Psychiatry - December 2008 - (Page 21)

than their pain? Are they trying to get out of work? Are they trying to dupe me into providing controlled substances? Will the Bureau of Worker’s Compensation and other agencies ever stop sending forms to complete? This article seeks to answer some of these questions to assist you in developing a therapeutic stance in a difficult scenario. Working with patients who are in chronic pain has its challenges and rewards, and is similar, in that regard, to other compelling conditions by which we earn our living and for which other providers welcome our assistance. It is natural for personal experiences to trigger one’s life interests. When contemplating patients in pain, I recall injuring my back when I was a nurse’s aide while attempting to prevent a large patient from falling. In the face of daily pain that interfered with restful sleep, I became whiny and irritable. Then, while I was a family doctor, prior to journeying into psychiatry, I witnessed a very ordinary, fairly content mother who worked full time as a janitor evolve into a whiny, irritable, and easily overwhelmed woman following a work injury. She developed what was then called reflex sympathetic dystrophy (now complex regional pain syndrome-I or CRPS-I).2 It confirmed for me the answer to the question about whether miserable people handle their pain poorly or whether unremitting pain causes normative individuals to become miserable wrecks: Most certainly, it is the latter. are beginning to clarify how it is that peripheral nociceptors sometimes fail to shut off, or how RNA in the cell body at the dorsal root ganglion begins to produce proteins and fashion them into additional receptors that travel back to the periphery.5 While these and other neurological tidbits make for a great afternoon of continuing medical education, they are not the focus of this article. The important issue is that these and many other processes occur in the peripheral and central nervous system in some individuals, and, in some contexts, keep the patient’s mind focused unwaveringly on the pain, despite the absence of ongoing tissue injury. It is our job to their ongoing personal battle with pain. Case example: discussing the patient’s pain. Psychiatrist: Tell me about your pain. Patient: (dubious) You really want to hear? Psychiatrist: Yes. Hearing your story is the main way I can determine how I might be helpful to you. Patient: Well, doc, no one really wants to hear about it. Psychiatrist: Hmm. It sounds like, in addition to feeling the physical pain, you are feeling isolated from people around you who don’t want to listen. Patient: That’s for sure. Psychiatrist: You know, there is In general, there is a large discrepancy between a patient’s need to tell his or her story [of pain] and the social support network’s capacity to hear it. The first and biggest therapeutic goal can be to ensure that we hear and acknowledge a patient’s ongoing struggle with pain. help the patient redevelop a meaningful life in spite of this phenomenon. something about other people’s pain that seems to turn most people off…and yet you need to talk with someone to help deal with it. It makes your burden even harder to bear. Patient: (visibly relaxing) That’s so true. You can’t believe what it’s like to be in pain day after day… and my wife… well I know she is tired of hearing about it. She just wants to know why I can’t mow the lawn. I can’t even carry in the groceries. Psychiatrist: So you’ve got pain, isolation, and the struggle of not being able to be the man-aboutthe-house you once were. Patient: You can’t believe how terrible it is, doc. Psychiatrist: I want to try to understand. PRACTICE POINT: THE PATIENT’S SUPPORT NETWORK QUICKLY GROWS WEARY OF HEARING ABOUT PAIN An individual patient’s attention can be glued to his or her pain. This is not so with acquaintances, loved ones, and doctors. Most pain patients report that no one will listen to them regarding their pain. In general, there is a large discrepancy between a patient’s need to tell his or her story and the social support network’s capacity to hear it. The first and biggest therapeutic goal can be to ensure that we hear and acknowledge a patient’s ongoing struggle with pain. It is likely that he or she will need to be told numerous times over the course of therapy that you “get it” in regard to his or her ongoing burden. This can be a tremendous relief for our patients and allow them to reengage their sense of self respect in the face of [VOLUME 5, WHAT IS PAIN? The brain is attuned to notice pain. Pain causes the individual to stop other activities and attend to the pain. This demand to stop and pay attention does not go away when the pain loop, due to plasticity in the nervous system, continues to send pain messages after the initial trigger has resolved.3,4 Unfortunately, in some cases, pain messages continue for months or years after their utility has gone, as in CRPS-I. Researchers 21 WHY IS THERE SUCH AN INTENSE NEED TO KEEP TALKING ABOUT PAIN? All of us have a story. Patients in pain are no exception. Life-altering events, such as the development of a terminal illness, the death of a loved 12, DECEMBER] NUMBER Psychiatry 2008 21

Table of Contents Feed for the Digital Edition of Psychiatry - December 2008

Psychiatry - December 2008 Editor’s Message Contents Editorial Advisory Board Antidepressant Prescribing by Specialty and Treatment of Premenstrual Dysmorphic Disorder Pain, Pain, Go Away: Antidepressants and Pain Management Why Psychotherapy Helps the Patient in Chronic Pain General Medical Drugs Associated with Depression Katatonia: A New Conceptual Understanding of Catatonia and a New Rating Scale Thermoregulation and the Role of Calcium Signalling in Neurotransmission Cognition and Schizophrenia: Is There a Role for Cognitive Assessments in Diagnosis and Treatment? Journal Watch Information for Authors

Psychiatry - December 2008

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