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Look at the Patient’s Life Story, Then Implement a Management Plan

Beyond the obvious symptoms, a full review of the biopsychosocial experiences and history of each chronic pain patient should be considered in devising a treatment plan.

The care of patients with pain requires a comprehensive assessment and thoughtful case formulation. Patients who present with acute pain presenting with high levels of distress, significant disabilities, and lives in chaos require a thoughtful approach that goes beyond simple and even aggressive analgesic therapies. While the concepts of acute and chronic pain appear straightforward, the management of patients with pain of any type is often performed without a careful application of a standardized method and conceptual formulation of the entire array of causes and relationships that explain their suffering.

Michael R. Clark, MD, MPH, MBA, promotes a comprehensive assessment in formulating a pain plan.

As a result, despite obvious disorder, there may be causes and consequences beyond the pain that should be considered. Without this thorough examination of all domains, the patient will be misdiagnosed, labeled with descriptions like “chronic pain” or incomplete pathophysiological mechanisms like “central sensitization,” and receive generic treatments that may not restore function and quality of life.

In the Department of Psychiatry & Behavioral Sciences at the Johns Hopkins Hospital, all patients receive an extensive evaluation to cover the patient’s entire life story, habitual unproductive behaviors, personal vulnerabilities, and signs/symptoms of disease(s). The purpose of this extensive gathering of information from many sources is to produce a case formulation that goes into more detail than just a list of diagnoses. The formulation is a coherent description of the patient’s distress and accompanying disabilities with a plan for how to address rehabilitation based on four etiological perspectives that guide treatment decisions by logic and established evidence rather than simply giving treatments based on complained about symptoms.

Consider External and Internal Pain

The disease perspective recognizes that many problems emerge out of brain-based and systemic medical problems such as traumatic brain injury, major depression, panic disorder, and bipolar disorder. In order to treat diseases, the broken parts or etiologies must be identified and fixed. In the event a cure is not possible, then remission and adaptation are the goals. In contrast, some problems emerge from a perspective of personal deficiencies (Dimensions), such as temperamental or cognitive limitations. These vulnerabilities place the patient at risk when under increasing demands and expectations. Treatment now focuses on quantifying deficits and remediating them so that capabilities increase in number and skillfulness.

The behavior perspective recognizes that a patient’s choices and actions result from a variety of factors such as beliefs, drives, and opportunities, but then can become sustained despite negative consequences based on reinforcements and comorbid illnesses that interrupt the patient’s ability to make changes and break bad habits. Treatment of behavioral disorders begins with a safe environment that prevents the patient from engaging in the behavior, followed by removing the barriers to understanding negative consequences and experiencing the rewards of productive actions.

Finally, the life story of the patient is a critical perspective to appreciate the individual encounters of the patient and the meaning attached to them. Treatment for the sense of failure and demoralization experienced by patients requires a detailed understanding of the narrative coupled with gentle re-scripting of the meaningful connections to restore a sense of optimism and confidence in achieving future success.

For patients with disabling pain, regardless of whether it is acute or chronic, the assessment and formulation would elucidate the problems and a treatment plan would be designed and implemented. For example, major depression would be treated with antidepressant medications and cognitive-behavioral psychotherapy. Personality vulnerabilities and cognitive deficits would be carefully documented, and occupational therapy would begin a plan for learning new skills and structuring the day to remain on task and reach personal goals. Medications with abuse potential and other psychological consequences would be gradually tapered and discontinued.

Behavioral strategies and group-based coping skills training would help the patient master stressful situations and develop problem-solving abilities. Repeated experiences of failure and feeling overwhelmed with life circumstances would be addressed through teaching new skills but also reconnecting the patient with close interpersonal relationships and exercising the potential to flourish in settings such as work, family, and community.

When the patient’s condition becomes stabilized and functioning improved, a transition of care would shift to the rehabilitative process, focusing on improving skills and gaining more real-world practice with immediate feedback and support. The family and other relevant relationships would be more closely involved to provide important information and reinforcement of the patient’s progress, with the goal of changing the patterns of daily living for when the patient can return to their premorbid level of function.

The important message for patients is that if straightforward approaches to treatment are unsuccessful, the evaluation must be enlarged in scope and depth, with a search for relevant causes that have been missed and the design of a treatment plan to more specifically addresses the nuance and complexity of the individual.

Last updated on: May 16, 2017
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