Chronic Pain: The Psychiatric Perspective

Patients with fibromyalgia or other rheumatic diseases frequently voice chronic pain complaints. Sorting out the underlying factors can be challenging when the cause is not only a manifestation of medical pain but may also be related to changes in the central nervous system (CNS).

Pain is the No. 1 reason patients go to see a rheumatologist, and it is consistently tagged as their highest priority at follow-up visits. A study of patients reporting their physician had diagnosed them with rheumatoid arthritis showed 86% said their disease was “somewhat to completely” controlled. At the same time, 64% were stating dissatisfaction with their pain control. Although all of these patients were under the care of a rheumatologist, 90% still rated their pain as moderate or worse.¹

A 2010 report from the American College of Rheumatology’s Pain Management Task Force showed that rheumatologists are not always sure they know the cause of pain and best strategy for management. They do not see themselves as pain managers, more often concentrating on tissue injury and inflammation as pain reduction treatments.²

Complex Phenomenon

Dr. Mufson

Thes

“Pain is a complex phenomenon that is driven by physiologic disorders, but is also impacted by psychiatric and psychological disorders,” says Michael J. Mufson, MD, director of the Complex Diagnostic Service at Brigham and Women’s Hospital in Boston. “Because of this, there should be a multidisciplinary approach to its treatment if you are going to get the best outcomes.”

The multidimensional nature of pain suggests that there is often a reason for both the rheumatologist and psychiatrist or psychologist to become involved in caring for the patient. There is also a complexity underscored by multiple sources for developing pain.

Two Pain Generators

“In rheumatic diseases there can be peripheral pain generators that result from localized changes in the joints or other tissues,” says Lesley M. Arnold, MD, professor of psychiatry and behavioral neuroscience at the University of Cincinnati College of Medicine. “In some patients, changes also occur in the central nervous system (CNS) that influence the pain experience.”

Dr. Mufson says there are three different kinds of patients with chronic pain. The first is purely within the practice of the rheumatologist. For these people, the only pain is peripheral pain caused by physical changes, such as bone and joint damage.

At the other end of the spectrum are those patients for whom the subjective report of pain is related to a psychiatric disorder. In these cases, the main indicator of a psychiatric illness is manifest as pain.