“Pain is a psychological and physiological disorder,” says Dr. Mufson. “The more the rheumatologist understands whether there is a psychiatric component to the pain, the better the outcome will be.”
Few Providers with Pain Interest
Dr. Arnold notes there are few psychiatrists who focus on the treatment of chronic pain related to rheumatic diseases. This may limit a rheumatologist’s ability to make a referral. However, it’s important for rheumatologists to identify psychiatrists, psychologists or other mental health providers in their community who are interested in treating patients with chronic pain because they can be helpful in managing patients.
She suggests several critical indicators that should raise a physician’s index of suspicion that changes in CNS pain processing system may be present when they are seen.
“One of these is when pain doesn’t respond to usual rheumatologic treatments,” she says. “If you have maximized the treatment for the rheumatologic disorder and chronic pain remains, then it is time to look more broadly at lifestyle issues, stressors the patient is experiencing and symptoms you don’t normally see in rheumatologic disorders that suggest a more central nervous system problem. Fibromyalgia, thought to be related to abnormalities in CNS pain processing, commonly occurs in patients with other rheumatologic diseases and requires treatment to help control pain.”
Symptoms that may reflect a CNS change include:
- Fatigue;
- Sleep disturbances;
- Cognitive changes, such as increased forgetfulness or less concentration;
- Anxiety; and
- Depression.
The Mental Health Assessment
The initial referral should give a clear indication from the rheumatologist of what the medical problem is. The rheumatologist should let the psychiatrist or other mental health provider know whether they believe their diagnosis explains the patient’s subjective experience and if not, why not.
The mental health provider will make their own assessment of the patient. They look for a psychiatric diagnosis that could explain pain amplification or point toward a somatoform disorder. Commonly, they will try to rule out the most common psychiatric reasons for pain, such as depression, anxiety disorders, an obsessive-compulsive disorder or somatic symptom disorder.
“We can provide sophisticated psychological testing, which helps us look objectively at the personality structure,” notes Dr. Mufson. “I don’t think that many rheumatologists realize how far we can get underneath some of these psychiatric issues to find many things that a patient might not always report to their doctor.”
He stresses that this is not necessarily a one-and-done proposition. Even if a patient’s initial evaluation shows no psychiatric or psychological comorbidities, changes in their life circumstances or even the cumulative stress of having a chronic disease, can trigger CNS pain at any time. A patient whose pain has been well controlled but all of a sudden complains of an increase in intensity that can’t be explained physically is a prime candidate for a second psychological evaluation.
