Chronic pain disorder has no clear physical cause, or occurs with illnesses that do not explain the pain. It is described in the mental-health handbook, Diagnostic and Statistical Manual of Mental Disorders (DSM). The pain is severe enough to need treatment, lasts more than six months, and includes psychological factors. The National Institute of Neurological Disorders and Stroke states that chronic pain lasts longer than the average expected time for any given condition. Furthermore, acute pain alerts the nervous system to protect against injury, but chronic pain is useless because the injury is gone.

Description

Chronic pain is different for each individual. It can be continuous or it can come and go. It is described as burning, tingling, shooting, electrical, or an ache, with numbness. Other patients report stiffness, discomfort, soreness, and tightness.

Incidence/Prevalence

Up to 40% of the American population may experience chronic pain. There is inadequate data available about the rates of pain, because the definition has changed within the American Psychiatric Association (APA).

The Chronic Pain Network reports tens of millions of people with low-back pain and arthritis, many

with a five-year pain history and pain occurring six days a week. In 2003, 38 million Americans reported chronic back pain, 36 million had migraines, 19.3 million reported arthritis, 3.1 million had diabetic neuropathy, 1.4 million reported cancer pain, and 0.5 million reported HIV/AIDS-related pain.

American Pain Society (APS) president C. Richard Chapman, PhD, states that only 25% of the 23 million patients who have surgery every year get pain relief. There are 65 million injuries per year and millions more cases where disease causes pain. Over 40% of pain patients in the moderate-to-severe range cannot find relief and only 30% of cancer-pain patients are relieved.

Causes and symptoms

Causes

Multiple causes of many types can cause pain. The most common noncancer pain types are back and neck, fibromyalgia, headache, arthritis, and neurolog-ically based pain.

Symptoms

The symptoms of chronic pain disorder, as described by the APA, include at least one of the following:

depression and anxiety
negative or distorted thinking
problems with social relationships
disability or reduced ability to participate in usual daily activities
increased pain that requires treatment
insomnia and fatigue

Demographics

Women are twice as likely as men to have chronic pain and adults aged 40-50 are the most affected.

Possible risk factors

The risk factors recognized for chronic pain disorder by the APA include:

one’s parents or siblings experiencing it
depression or alcohol abuse occurring in one’s family
being pain-prone and having a usual behavior pattern of self-sacrifice, self-defeating behavior, and abusive interactions
demonstrating underlying severe depression
being a hard-working, rigid, obsessive, or perfectionistic individual

Complications

Complications stemming from chronic pain disorder can include suicide , anger and depression, anxiety, and substance abuse and addiction and/or alcohol abuse. Substance and alcohol abuse can often be a self-medicating behavior used to mask the pain experience and to remove pain behaviors as well as feelings of anxiety, anger, and depression arising from the frustration of unrelieved pain. The patient may overuse prescription medications, use medications for off-label purposes, or seek illegal substances. This may be especially true if the patient lives among unsupportive or abusive others. Suicide may be an act of ending pain permanently or the accidental result of drug overdose or alcohol poisoning.

Associated conditions

These include secondary gain, substance use, dependent or histrionic personality disorder , major depression in 25–50% of cases, and dysthymia (milder depression) in 60–100% of chronic-pain cases.

Diagnosis

A psychiatrist first determines if the pain is medical. If so, then there is no pain disorder. If not, then the psychiatrist determines whether the pain is pretended. If this is the case, the diagnosis is either malingering for rewards such as narcotics, or a factitious disorder that rewards the patient for acting sick.

A pain disorder includes pain that occurs in at least one place in the body and needs treatment, as well as psychological factors, significant distress, and pain that is not better explained by mood, anxiety, or psychosis .

Psychological measures

The psychiatrist uses several methods to find the severity of pain and the role of psychological factors. These include standardized and informal interviews, pain-rating scales, and visual scales where the patient marks a place on a line to show the amount of pain, or chooses a picture of a facial expression to represent the degree of pain.

The simplest test for pain is to ask the patient how much pain they are feeling on a scale of 1 to 10. On this scale, 1 is the least amount of pain and 10 is the most or worst pain ever felt. Other tests used are the McGill Pain Questionnaire and the West Haven-Yale Multidimensional Pain Inventory.

Treatments

The goal of treatment is controlling and managing pain in order for the patient to be able to function in daily life. In 2007, the American Chronic Pain Association (ACPA) concluded that: “An essential concept in pain management is that each person is different and will respond differently to situations, interventions, and medications. It is important for the person with pain, family members, and others to avoid quick judgments based on what they hear or read about medications. The best place to get advice about medications is from the health care provider.”

Multidisciplinary approach

Patients should seek interested, well-qualified health care professionals and work with them to find solutions effective for their unique pain experiences. This may include physicians, medical specialists, nurse practitioners, alternative therapists, mental health professionals, physical therapists, chiropractors, massage therapists, a personal trainer; and a pastor, rabbi, or spiritual mentor.

Several methods of treatment can work together to manage chronic pain. This combined treatment can be different and require unique “doses,” according to individual needs. It is not one-size-fits-all, and medication alone is often not the total solution.

Patients should learn everything possible about their unique pain in order to understand it. Learning should be with the intent of accepting, targeting, and effectively treating the pain. Patients and families can investigate through public, university, and hospital libraries; Internet research databases; pain-related discussion boards; and online and in-person support groups of encouraging, like-minded people. In addition, it is vital to stay up-to-date concerning the progress of Decade of Pain Control and Research, which was declared January 1, 2001 by the U.S. Congress.

Medications

Medication schedules can be tricky, but they are important. The ACPA promotes the use of a long-term daily pain reliever supplemented by a short-term fast-acting drug for flare-ups.

Depression often occurs with pain. In using opioids (narcotics), potential pain relief must be considered in the light of the side effects of nausea and constipation. Long-term narcotic use presents the risk of drug dependency. Pain-modifying drugs like amitriptyline affect the brain with doses lower than those given for depression. This resulting untreated depression can then result in increased pain. Other antidepressants may also be prescribed. Further, anticonvulsant drugs can be used off-label in pain trigger point injections. This involves the injection of a cocktail of steroid and anesthetic combinations at the body’s affected pressure points to relieve painfully contracted tissues.

Psychological and social interventions

Chronic pain treatment may require individual or group psychotherapy ; family, behavioral, physical, or occupational therapy; or biofeedback . Treatment for insomnia may require relaxation training and education about good sleep habits.

Cognitive-behavioral therapy

Cognitive-behavioral therapy (CBT) educates patients about the pain-and-tension cycle, teaching them how to manage pain and distress, and about the effects of their medications. It helps patients to change their thinking about pain. Patients are taught to identify and modify negative or distorted thought patterns, such as the helplessness and hopelessness of depression. Within CBT, progressive muscle relaxation, deep breathing, visual imagery, hypnosis, and biofeedback are all useful treatments. Pain diaries are useful for charting patterns of pain so patients can identify what affects it, and help determine how well medication are working.

Behavior modification

Behavior modification is taught to the patients and families so that usual activity and non-pain behaviors are encouraged and the pain behaviors of passiveness, inactivity, and medication dependency are removed.

Alternative therapies

Other treatments include acupuncture , electrical stimulation acupuncture, transcutaneous electrical nerve stimulation, massage, nerve blocks, surgery, meditation , exercise, yoga , music, poetry, and art therapy.

Other management

Organization

The Asian concept of feng shui says that unhealthy layouts of homes and workspaces causes stress . If spaces are difficult to maneuver or are cluttered and dim, then pain may increase and last longer. Spaces are best arranged for openness and convenience. Pain patients can also eliminate unnecessary tasks, break big jobs into smaller steps, take breaks, use schedules, and enlist help to reduce stress and pain.

KEY TERMS

Ankylosing spondylitis —A spinal arthritis that begins in the low back and can spread upwards to the skull.

Feng shui —The Chinese method of arranging of objects to increase positive energy flow.

Secondary gain —The advantage gained by having symptoms.

Yoga —A form of stretching and breathing mediation.

Laughter

That laughter is good medicine was demonstrated by journalist and medical professor Norman Cousins as he used planned bouts of laughter to treat himself, with his doctor’s collaboration, for the debilitating pain of ankylosing spondylitis.

Prognosis

The prognosis for total relief of pain symptoms is not good in cases of chronic pain disorder. The usual pattern includes flare-ups between periods of moderate or less-severe pain. The prognosis is best if a patient can keep working. Unemployment leads to isolation, inactivity, and negative thinking, which results in more pain. If there is reinforcement of pain behavior by disability payments, gaining attention, or abuse of addictive drugs, relief of chromic pain is less likely. Recent studies show that cognitive-behavioral therapy along with antidepressants is the most effective treatment.

Prevention

Pain disorder may be prevented by early intervention at the beginning of pain. When pain becomes chronic, it is important to find help with using strategies to manage the pain before inactivity, immobility, and depression appear. Most pain patients see their own doctor first, and the doctor may refer them to a psychiatrist or pain clinic. This does not mean that the doctor does not believe the pain is real. It means that he or she needs to work with other professionals in order to relieve the pain.

Resources

PERIODICALS

Flor, H., and C. Hermann. “Neuropsychotherapy for Chronic Pain. Changing Pain Memories by Behavioral Interventions.” Verhaltenstherapie 16.2 (2006): 86–94.

Gallagher, Rollin M., Maripat Welz-Bosna, and Arnold Gammaitoni. “Assessment of Dosing Frequency of Sustained-release Opioid Preparations in Patients with Chronic Nonmalignant Pain.” Pain Medicine 8.1 (2007): 71–74.

“Hospitals Get Better at Pain Management, Often Led by Clinical Nurse Specialists.” Hospitals and Health Networks 80.11 (2006): 94.

McWilliams, A. Lachlan, R. Goodwin, and B. Cox. “Depression and Anxiety Associated with Three Pain Conditions: Results from a Nationally Representative Sample.” The Journal of the International Association for the Study of Pain 111 (2004): 77–83.

Monina, E., G. Falzetti, V. Firetto, L. Mariani, and C. A. Caputi. “Behavioural Evaluation in Patients Affected by Chronic Pain: A Preliminary Study.”The Journal of Headache and Pain 7.6 (2006): 395–402.

Naughton, Felix, Polly Ashworth, and Suzanne M. Ske-vington. “Does Sleep Quality Predict Pain-related Disability in Chronic Pain Patients?” PAIN. The Journal of the International Association for the Study of Pain 127.3 (2007): 243–52.

Osborne, Travis L., and others. “Psychosocial Factors Associated with Pain intensity, Pain-related Interference, and Psychological Functioning in Persons with Multiple Sclerosis and Pain.” PAIN. The Journal of the International Association for the Study of Pain 7.102 (2007): 52–62.

Phillips, Donald M. “JCAHO Pain Management Standards Are Unveiled.” Journal of the American Medical Association 284.4 (2000): 428–9

Smith, Blair H., Gary J. Macfarlane, and Nicola Torrance. “Epidemiology of Chronic Pain, from the Laboratory to the Bus Stop: Time to Add Understanding of Biological Mechanisms to the Study of Risk Factors in Population-based Research?”PAIN. The Journal of the International Association for the Study of Pain 127, 1–2 (2007): 5–10.

ORGANIZATIONS

American Chronic Pain Association. P.O. Box 850, Rocklin, CA 95677-0850. Telephone: (800) 533-3231.

American Pain Society. 4700 W. Lake Avenue, Glenview, IL 60025-1485. Telephone: (847) 375-4715. <http://www.ampainsoc.org>.

American Psychiatric Association. 1000 Wilson Boulevard, Suite 1825, Arlington, VA. 22209-3901. Telephone: (703) 907-7300 <http://www.psych.org>.

Chronic Pain Network.<http://www.chronicpainnetwork.com>.

National Institute of Neurological Disorders and Stroke. P.O. Box 5801, Bethesda, MD 20824. Telephone: (800) 352-9424. <http://www.ninds.nih.gov>.

UCLA History of Pain Project, The John C. Liebeskind History of Pain Collection.<http://www.library.ucla.edu/libraries/biomed/his/pain.html>.

OTHER

Masuda, A., M. Hattenmaru, and C. Tei. “Repeated Thermal Therapy Improves Outcomes in Patients with Chronic Pain.” International Congress Series. 18th World Congress. Kobe, Japan. (2005).

National Institutes of Health. Statement by National Institutes of Health, U.S. Department of Health and Human Services, on An Update of NIH Pain Research and Related Program Initiatives, before Statement for the Record, Subcommittee on Health, Committee on Energy and Commerce, U.S. House of Representatives. (Dec. 8, 2005).

Patty Inglish, MS

The Gale Encyclopedia of Mental Health