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Pain management in Psych conditions

Updated: Mar 31, 2021

Personality Disorders:


DSM-5 = 'an enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual's culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment'


Cluster A = Odd = Paranoid (suspicious), Schizoid (detached), Schizotypal (eccentric)

Cluster B = Dramatic = Antisocial (disregard for others), narcissistic (self-important), borderline (emotionally unstable), histrionic (attention seeking)

Cluster C = Anxious = Dependent (submissive and clingy), avoidant (feels inadequate), obsessive-compulsive (perfectionistic).


Cluster C types are known to be at higher risk of persistent pain

(higher harm avoidant, and and lower self-directedness. These lead to fear-avoidance).


Cluster B types are known to be at higher risk for problematic substance abuse

(they often like the euphoric effects of opiates and Benzos)



Borderline personality disorder presents in up to 30% of patients presenting to pain clinic - higher than the 2-6% expected in general population


Treatment goals in BPD are the same: improve function and develop skills to reduce discomfort. The goals of therapy are based upon changing behavior in the face of intense and distressing emotional states. Dialectical behavior therapy is the most widely recognized treatment for borderline personality disorder. This treatment is based on validating strong emotions and negative experiences, while helping the patient choose healthier behaviors despite these feelings.



 

Consequences of chronic pain:

Increased risk of depression, anxiety, physical deconditioning, sleep distrurbance, poor self-esteem, social isolation and relationship breakdown

Stigmas associated with the pain

Lower productivity


Yellow flags

The belief that pain is harming or disabling


Family:

Overprotective spouse

Solicitous spouse behaviours

Socially punitive spouse issues

Negative attitudes from family members

Lack of support person


Beliefs or attitudes about pain

Belief that pain is harmful and fear-avoidance behaviours

Belief pain must be abolished before return to work

Expectation of worse pain if returns to work

Catastrophising

Belief pain is uncontrollable

Passive attitude to rehab


Behaviours

Extended rest

Reduced activity

Irregular boom-bust cycles of activity

Avoidance of normal activity

Severely high reporting of pain

Excessive reliance on aids

Sleep quality reduced

High alcohol or smoking or other substances


Compensation issues

Lack of financial incentive to return to work

Delay in accessing income support and dispute over eligibility

History of claims

Extended time off work

Previous back pain

Ineffective case management


Work

Belief that work is harmful

History of manual work

Low education or socioeconomic background

Unhappy environment


Diagnosis issues

Health professional sanctioning disability

Conflicting diagnoses

Unhelpful diagnostic language

Dramatisation of back pain and focus on passive treatment

Expecting a 'techno fix'

Advice to withdraw from job

Lack of satisfaction with treatment


Emotions

Fear of increased pain with work

Depression

Grief

Irritability

Anger

Anxiety

Social anxiety

Feeling unneeded or unwanted



 

Psychological focuses in chronic pain:

Reconceptualise his pain

Identify realistic and practical goals

Reinforce progress

Identify obstructive factors such as catastrophising

Develop coping skills


Relaxation training, breathing techniques, biofeedback, autogenic training


Red flags

Concerning features for possible physiologically harmful causes of pain


 

Essentials of pain Medicine - Summary


Somatoform disorders are now under somatic symptom and related disorders


Somatic symptom disorder

Undesired or unpleasant sensations are common - occurring in 60-80% of people in a given week


Patients may seek help when these are prolonged or they are associated with anxiety of serious illness

DDx:

Depression (mood is more prominent), panic disorder (more acute), GAD (worry about everything), Illness anxiety disorder (worry about health specifically), Conversion disorder (loss of function primarily not distress), organic disease, substance use, cog dysfunction


Conversion disorder (Functional Neurological Symptom Disorder)

Neurological symptoms incompatible with neurological pathophysiology


Can be sensory and/or motor

Symptoms may include seizures or convulsions or unconscious episodes


Diagnosis can only be made after appropriate medical investigation


Patients with a neurological condition can still have functional neurological symptom disorders


Factitious disorder (Munchausen syndrome)

Intentional production of physical or psychological symptoms


It requires proof that the person is falsifying symptoms in the absence of obvious rewards

Malingering

NOT a mental illness




 


Questions:

3. Critically discuss current views on the possible importance of personality and personality disorders in chronic pain and their implications for treatment outcome.



References:

Argoff, C. E., Dubin, A., Pilitsis, J., & McCleane, G. (2009). Pain management secrets E-Book. Elsevier Health Sciences.


FPM - Module 2

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