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Chapter 25. Pain Disorders

Raphael J. Leo, M.D.
DOI: 10.1176/appi.books.9781585623402.299802

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Excerpt

Complaints of pain are the most common reason for patient presentations to ambulatory medical settings (Schappert 1992), accounting for approximately 35 million office visits annually (Knapp and Koch 1984). Most of these remit spontaneously or respond to simple treatment interventions; however, as many as one-fourth of these symptoms remain chronic (Schappert 1992). Chronic pain is pervasive; clinicians in a variety of specialties are likely to encounter patients with pain who present treatment challenges. The costs of chronic pain are monumental when health care, absenteeism, lost wages, and disability are considered (Fishman et al. 1997; Loeser 1999; Stewart et al. 2003). The pervasiveness, refractoriness, and costs associated with chronic pain have rendered chronic pain management a public health priority, spurring multiple efforts directed at understanding the pathophysiological processes underlying pain and at refining treatment strategies. Because of the complexities involved in the experience of pain, its management requires a comprehensive assessment and the implementation of multimodal treatment strategies, including psychopharmacological and psychosocial interventions.

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TABLE 25–1. DSM-IV-TR diagnostic criteria for pain disorder
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TABLE 25–2. Criticisms of the DSM-IV-TR nosology of pain disorder
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TABLE 25–3. Components of a comprehensive biopsychosocial assessment of chronic pain patients
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TABLE 25–4. Psychometric scales used in assessing chronic pain
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TABLE 25–5. Biological substrates common to pain and depression
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TABLE 25–6. Problematic cognitive patterns in pain
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TABLE 25–7. Psychotherapeutic modalities employed in pain management
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TABLE 25–8. Adjuvant medications for pain management
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TABLE 25–9. Pharmacological approaches for mild to moderate pain
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TABLE 25–10. Management strategies for opioid adverse effects
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TABLE 25–11. Analgesic effects of antidepressants
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TABLE 25–12. Anticonvulsant mechanisms of action
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TABLE 25–13. Herbal agents used for pain
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TABLE 25–14. Treatment interventions for management of acute and chronic pain conditions
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Pain is a complex perception involving sensory as well as psychological components.

The diagnostic taxonomy of pain disorder in DSM-IV-TR recognizes that psychological factors can contribute to the experience of pain; however, critics contend that the criteria are insufficiently operationalized to distinguish pain disorder from other psychiatric conditions and that the nosology still retains vestiges of mind–body dualism.

Common psychiatric comorbidities that accompany chronic pain include depression, anxiety, substance abuse, and sleep disorders. Treatment of comorbidities is required as part of comprehensive pain management.

A complex array of adjuvant agents with different mechanisms of action can be employed for chronic pain treatment, including antidepressants and anticonvulsants, among other agents.

Antidepressants have direct pain-mitigating effects apart from influences on mood. Those agents with simultaneous norepinephrine and serotonin effects appear to be most efficacious.

Psychotherapeutic measures can be useful in the comprehensive management of pain to address comorbid psychiatric conditions and subsyndromal psychological states interfering with rehabilitation as well as to reduce the adversity produced by the pain itself.

Multidisciplinary treatment approaches can be useful in reducing perceived pain, enhancing rehabilitative measures, reducing disability, and addressing the psychological comorbidities accompanying chronic and enduring pain.

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CME Activity

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Sample questions:
1.
Depression coexisting with pain is a critical comorbidity pattern that informs many clinical interventions. Which of the following statements is true?
2.
Physicians are frequently concerned about the association between pain disorder and substance abuse. Which of the following statements regarding substance abuse and pain is true?
3.
Which psychotherapy model is most closely associated with the treatment of pain conditions?
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