Psychogenic Pain : Psychosomatic Point of View
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This presentation was presented in "Medical Approach in Holistic Management to Relieve Pain" 13 Des 2015 at The Sunan Hotel, SOLO. Since Pain is always subjective, Psychogenic pain is very related to psychiatric problems and very often it does not recognized by physicians in their practice.
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Psychogenic Pain : Psychosomatic Point of View
- 1. One Day "Medical Approach in Holistic Management to Relieve Pain" 13 Des 2015 at The Sunan Hotel, SOLO
- 2. Pain Is the 5th Vital Sign Phillips DM. JAMA 2000; 284(4):428-9. TemperatureRespiration Pulse Blood pressure Pain
- 3. Pain. What is it? “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” International Association for the Study of Pain
- 4. The Pain Continuum Time to resolution Acute pain Chronic pain Chapman CR, Stillman M. In: Kruger L (ed). Pain and Touch. Academic Press; New York, NY: 1996; Cole BE. Hosp Physician 2002; 38(6):23-30; International Association for the Study of Pain. Unrelieved Pain Is a Major Global Healthcare Problem. Available at: http://www.iasp-pain.org/AM/Template.cfm?Section=Press_Release&Template=/CM/ContentDisplay.cfm&ContentID=2908. Accessed: July 24: 2013; National Pain Summit Initiative. National Pain Strategy: Pain Management for All Australians. Available at: http://www.iasp-pain.org/PainSummit/Australia_2010PainStrategy.pdf. Accessed: July 24, 2013; Turk DC, Okifuji A. In: Loeser D et al (eds.). Bonica’s Management of Pain. 3rd ed. Lippincott Williams & Wilkins; Hagerstown, MD: 2001. Insult Normal, time-limited response to „noxious‟ experience (less than 3 months) Pain that has persisted beyond normal tissue healing time (usually more than 3 months) • Usually obvious tissue damage • Serves a protective function • Pain resolves upon healing • Usually has no protective function • Degrades health and function Acute pain may become chronic
- 5. Pain Categories 1. Somatogenic pain is pain with cause (usually known) localised in the body tissue a/ nociceptive pain b/ neuropatic pain 2. Psychogenic pain is pain for which there is no known physical cause but processing of sensitive information in CNS is disturbed
- 6. Psychological Pain = Psychogenic Pain • Psychological pain – “Pain specifically attributable to the thought process, emotional state, or personality of the patient in the absence of an organic or delusional cause or tension mechanism.” International Association for the Study of Pain
- 7. Case from Clinic (1) • A 52 yrs old woman complained headache since 3 years ago. She had already checked to a neurologist, a TNT-Specialist and internist and did some examinations. • The previous physician did not find any problems and the examinations ruled out any underlying disease, except “the pain” still existed • She could not described the pain specifically, “come and go” but very annoying. She realized that the pain intensity was related to stress
- 8. Psychiatry and Pain Diagnosis of Pain in Psychiatry (DSM) • DSM I (1952) – Psychophysiological disorders“ – “Psychoneurotic Disorders” • DSM II (1968) – Hysterical neurosis • III (1980) – Psychogenic Pain • Etiologically related • III-R (1987) – Somatoform pain – Dropped etiology part
- 9. Psychiatry and Pain • DSM IV – Pain Disorder • Pain=predominant focus • Substantial distress/impairment • Psych factors “have role” – Onset or expression • Not malingering/factitious disorder • DSM 5 : Somatic Symptoms Disorder and Its Related Disorder. – Somatic Symptoms Disorder with predominant pain
- 10. PPDGJ and Pain • Dalam diagnosis gangguan jiwa menurut PPDGJ 3 terdapat diagnosis gangguan nyeri sebagai bagian dari gangguan somatoform yaitu F. 45.4 . GANGGUAN NYERI YANG MENETAP. – Nyeri pada satu atau lebih tempat anatomis – Nyeri menyebabkan penderitaan yang bermakna secara klinis atau gangguan dalam fungsi sosial, pekerjaan, atau fungsi penting lain. – Faktor psikologis dianggap memiliki peranan penting dalam onset, kemarahan, eksaserbasi atau bertahannya nyeri. – Gejala atau defisit tidak ditimbulkan secara sengaja atau dibuat-buat (seperti pada gangguan buatan atau berpura-pura). – Nyeri tidak dapat diterangkan lebih baik oleh gangguan mood, kecemasan, atau gangguan psikotik dan tidak memenuhi kriteria dispareunia.
- 11. Assessment of Pain • Immediate Pain • Physical Functioning • Psychological Factors • Pain Behaviors • Objective Correlates
- 12. The Cause of Psychogenic Pain • Theory 1: Underlying psychological factors cause psychogenic pain • anxiety disorder • depression • Theory 2: Psychogenic pain results from some previous injury that hasn’t yet fully healed. • Theory 3: Psychogenic pain causes existing pain to feel worse than the situation actually warrants.
- 13. Symptoms of Psychogenic Pain • Constant discomfort despite taking medication • Difficulty describing the location, quality and depth of pain • Non localized pains that encompass larger parts of the body • Worsening pain independent of any underlying medical condition. All above symptoms exist in absence of any chronic disorder with physical cause
- 14. Case from Clinic (2) • A 45 yrs old man with history of major depressive disorder in his 30’s. • He complained that the symptoms of depression were coming back recently • He also complained aches all over his body • The man was diagnosed with MDD with somatic as a predominat symptoms Notes : Approximately two thirds of patients with depression in primary care present with somatic symptoms (Tylee, et al, J Clin Psychiatry. 2005; 7(4): 167–176)
- 15. Psychiatric Disorder and Pain DEPRESSION • Approximately 60% of patients with depression present pain at the moment of the diagnosis • The presence of depressive disorder may increase the risk of developing a musculoskeletal pain, headache and chest pain 3 years later on. • Elderly patients with depression are at increased risk for cervical, lumbar and hip pain. • Depression prevalence was 12 times in individuals with three or more pain-related symptoms, as compared with patients without pain. • Patients with chronic pain suffered from major depression between 8% and 50% Pain and psychiatry: a critical analysis and pharmacological review. Marazziti, et al, Clinical Practice and Epidemiology in Mental Health 2006, 2:31
- 16. Psychiatric Disorder and Pain ANXIETY • Patients with different painful syndromes showed an increased risk of anxiety syndromes or disorders (50% have anxiety symptoms and 19% have a panic disorder or generalized anxiety disorder) • A prospective study involving 1007 young adults found that a history of headache was associated with a higher of panic disorder • Anxiety disorders are associated with high somatic preoccupation levels and physical symptoms. • In a study of panic disorder, at least 40% patients described chronic pain symptoms and more than 7% took pain relievers daily
- 17. Unpublished survey. Conducted by Dr Andri for educational and promoting mental health purpose only. Data were collected using ww.surveymonkey.com. Bias of the result is one of the weakness of this survey PAIN in Psychosomatic Patient
- 18. Multimodal Treatment of Pain Based on Biopsychosocial Approach Pharmacotherapy Stress management Interventional pain management BiofeedbackComplementary therapies Physical therapy Education Lifestyle management Sleep hygiene Gatchel RJ et al. Psychol Bull 2007; 133(4):581-624; Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research.; National Academies Press; Washington, DC: 2011; Mayo Foundation for Medical Education and Research. Comprehensive Pain Rehabilitation Center Program Guide. Mayo Clinic; Rochester, MN: 2006. Occupational therapy
- 19. Barrier to Psychiatric Approach A referral to psychiatrist may mean to the patient: - The pain is not real - Physicians are giving up on them - Physicians have failed to diagnose the underlying disease - Physicians refer only when they think no organic pathology could be detected
- 20. Psychiatric Treatment Approach • Interdisciplinary approach with other specialists • Acknowledge the symptoms : “the pain is real “ • Supportive therapy and cognitive therapy: “How can I live with this pain? ; “How can I adapt with it?” • If commorbid with mental disorder, Treat it Well • Drugs that psychiatrist usually use : – SNRI (duloxetine), Amytriptiline, Pregabalin
- 22. Twitter : @mbahndi IG : andripsikosomatik
- 23. Curriculum Vitae • Nama : Dr.Andri,SpKJ,FAPM • Usia : 37 tahun • Pendidikan : – Dokter : Fakultas Kedokteran Universitas Indonesia (Lulus 2003) – Psikiater : Fakultas Kedokteran Universitas Indonesia (Lulus 2008) – Pendidikan tambahan di bidang psikosomatik medis dari American Psychosomatic Society di Portland, Oregon, USA tahun 2010 dan Academy of Psychosomatic Medicine di Atlanta, USA 2012, di Tucson 2013 dan di Fort- LeDaurdale 2014 – Pengakuan sebagai Fellow of The Academy of Psychosomatic Medicine (FAPM) November 2013 • Organisasi : – IDI – PDSKJI – American Psychosomatic Society – Academy of Psychosomatic Medicine • Jabatan : – Dosen Psikiatri di FK UKRIDA, Jakarta – Kepala Klinik Psikosomatik Omni Hospital, Alam Sutera – Ketua Sub Kredensial Komite Medik RS OMNI Alam Sutera