Chronic Pain: The Psychiatric Perspective

“This is a group that presents to the rheumatologist looking for a medical reason to explain their chronic pain,” says Dr. Mufson. “The doctor can’t find any signs or symptoms of a physical problem. The patient is displacing psychological conflict into these somatic preoccupations.”

Pain complaints can be seen in mood disorders, depression, anxiety and somatoform disorders within the realm of psychiatry. These can be among the hardest to diagnose and treat because both the rheumatologist and the patient become increasingly frustrated when no cause can be found for the lack of response to traditional medication and treatment.

“There is a group in the middle with verifiable physical pain who also have a distinct psychiatric overlap,” says Dr. Mufson. “The psychiatric/psychological condition works as a somatic intensifier. There is a baseline of medical pain that is being made worse by comorbid psychiatric disorders.”

Management Techniques

Pain management techniques in rheumatic diseases are not well settled from a scientific standpoint.

Dr. Arnold

“This is an area where you are going to get a diversity of opinions and approaches because there remains a lot we don’t know about how chronic pain develops in individual patients,” says Dr. Arnold. “Functional brain neuroimaging studies of patients with fibromyalgia have demonstrated abnormalities in CNS pain processing that are distinct from changes related to depression or anxiety. While patients can have both fibromyalgia and depression, for example, they seem to reflect different changes in the brain.”

These various, and possibly overlapping, causes for pain in rheumatologic diseases can make the differential diagnosis very difficult. However, discerning what is going on in a particular person is an integral part of proper care.

“Teasing out how much of the pain is peripheral and how much of the pain is driven by CNS changes is a big concern because it affects how the pain is managed,” says Dr. Arnold. “It takes clinical judgment and can be a very challenging diagnostic problem.”

Treatment Frustration

Improperly treated pain is often a source of friction and frustration for both the patient and the physician. The rheumatologist is upset, because the patient’s pain does not resolve with maximum treatment. The patient is upset for much the same reason.

The mental health provider will assess the patient and look for a psychiatric diagnosis that could explain pain amplification.

Dr. Mufson suggests that a mental health provider should screen every patient with chronic pain. Even if the outcome indicates that the person is well adjusted and doing fine, many important questions have been answered. Not the least of which is that traditional treatments for rheumatic disease should continue to be evaluated.