Pharmacologically Resistant Psychologically Conditioned Pain

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"Functional" and feigned pain patients who seem to magnify their physical complaints may be described as exhibiting hysteria, conversion disorder,

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Figure I-56. Combination of voltage- and ligand-gated ion channel at the NMDA receptor hypochondriasis, somatization disorder, depression, and malingering or compensatory behavior. These terms are used in a general fashion, without the specificity that a psychiatrist or psychologist would apply. The general practitioner may call the back pain and its manifestations functional overIay or of psychogenic origin, that is, conditions for which no organic origin can be found. Current evidence suggests that the majority of these patients really do perceive disabling pain. Thus,

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Figure I-57. Putative effect of anticonvulsants as analgesics on ionotropic glutamate receptors assuring a patient that the pain is all in the mind offers no benefit. Such labeling creates a negative response in the patient and impairs the working relationship between physician and patient. There is often a strong correlation between inappropriate responses on physical examination and inappropriate response to treatment. These physical responses are (Figure I-58):

1. Tenderness that is nonanatomic and responsive to the lightest touch.

2. Simulation, indicated by inappropriate pain response to light axial loading of the spine by pressure on the head, or pain in the back when the pelvis rather than the spine is rotated.

3. Distraction, in which there is normal straight leg raising in a sitting but not a supine position.

4. Regional abnormalities, such as widespread weakness and sensory disturbance throughout the entire limb or side of the body; and

5. Overreaction to examination, including cogwheel-type resistance to strength testing of an extremity.

All of these responses can be correlated to abnormalities defined on self-report tests such as pain drawings, psychologic tests, depression scales, and pain analogue scales. Once pathologic changes have been ruled out, the best treatment for the mildly anxious patient is reassurance and a time-limited regimen of mild sedatives. In more severe cases, psychiatric referral may be necessary.

The biggest problem in treating pain patients, when therapeutic interventions are without any effect, is that of a functionally related somatization of pain. In the International Classification, a "somatozised pain syndrome" is as follows: "A prevalent symptomatic ongoing, and agonizing pain, that cannot be explained by organic pathology". Pain then appears in connection with psychological and/or psychiatric problems and emotional conflicts, which are of sufficient intensity to become the dominant cause of pain. A large number of patients with apparently

Psychogenic pain syndrome

Psychogenic pain syndrome

Figure I-58. Patient with psychogenic pain syndrome characterized by typical symptoms

somatoforme pain, is not only seen in the head, the heart, the gastro-intestinal and the genital area, but more frequently in patients with neck and back pain. Patients regularly displace such psychosomatic interconnection, which is very difficult to treat. The patient refuses to acknowledge such cause and demands newer and more extensive medical examinations. Although any premature psychosomatic diagnosis is dangerous, because it impairs the diagnostic assessment and results in a displeased and angry patient, a functionally related ailment has to be suspected when prolonged therapy shows resistance. In the search of an organic cause, ultimately the patient in pain wanders from one doctor to the next ("doctor shopping").

With newer and more costly outpatient, and/or clinical examinations, the patient turns into a "specialist killer" at shorter intervals. This is because with every new step in the ladder of the medical hierarchy, any therapeutic intervention in this psychosomatic disorder is doomed to fail. On the basis of number of various pseudo findings, therapy is only symptom oriented; it could even result in surgical interventions, which the patient is willing to endure without resistance. And although stress reactions resolve within two or three days of a traumatic event, they may be associated with later symptomatology and chronic pain. For instance almost one sixth of all patients involved in a traffic accident develop phobia of traveling in cars trains or even trams subsequent to the accident. The stress of the traumatic event is likely to contribute to later avoidant behavior on standing-learning theory grounds.

A symptom, suggesting a functionally-related pain syndrome, is that of lavished depression, where the depressive symptoms are in the background, while somatic symptoms become evident. Another case of a functionally, psychosomatic-related pain problem is that of a conversion. Here, subconscious conflicts emerge to the surface, disguised as somatic pain (conversion) and where the painful sensations act as an equivalent or a replacement for past stressful events. Such a disorder is difficult to treat because pain has a symbolic character, mirroring subconscious desires, aggressions, and affections, which should to be kept away from the conscious mind. Pain in such sense may also be some kind of self-punishment of uncondoned, not socially accepted desires. This is also reflected in the word "pain" and a linguistic association with the latin word "poena" (penalty), where pain is the attempt of the patient to prevent a nervous breakdown (ailment in the sense of self-healing).

Finally, psychosomatic pain may play an important role in that the patient consciously or unconsciously gains some kind of profit by maintaining the malfunctions. It is there the psychologist comes into play and where the body language points to a problem with his/her significant others, which are not outspoken and otherwise are not confronted. According to some psychoanalysts (Dr. I. Freye/Zurich), such symptoms wrongly often are linked to the everyday "battle of the sexes" as they follow the mainstream of current psychological thinking. Here, the actual problem is misjudged, and where early physical and/or sexual harassment in childhood, chronic pain experiences of family members, psychosocial load such as a divorce, or early personal pain experiences act as predisposing factors in the development of chronic pain. And when somatoform pain is transferred into a partnership symptomatic therapy ultimately does not result in a relief of pain. Contrary, the conflict is further somatized, e.g. it is diffused and further transferred onto the bodies level. As a result, family members spare the sick partner, and any demands upon him/her are avoided. Ultimately however, the patient gains some advantage from the ailment, pain is being misused as an instrument of power resulting in further manifestation if it is not being analyzed. In such patients, principally no physical cause of pain is found, and although they complain of persistent pain, it is described very emotionally, such as if being reported by someone else. In addition, pain typically starts with the stressful situation.

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