link to bibliographies
| There are many categorizations and specific disorder diagnoses in which pain is the predominant focus. Many physicians are not aware that pain can be used as a diagnosis. The simple diagnosis of pain should be considered when there are no objective clinical findings of injury or disease and no evidence of factitious disease or malingering. Pain disorders can be categorized as either acute (less than six months) and chronic (greater than six months). In addition, they can be categorized as to whether they exist primarily in response to psychogenic factors, medical illness, or a response to both. According to Stuart Eisendrath, "with the concept of psychogenic factors the mind unconsciously or consciously plays the role of initiating or maintaining pain symptoms" (28). Chronic pain is a pain that is persistent long after the initial finding has been alleviated. The pain is usually maintained unconsciously, and is felt by the individual as a real and occurring pain. When pain occurs with a conscious mind, it usually is initiated for secondary gain. Secondary gains are found in cases where the patients primary concern is attention, or it may be that the patients primary concern is money such as work related incidents. "Factitious disorder, a disorder where the patient will create signs and symptoms consciously, although their motivation may be unconscious. The latter involving money is found in malingering patients, persons with malingering have a conscious mind throughout the entire pain claim" (Eisendrath 29-30). |
Engel, George L.
M.D.: "Psychogenic" Pain and the Pain-Prone Patient. American
Journal of Medicine 899-918.
June, 1989.
| In Engel's article he describes his definition of pain and other types of reasoning behind pain and how individuals perceive or come about to perceive their pain. What matters most is the crucial recognition that our minds and emotions help to constitute the experience we call pain. "Pain is an illness, and relief is probably the most common demand made by the patient upon the physician" (Engel 899). Engel says there are special meanings of pain for each individual, they are as follows: 1) pain warns of damage to the body and becomes involved in learning of the dangers and limitations of the body, 2) From infancy, pain leads to crying and to a response from the mother or some other close person, 3) Fairly early in childhood pain and punishment become linked, therefore pain is inflicted when one is bad, 4) We learn also that pain is power and by suffering we gain power, 5) The loss of loved ones, or guilt can develop pain, 5) Pain may also be associated with sexual feelings, we know at the height of sexual excitement pain can be inflicted and well enjoyed (901). All of the aforementioned are characteristics of how pain is thought of and remembered and all can have long lasting effects. |
Kasdan, Morton
L. M.D., Lewis, Kathleen, Bruner, Anne, Johnson, Amy L. M.D. The
Nocebo Effect:
Do No Harm. Journal of the Southern Orthopaedic Association.
Vol. 8, No. 2, Summer 1999.
| "The Nocebo effect creates negative health expectations that are detrimental to the outcome of the patients recovery. During the 1960's the nocebo effect was first described as the "voodoo death". In some regions of the world the "medicine man" used the nocebo effects to cause death by fright. More recently, this type of effect is described as psychogenic illness or mass hysteria" (Kasdan 2). Epidemics usually start by an individual, in the work place an epidemic is commonly triggered by an odor. If one or more workers become sick, attributing symptoms to the smell, anxiety spreads throughout the workplace and fuels the spread of illness. Nocebo means "I will harm" in contrast to the placebo "I will please". For my study with pain management the nocebo effect helps me to understand how a diagnosis can harm or help a patient with their recovery. In the diagnosis of pain some may say a more general diagnoses such as chronic pain has a lesser effect on the patients initial response and a greater effect on the patients recovery. Where as with a diagnosis of Reflex Sympathetic Dystrophy, this diagnosis may lead a patient into a negative frame of mind in the initial and create long lasting symptoms and recovery time. Both diagnosis are for pain and both lack objective findings for the pain. We learned at a young age how to cope with symptoms and feelings, i.e.. children get the flu they whine for assistance and they get a reaction. We learn to play the patient role, and the placement of a name upon a concept, whether real or imaginary, brings it into clinical existence. The words used in medicine largely influence the diagnosis they describe. I guess we could say mind over matter comes into play when dealing with what a diagnosis really is saying or what we think it is saying. |
Large, R. G.: Chronic
Pain and The Psychiatrist. Aust. N.Z. Journal of Surgery, Vol. 48-No.
1,
February, 1998.
| The usual response to the experience of pain is anxiety in the acute phase, later changing to depression in the chronic phase. Pain of whatever origin makes healthy people neurotic and neurotic people more neurotic than ever (Large, 1988). This article describes how the psychiatrist goes about diagnosing chronic pain and what kind of treatments are needed. The biggest problem in clinical diagnoses for pain are the lack of objective findings and deciding whether the pain is organic in nature or completely psychological. If the pain is psychologically maintained either by environmental or by internal cues it may still be organic in nature. When there are psychiatric findings which usually there are, they should be treated along with any physical findings. Regardless of the cause of or maintenance of pain, it is always real to the person who is experiencing it, and should be treated as so. According to R.G. Large, "treatment should be divided into psychopharmacological, psychotherapy, behavioral therapy, biofeedback, and distractional methods. Although the use of pharmacology's should not replace the use of proper explanation and reassurance, and the key to successful therapy lies in the attitude of the patient towards these methods" (115). |
Morris, David:
The
Point of Pain: Arthritis Today, 17-28, November- December 1995.
| This article is giving us as readers an understanding what pain is and some approaches for treating pain without creating reverse effects. The strong power of belief is plainly evident in the placebo effect. Doctors have long known that placebos such as sugar pills will relieve pain as effectively as morphine, but only if the individual believes the treatments have medical value. We know that the power of belief can also work in reverse; instead of relieving pain, it can create pain. "My pain is not your pain, and your pain is not mine. We come to pain like love from very different angles. What you think and feel, then, can dramatically affect the pain you experience, including its intensity and your ability to endure it" (Morris, 18). Pain is much more than the mere sensation going from an external source to the brain and back again. It is a complex individual experience influenced by the social aspects which shape our lives: upbringing, interpersonal relationships, work environment, personality, and other social practices. The most destructive myth about pain comes in the familiar phrase, "Its all in your head." Everyone should be made aware that there is no such thing as imaginary pain. Pain is always real to the person who is experiencing it. |
Ochoa J: Reflex
Sympathetic Dystrophy (RSD): A Tragic Error in Medical Science.
Hippocrates'
Lantern. 3:1-6, 1995.
| According to Ochoa, reflex sympathetic dystrophy (RSD) is a descriptive term not determining a specific cause. RSD is a nonspecific symptom complex behind which there may be a variety of legitimate organic or psychogenic disorders. A few of the many symptoms considered for RSD are pain (severe and constant), swelling, stiffness, hand temperature fluctuations, and atrophy to the skin (2). Physical therapy, local anesthetic blocks, stellate ganglion blocks, and psychiatric therapy are used in treating RSD. Physical therapy such as heat therapy is used to relieve symptoms and to motivate the patient into recovery, while local anesthetics and ganglion blocks help to eliminate the sympathetic reflex. Many patients are misdiagnosed having RSD due to their psychological problems, such as those having factitious disorders. RSD patients with pain and psychological disorders are fearful, suspicious, depressed, and socially inept, and with this psychological profile can cause problems in both the diagnosis and the treatment of the condition. |
"Pain: Definition."
Stedman's
Medical Dictionary. 27th ed. 2000.
| According to Stedman's Medical Dictionary, "pain is a subjective experience that can be associated with actual or potential tissue damage. It is mediated by specific nerve fibers to the brain where its conscious appreciation may be modified by various factors" (1297). Organic pain is pain which occurs due to an organic lesion. This term is used in describing peripheral findings to cause pain, such as cuts, bruising, and breaks. Psychogenic pain is pain that is associated or correlated with a psychological, emotional, or behavioral stimulus. This term is used in describing pain without peripheral or objective findings, and leads us to believe the pain is related to the psychological field and not the physiological. Arthritic pain deals in the form of inflammation of a joint or a state characterized by the inflammation of the joints. Fibromyalgia a syndrome of chronic pain of musculoskeletal origin but of uncertain cause. |
SZASZ, T.S.: The
Painful Person: The Journal-Lancet 18-22, January 1987.
| The painful person refers to a person that is dealing with pain that does not point to an underlying bodily disease and treatment does not relieve the pain, this pain would be considered chronic in nature. According to SZASZ, when the pain is chronic, it preempts the patient's complete attention, and the situation resembles mental illnesses such as Schizophrenia, and other compulsive states (19). The patient's pain becomes their job, their center of life, and their topic of all conversation. Pain is subjective and a personal experience, it is actively created by the self. Chronic pain in the absence of bodily illness is often a sign that the sufferer wants to occupy the sick role. Chronic pain is very common and also represents the most common presentation of hysterical conversion reaction (HCR). HCR is a subconscious, neurotic behavior that alters the sensory and voluntary motor systems producing bodily dysfunction. |
Tran, Kha M. MD &
Frank, Steven M. M.D. Sympathetic Nerve Blocks: In Search of a
Role.
Anesthesia & Analgesia. 90(6): 1396-1401 June 2000.
| This article is based on the concept of pain management and the issues that arise with it. There are many different opinions about this subject and most do not come from the patient, they come from the doctors and nurses that either disagree or agree with the procedures. According to Frank and Tran the main search in pain management is the role of sympathetic nerve blocks and are they necessary during the course of recovery (1398). In 1991 a young lady fell at work and had injured her right arm, and since this time she has had continued pain. From 1993 until the present, she has been under the care of a pain management physician who diagnosed her with reflex sympathetic dystrophy, a pain disorder based on subjective pain from the patient. He has prescribed over the span of seven years hundreds of sympathetic blocks to release the pain, but thus far she has only had temporary relief from the pain. She was sent to an extremities specialist for a second opinion, and in his findings found her pain to be more psychogenic than that of peripheral pain. Sympathetic nerve blocks: in search of a role, helped me to identify that sympathetic nerve blocks are not necessary to help in the diagnosis and can only help in long term relief if the patient's mindset will allow for this. Drs. Frank and Tran talk about physical therapy as the first priority in recovery and nerve blocks as an alternative and then only for severe, objective pain (1400). Pain without peripheral cause and objective findings needs to be thoroughly psychologically analyzed before any prescriptions are made. |
Weintraub, Michael
I. M.D. Regional Pain Is Usually Hysterical. Arch Neurology-Vol.
45 914-918,
August 1988.
| Pain can be divided into two types, acute and chronic, acute being almost always organic, regardless of the cause. This implies a biological signal of actual or impending tissue damage. Chronic pain syndrome reflects symptoms of pain lasting longer than six months although with chronic pain it has lost its biological significance and seems to have evolved into a negative self sustained state. Weintraub gives the following eleven symptoms of chronic pain patients: 1) profound disability disproportionate to the actual physical findings, 2) extensive diagnostic workup that is negative and lack of response to various therapeutic modalities, 3) excessive drug use and/or drug dependence, 4) mood and personality changes, 5) exaggerated "pain behavior," designed to attract attention and suffering, 6) symbolic choice of symptoms with manipulation of the environment for primary or secondary gain, 7) altered socialization, 8) usually patients are unemployed with little incentive to return to work, 9) patient is convinced of the reality of the discomfort and usually rejects a psychiatric explanation, 10) litigation lurks in the background, 11) psychopathology (schizophrenia, depression, or neurosis) is seen in a significant number of patients (914). Patients who perceive their symptoms as real are usually reluctant to see a psychiatrist and should be further encouraged to do so. Economics plays a role with CPS because litigation affects the majority of patients associated with soft tissue damage. According to Weintraub the rising tide for litigation (malpractice, no fault, and workers compensation) has resulted in a medical lottery for compensating injury and "pain and suffering" (915). Some benefits for workman's compensation include medical care, cash payments, and rehabilitation services. The role of compensation seems to have had a reverse effect on the outcome of rehabilitation and return to work status. Some say the greater the financial compensation, the longer individuals will remain off work. |
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