Patienthood as a Psychosocial State The Patient With Simple Versus Chronic Pain

An array of factors can become central to the life experiences of the patient with chronic pain (Table 2-7). As a result of these factors, a number of emotional and psychological sequelae are associated with the chronic pain state. Physicians have long noted a puzzling discrepancy between physical disease status and progression and the patient's subjective experiences (Weisberg and Clavel 1999). Some patients with severe disease present few complaints and report less disability and emotional distress. Yet some others with little documented disease report severe symptoms and experience marked distress and disability.

Despite the pervasiveness of chronic pain, most individuals with chronic pain can nonetheless maintain basic functioning, work, and interests. They are able to work with their clinicians and other care providers and can respond with some relief to medications or interventions. At times, psychotherapeutic interventions may be required to address mood disturbances, stress, and coping. This cluster of patients is sometimes referred to as having simple chronic pain. Small proportions of patients with chronic pain are entirely debilitated by the pain and are sometimes referred to as having complex chronic pain (see

Table 2-6. Categories of chronic pain fO 00

Table 2-6. Categories of chronic pain

Source

Localization

Features

Examples

Effective medication

Nociceptive: somatic

Damage to tissue, soft tissue, or bone; inflammation; trauma

Well localized

Aching, sharp

Pain of arthritis, cancer

Aspirin, NSAIDs, COX-2 inhibitors, opiates

Nociceptive: visceral

Injury or damage to visceral structures, organs

Referred pain, fairly well localized

Aching, sharp

Pain of angina, kidney stones, appendicitis

Opiates, other analgesics

Neuropathic

Damage to nerve tissue, either peripheral or CNS

Nerve distributions, poorly localized with CNS sources

Paresthetic, numb, burning, pins-and-needles

Postherpetic neuralgia, trigeminal neuralgia

Antidepressants, anticonvulsants

Psychogenic

No clear underlying cause; psychological distress

Poorly localized

Vague, sweeping

Somatization disorder

Psychotropic medications, psychotherapy

Note. CNS = central nervous system; COX-2 = cyclooxygenase-2; NSAID = nonsteroidal anti-inflammatory drug.

Source. Reprinted from Leo RJ, Singh A: "Pain Management in the Elderly: Use of Psychopharmacologic Agents." Annals of Long-Term Care: Clinical Care and Aging 10:37—45, 2002. Used with permission.

Note. CNS = central nervous system; COX-2 = cyclooxygenase-2; NSAID = nonsteroidal anti-inflammatory drug.

Source. Reprinted from Leo RJ, Singh A: "Pain Management in the Elderly: Use of Psychopharmacologic Agents." Annals of Long-Term Care: Clinical Care and Aging 10:37—45, 2002. Used with permission.

Table 2-7. Common problems encountered by patients with chronic pain

Medical Problems with access to appropriate care

Difficulties in establishing a working relationship with practitioner skilled in pain management Psychological Comorbid mood disturbances

Physical The pain itself

Deconditioning resulting from inactivity Medical complications from use of multiple medications Vocational Job loss

Restrictions from usual types of job activities Financial Financial problems arising from job loss, loss of medical coverage, or the cost of medical care Legal Litigation related to injuries, workers' compensation, or disability issues

Family Pain's interference with customary role of the patient, causing others within the family to adopt new roles Limited reserves of energy and time left for other family members' needs (e.g., children's needs, their activities, their schoolwork, etc.) because so much is taken up with pain and the pain patient Sociocultural Pain's interference with patient's ability to engage in customary activities and maintain social ties, resulting in significant losses in the patient's social support network

Table 2-8 for a comparison of the two categories). In this subset, patients have a notable preoccupation with pain. For these persons, life revolves around the pain. Activities are forestalled, and work is not pursued. The patients may be thrust into positions of marked dependency on others. Several, perhaps all, aspects of their lives are made contingent on pain experiences or are put off because the patients fear their pain might get worse (Sternbach 1974). For such persons, being a patient is a primary psychosocial state. Life experiences become centered on doctors' visits. If these visits are unsatisfying, patients may develop a history of "doctor shopping." They may seek invasive and diagnostic procedures to confirm the existence of the pain or alleviate their distress. Such patients may display increasing preoccupation with medication use and, possibly, abuse. Numerous psychological factors beset the patient with complex pain, many of which can exacerbate and maintain pain (Weisberg and Clavel 1999).

Table 2-8. Simple versus complex chronic pain

Simple pain Complex pain

Pain is clearly defined.

Patient is easily enlisted into treatment.

Patient's support systems are stable.

Comorbid psychological factors are easily defined.

Patient's pain shows some response to medications and treatment.

Patient may require short-term psychotherapy or psychological interventions.

Litigation is not central to the patient's presentation.

Multiple pain complaints are present.

Difficulty can be encountered enlisting patient into treatment.

Patient has unstable social systems.

Severe complicating psychological factors can be present.

Patient's pain shows poor response to medications and treatment.

Patient may require multidisciplinary treatment approaches, including psychiatric treatment.

Litigation is apt to be central to the patient's presentation.

Patients with simple chronic pain may do well with a single pain specialist, with referral as needed to services provided by practitioners in other specialties (e.g., psychiatrists, therapists). Patients with complex pain, on the other hand, can overwhelm a single practitioner. Clearly, such patients need a multidisci-plinary approach to their pain, involving the coordinated joint efforts of practitioners in medical, surgical, physical, neurologic, or psychiatric services.

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