Psychiatry—Chronic Pain and Somatoform Disorders



Psychiatry—Chronic Pain and Somatoform Disorders

Chronic Pain Syndrome

Chronic pain syndrome is a poorly-defined medical condition consisting of pain that is of a complex natural history and unknown etiology. This syndrome is considered when pain persists for at least 3 months, or when its duration continues beyond the expected healing time for the involved tissue.

While the chronic pain syndrome usually results from an initial organic pain condition (any noxious stimulus that causes pain via myelinated alpha and unmyelinated delta and C-fibers), the continued, unrelieved pain characterizes this syndrome. There are two purported factors thought to be associated with this syndrome:

Internal Reinforcers – emotions of guilt, or fear of work, sex, or responsibilities

External Reinforcers – increased attention from family and friends, increased socialization from physician/PA, medication, compensation, and time off from work

Epidemiology

1) Prevalence – 35% have chronic pain

2) 49 million Americans are partially or totally disabled

3) Females >Males

4) Groups with disproportionately greater disability – ethnic distribution, elderly, lower socioeconomic group, children living in poverty, and female headed households

Associated Contributory History and Risk Factors

1) History of loss – death or divorce

2) Prior traumatic life events

3) Increased stressors – financial, emotional

4) Physical or sexual abuse history

5) Concurrent and worsening psychiatric illness – major depression, anxiety disorder, somatoform disorders, alcoholism or drug abuse

6) Termination of prior physician-patient contracts – history of “doctor shopping”, frustration and anger of previous “ineffective care”, and high expectations for help from the new provider

7) Hidden agendas – narcotic seeking, disability, sick-role privilege, and legitimize illness to family and coworkers

Sternbach’s 6 D’s of Chronic Pain Syndrome

1) Dramatization of complaints

2) Drug misuse

3) Dysfunction/disuse

4) Dependency

5) Depression

6) Disability

History

Pain

1) A thorough history is necessary to direct further evaluation and appropriate consultations, and to avoid repeating invasive and expensive procedures

2) Descriptors – OPPQRST

Past Medical History

1) Adult illnesses

2) Psychosocial history – occupational, family and marital problems, stressors, recreational/hobbies, religious affiliation, sleep patterns/diet/exercise, drug/alcohol abuse, physical abuse, and social support systems

3) Sexual history

Physical

Waddell signs – used to indicated non-organic or psychological components of pain

1) Superficial tenderness – skin discomfort on light palpation

2) Non-anatomic tenderness – tenderness crossing multiple anatomic boundaries

3) Axial loading – eliciting pain when pressing down on the top of the patient’s head

4) Pain on stimulated rotation – rotating the shoulders and pelvis together should not be painful as it does not stretch the structures of the back

5) Distracted straight leg raise – if a patient complains of pain on straight leg raise, but if the examiner extends the knee with the patient seated (e.g. when checking Babinski reflex)

6) Regional sensory change – stocking sensory loss, or loss in an entire extremity or side of the body

7) Regional weakness – weakness that can be overpowered smoothly. Organic weakness will be jerky, with intermittent resistance

8) Overreaction – exaggerated painful response to a stimulus, that is not reproduced when the same stimulus is given later

9) Detailed physical examination of the musculoskeletal, cardiovascular, GI, GU, reproductive, and neurological systems are warranted

Diagnosis

1) Review of prior studies

2) Utilize necessary diagnostics to confirm suspected diagnosis

3) R/O life threatening illnesses

4) CBC and differential

5) Comprehensive/basic metabolic panel

6) UA

7) Urine toxicology

8) Plain films

9) CT scan

10) MRI

11) EMG/NCV

Treatment

1) Underlying cause

2) Rehabilitation – physical therapy and exercise, hot and cold applications, TENS, massage, trigger point injections, occupational therapy, recreational therapy, acupuncture, and chiropractic therapy

3) Surgery – nerve blocks, spinal cord stimulation, external or internal intrathecal morphine pumps

4) Pharmacological – OTCs, non-opiod, opiod, and BDZ

5) Psychophysiological – reassurance, counseling, relaxation therapy, stress management programs, biofeedback

6) Other – hypnosis

7) Appropriate referrals

Strategies

1) Do no suggest “it’s all in your head”

2) Do no order endless testing without indication – avoid unnecessary invasive tests or medications, avoid over referring to specialists

3) Do not focus on symptoms (focus on function instead)

4) Establish long-term empathetic relationship

5) Schedule frequent visits

Prognosis

Poor Prognostic Factors

1) High frequency of physical complaints – somatization

2) Long history of frequent healthcare visits

Good Prognostic Factors Suggestive of Recovery

1) Brief history of chronic pain (> men (10-20:1)

7) Manage with frequent appointment

Hypochondriasis

Hypochondriasis is characterized by the patient’s belief or fear that he or she has some specific disease, usually >6m. Despite constant reassurance the patient’s belief remains the same. Symptoms are often consistent with patient’s conception of specific illness.

Characteristics

1) Onset is 20-30

2) Men = women

3) AA > Caucasian

4) Often a history of prior physical disease

5) Causes significant distress and impairment

Conversion Disorder

Conversion disorder is characterized by one or two neurological symptoms (sudden loss of neurological function) e.g. inability to walk, sudden blindness, limb weakness, or paralysis, aphonia) affecting voluntary or sensory function that cannot be explained by any known neurological disorder. Must have psychological factors (Stressors) associated with the onset or exacerbation of the neurological symptoms

Characteristics

1) Onset – adolescents and young adults

2) Women – 2:1

3) More common among lower SES, rural populations, low IQ’s, and military personnel

4) Associated features – often a history of conversion or somatization disorder, modeling the symptom after someone else with a similar presentation, a serious preceding emotional event, or underlying history of depression, schizophrenia, or personality disorder

Pain Disorder

Pain disorder is characterized by the presence of pain in one or more bodily sites. Psychological factors must be present in the onset, exacerbation, or continuation of the pain. Complaints of pain are inconsistent with anatomic and clinical signs.

Characteristics

1) Onset – 40-50

2) Women > men

3) More common among persons with blue-collar jobs

4) Coexisting depression, anxiety, and substance abuse may be present

Body Dysmorphic Disorder

Body dysmorphic disorder is characterized by the belief that some body part is abnormal, defective, or misshapen, and is not evident to other. There is a preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person’s concern is markedly excessive

Characteristics

1) Most common age of onset is between 15-20

2) Women > men, likely to be unmarried

3) Often a personal history of depression, anxiety, and psychotic disorders

4) Family history of depression and OCD

5) Associated with multiple, frantic, and unsuccessful attempts to correct imagined defect by cosmetic surgery

Diagnosis

1) Physical exam findings are either negative or incongruent to complaints

2) Initially, it must be accepted that the patient’s distress is real

3) Utilize laboratory and imaging testing as indicated

4) Avoid invasive diagnostic procedures and aggressive surgical assessment

5) Minnesota Multiphasic Personality Inventory (MMPI) testing

Approach to the Patient with Somatoform Disorders

1) Build trust with patient to facilitate a therapeutic relationship

2) Realize that not every problem not found to have an organic basis is NOT necessarily a mental disease

3) Patient reassurance

4) Schedule regular, frequent, but short appointments – drugs are not meant to replace visits. Avoid excessive referrals; one primary physician/PA is the preferred route

5) Utilize patient diaries

6) Psychoeducation – physical complaints may be exacerbated by anxiety and emotional problems, related symptoms to adverse developments in the patients life

7) Psychologic therapy – hypnosis, group therapy

8) Behavioral therapy – biofeedback

9) Social support – family and coworker involvement

10) Pharmacotherapy – pain and body dysmorphic disorders (analgesia, TCAs, SSRIs, and MAO-Is)

11) Referrals – psychiatry

12) Follow CPS strategies

13) Best prognosis with early intervention

Factitious Disorders

Factitious disorders are characterized by the conscious production of signs and symptoms of both medical and mental disorders. The main objective is to assume the sick role, and possible eventual hospitalization. The pathophysiology of FD is unclear, and symptoms are produced intentionally but for unconscious reasons.

DSM –IV Criteria

1) Intentional production or feigning of physical or psychological signs or symptoms

2) Motivation for the behavior is to assume the sick role (primary gain)

3) Absence of external incentives for the behavior (secondary gain: economic gain, avoiding legal responsibility, improving physical well-being, as in malingering

Malingering is not a mental disorder, nor a factitious disorder. It is the intentional and conscious production of signs and symptoms for an obvious gain. Symptom motivation is also conscious: money, avoid work, evading the police, free bed and board.

Two well-known examples are Munchausen syndrome (chronic FD) and Munchausen syndrome by proxy (the intentional production or feigning of physical or psychological signs or symptoms in another person who is under the individual’s care, i.e. mother through her child).

Epidemiology

1) Reliable percentages are not available

2) Overall FD and Munchausen syndrome by proxy more common in women aged 20-40

3) Chronic FD (Munchausen syndrome) more common in middle-aged men

Risk Factors

1) Hospital and health care workers – knowledge of textbook descriptions of illness, an unusual grasp of medical terminology

2) Underlying psychological illness

Manifestations, Mechanisms, and Course

1) Dramatic or atypical presentation

2) Controlling, hostile, angry, disruptive, or attention-seeking behavior during hospitalization

3) Symptoms or behaviors only present when the patient is being observed

4) Fluctuating clinical course – rapid development of complications or a new pathology if the initial workup findings prove negative

5) Long medical record with multiple admissions at various hospitals in different cities

6) Presentation in the ED during times when obtaining old medical records is hampered or when experienced staff are less likely to be present (holidays, late Friday afternoons)

7) FD – self-mutilation, fever (injecting bacteria to produce infection), hematuria (adding exogenous blood to urine), hemorrhage, hypoglycemia (exogenous administration of insulin), ingesting CNS-active medications to induce psychiatric symptoms, seizures, nephrolithiasis, un-witnessed syncopal episodes

8) Munchausen syndrome by proxy – child apnea, evidence of suspected child abuse

Diagnosis

1) FD is often a late diagnosis, after extensive diagnostic modalities to r/o organic pathologies have been employed

2) Helpful diagnostic methods – hypoglycemia (increased serum insulin/C-peptide ration (>1.0) during a hypoglycemic episode), tissue biopsy for suspected false lesions, or nephrolithiasis (urine filtration and composition analysis)

Treatment

1) Psychiatric referral

2) Psychotherapy/cognitive-behavioral therapy

3) Patient and family education

4) Gentle, supportive confrontation

5) Treat underlying psychiatric disorders

Complications

1) Wasted resources, iatrogenic

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