner—each component of treatment can add something to the whole. As well, each practitioner can focus on what he or she does best, knowing that the other parts of treatment are in place. This can help patients appropriately use the expertise of each member of their team so that practitioners do not get over-whelmed trying to treat problems they are not equipped for.

However, when you refer your patient to a pain management psychiatrist or psychologist, clearly telling patients in what ways they may benefit will increase the number who actually attend treatment, practice skills, and thus benefit from psychiatric pain management therapy. This article will review the benefits of this modality.

Benefits of psychiatric pain management include:

  1. Psychiatric evaluation
  2. Diagnosis and treatment of psychiatric disorders
  3. Evaluation of psychiatric medication for pain
  4. Psychological pain management skills
  5. Positive behavioral changes
  6. Positive psychological changes
  7. Supportive therapy
  8. Group therapy
  9. New brain-based treatments

Psychiatric Evaluation

A psychiatric pain management evaluation assesses:

  1. Prior psychiatric functioning and psychiatric diagnoses. If psychiatric disorders were present prior to a pain disorder diagnosis, there is increased risk for recurrence.
  2. Current psychiatric symptoms. There is a high level of psychiatric co-morbidity with chronic pain. For example, depression occurs in 8-50% of patients with pain,3 anxiety in 19-50%,4,5 PTSD in 10%,6 sleep disturbance in 50% or more,7 and drug and alcohol problems in 3-19%.8 If multiple disorders are present, it is necessary to treat them all. For example, if someone has depression and pain, treating just one does not necessarily mean the other will go away. As well, neither condition may get better unless you treat both.
  3. Psychiatric interactions with medications. Many drugs used for pain cause psychiatric symptoms, including sedation and depression. Differentiating side effects and underlying psychiatric illness is crucial and medication recommendations to decrease side effects can be helpful. Some pain medications cause unusual or serious side effects.

For example, NMDA receptor antagonists can cause significant anxiety, hallucinations, or cognitive problems. Psychiatric input can help evaluate or treat these side effects.

Diagnosis and Treatment of Psychiatric Disorders

After assessing psychiatric symptoms, a psychiatric diagnosis is made. Psychiatric symptoms should not be dismissed as “expected” or attributed solely to pain. In addition to the psychiatric disorders mentioned above, suicidal ideation is assessed in a psychiatric evaluation. Rates of suicidal ideation may be two to four times greater in chronic pain patients than in the general population9 and are crucial to identify.

Treatment for any disorders which are present may include therapy, medication or both. Since patients with chronic pain are often already on multiple medications, using therapy or sleep hygiene techniques may be preferred. When psychiatric medications are indicated, using ones with pain-relieving qualities—or knowing how to take advantage of side effects—may give added benefit.

Substance use or abuse may be a concern of others on the team and an area in which a mental health practitioner can shed light. One important area is differentiating substance use and addiction (either abuse or dependence) from tolerance to pain medication. “Pseudo-addiction,” the presence of behavior which appears to indicate addiction but is caused instead by the under-treatment of pain, can also be determined.

Psychiatric Medication for Pain

Many medications originally used in psychiatry can also be helpful for chronic pain itself, separately from treating any psychiatric illness. Antidepressants and anticonvulsants are two such categories of medication.10,11 SNRI’s (serotonin-norepinephrine reuptake inhibitors) have been shown to be helpful in both diabetic peripheral neuropathy and fibromyalgia. Tricyclic antidepressants (TCA’s) such as amitriptyline and nortriptyline have been shown to help in many different pain disorders, although none are FDA-approved to treat pain. The use of SSRI’s (selective serotonin reuptake inhibitors) for migraines and chronic daily headache is supported by some research, although evidence has been mixed. Although anticonvulsants are FDA-approved for a few select pain conditions such as diabetic peripheral neuropathy, fibromyalgia, post-herpetic neuralgia, and trigeminal neuralgia, they are more widely used for other pain conditions as well.

When using an antidepressant, it is helpful to clarify for patients that this does not mean their pain is “in their head” or imagined. A second point is that pain often exists along with psychiatric disease. As antidepressants also target depression, anxiety, panic, PTSD and sleep disturbance, using a single medication to target multiple diseases can be wise.

Psychological Skills

Patients can learn psychological skills that can help them both decrease and cope with pain. Breathing, relaxation and visualization help in several ways, including: 1) increasing relaxation and decreasing anxiety, 2) decreasing the stress response associated with pain, 3) improving sleep, and 4) indirectly helping decrease pain by increasing relaxation and distraction. Guided imagery and hypnosis, where suggestions of decreasing pain are paired with imagery, help in the same previously mentioned ways and can also directly decrease pain through the use of suggestion. These skills are taught to patients so they can practice them regularly on their own.

On HowToCopeWithPain.org, there is a series of on-line classes which teach these skills, as well as others such as stress management and improving sleep.

Positive Behavioral Changes

Patients can be supported in making behavioral changes to help themselves live better and get better. In addition to decreasing pain, if possible, an important pain management treatment goal is increased functioning. Psychiatric pain management introduces concepts such as pacing, and helps patients implement a schedule of regular, positive activities, as well as any assigned physical therapy exercises.

Effort is spent to help patients figure out what activities to do and which to avoid. Most important is altering favorite activities so patients can still do them or replacing them with other positive activities. For example, if a patient loves gardening but cannot do as much as previously, she can identify what part of gardening brought enjoyment while recognizing the importance of not completely dropping something previously enjoyed. If it was seeing green and nature by her front door, she could try container gardening instead of her whole backyard. If it was being outside, she could garden for fifteen minutes instead of five hours, then sit in or walk through a garden to enjoy the outdoors.

Patients learn to focus on what they can do and decrease fear of movement while avoiding having pain determine what their life is like. Patients can also benefit neurologically from doing normal activities in that brain reception of signals from normal activity can override pain signals.

Positive Psychological Changes

Because of the multiple losses that occur for patients with pain, they may experience the stages of grief. These include denial, anger, bargaining, depression, and acceptance.12 Acceptance as a psychological stance towards pain is a worthwhile goal for patients. Acceptance includes no longer struggling to control pain, adopting a realistic approach to pain treatment, and engaging in positive everyday activities despite pain.13

McCracken has shown that, no matter what level of pain intensity, greater acceptance of pain predicts lower reports of pain, less pain-related anxiety and avoidance, less depression and disability, and better work status.14 Moving towards acceptance is a process and is sometimes slow. Helping in this process is to grieve for what a patient has lost, to focus on living a full life despite pain and, at times, mindfulness training.

Mindfulness training is a type of meditation that focuses on the acceptance of what is, without judgment. For experimental pain,15 research has shown that subjects taught to use a mindfulness- or acceptance-based strategy had greater tolerance of pain. Older adults with low back pain who were taught mindfulness meditation showed significant improvement in acceptance of pain and physical functioning, and reported decreased use of pain and sleep medication.16

Supportive Therapy

Supportive therapy consists of helping people cope with a difficult situation through listening and support, problem-solving, and instilling hope. This type of therapy allows patients to tell their story and understand how an often life-changing illness fits into their life narrative. Research by Viederman and others has shown that “life narrative” therapy for patients with cancer is beneficial.17 Chronic pain often requires ongoing adjustment, either as a patient’s medical condition changes or pain impacts his life differently at various points. Having a place to work through these issues is important.

Family support can also be offered in psychiatric pain management treatment. Pain affects not just the patient, but family and friends as well. Sessions with families can improve family functioning, as well as help families better support their family member in pain. Supportive therapy for a patient can also provide a respite for an overwhelmed family. A good resource for families (co-written by this author and available online at PPM at www.PPMjournal.com/Handout.pdf) is Surviving a Loved One’s Chronic Pain.18

Group Therapy

For many years, the author has held eight-week Coping with Pain support groups.19 These sessions are divided into four weeks of skill-building, where the focus is learning exercises such as relaxation and visualization. For the remaining four weeks, discussions are held which focus on issues related to living with chronic pain, including positive coping techniques and dealing with changes in patients’ lives such as a decrease in independence. In addition to skill-building, this type of treatment:

  • decreases isolation, especially important in less common diseases such as CRPS;
  • encourages problem-solving with others, so patients can share what helps them live their lives;
  • allows patients to help others. They become a helper, rather than always being the recipient of aid; and
  • expands support networks, which can reverse the isolating effect of pain.

New Brain-based Treatments

For many chronic pain conditions, there are changes in brain architecture in the neuromatrix, which can be thought of as the representation of the body within the brain.20 The degree of change in the neuromatrix parallels the degree of pain. Several newer brain-based treatments can reverse these brain changes and thus decrease pain.21

Mirror therapy uses the patient’s visual system to allow the brain to register normal movement and decrease pain signaling. Graded motor imagery is a step-wise program which uses components of movement to gradually allow the brain to accept physical movement without an increase in pain. Mirror therapy has been shown to be helpful in early CRPS,22 phantom pain,23 and stroke.24 Graded motor imagery is efficacious in chronic CRPS25 and phantom limb pain.26 These treatments are innovative, effective, and have the advantage of being non-medication and non-invasive. Although not all psychiatrists are familiar with these treatments, they match the field of psychiatry’s expertise in the area of brain/body interface.

Summary

Psychiatric pain management treatment is a crucial component of comprehensive treatment for chronic pain. Outlined in this paper are the numerous benefits of this modality. It is hoped that, with an increased understanding of what is offered by psychiatric pain management, other practitioners can add this modality to their patients’ care.

Acknowledgements

This article is adapted from a series for patients on psychiatric pain management treatment on Dr. Whitman’s website, www.HowToCopeWithPain.org, and a presentation at the 2009 Annual RSDSA Conference.

Last updated on: January 6, 2012
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