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).
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Explore This IssueJanuary 2015
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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
“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.
“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.”
Pain management techniques in rheumatic diseases are not well settled from a scientific standpoint.
“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.”
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.
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.
“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:
- Sleep disturbances;
- Cognitive changes, such as increased forgetfulness or less concentration;
- Anxiety; and
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.
When the diagnosis is made, there are a number of treatments that mental health providers bring to the management of those with chronic pain. One option is psychiatric medications to address the presenting problem, such as anxiety or depression. Some antidepressants also have independent effects on pain and are effective analgesics for chronic pain disorders, like fibromyalgia. These include medications that increase serotonin and norepinephrine in the CNS.
Other interventions are available in addition to, or instead of, medications. Cognitive behavioral therapy (CBT) is a therapy that addresses cognitive patterns, such as preoccupation with pain or negative thoughts about the illness. The patterns can be addressed with CBT, and new approaches can be learned to improve coping skills and decrease focus on the illness.
Other interventions include teaching techniques to lessen other issues. Stress management, relaxation techniques and biofeedback have proved useful.
“Evidence-based studies reveal that a multidisciplinary approach to the management of chronic pain yields the best outcome,” says Dr. Mufson. “This works for both reduction of pain and improvement in social and work function.”
Kurt Ullman is a freelance writer based in Indiana.
- Taylor P, Manger B, Alvaro-Gracia J, et al. Patient perceptions concerning pain management in the treatment of rheumatoid arthritis. J Int Med Res. 2010;38:1213–1224.
- Borenstein D, Altman R, Bello A, et al. Report of the American College of Rheumatology Pain Management Task Force. Arthritis Care Res. 2010;62:590–599.