The magnitude of human pain is immense. Estimates suggest that more than 34 million Americans suffer from chronic, nonmalignant pain (1). Pain has far-reaching repercussions, adversely affecting work and contributing significantly to disability. For example, chronic low back pain is the most common cause of occupational disability among persons under age 45 (2,3). The economic impact of chronic pain is enormous when one considers the costs of absenteeism, reduced productivity, medical care, and workers' compensation (4,5). In addition, pain limits enjoyment and interferes with activities, interests, and relationships.
Significant losses, such as reduced income and autonomy, can accompany chronic pain. Patients may experience guilt, blaming themselves for their inability to overcome or master pain. The patient's role, and consequently the roles of others in the home, may require modification, leading perhaps to strained relationships. Yet despite the pervasiveness of pain and its multiple ramifications, education in pain medicine has been virtually nonexistent in graduate and postgraduate training (6).
Specialists in Pain Medicine view pain as a distinct multifactorial illness with biopsychosocial components (7,8). Thus psychiatrists, accustomed to viewing patients in a biopsychosocial paradigm, are particularly well suited to treat patients with pain.
Psychiatric intervention is sought to help with patients who have acute pain or painful terminal disorders, especially to address psychological consequences and psychiatric comorbidities. More frequently, physicians seek consultation because they are frustrated by lack of treatment response in patients with chronic pain. So often, such patients are pejoratively labeled as noncompliant, uncooperative, attention-seeking, medication-seeking, and malingering (7). Deciphering the relative contribution of biological and psychological variables to pain complaints requires the evaluation of a psychiatrist with skills in the biopsychosocial assessment of pain. However, the contributions of psychiatrists can be much further-reaching.
Psychiatrists may be enlisted to diagnose and treat discrete psychiatric disorders accompanying pain. They can offer pharmacologic interventions for pain and/or address its emotional and cognitive sequelae, treatment, and factors that may be interfering with treatment. For example, the patient with chronic pain can become dependent on opiate analgesics, requiring psychiatric intervention. Psychiatrists can facilitate the patient's adaptation after trauma or injury resulting in pain and can, through a variety of treatment measures, foster an improved quality of life in both the social and vocational aspects.
The frustration caused by ongoing pain, the effects on functioning, and the impact on families and relationships contribute to significant psychiatric morbidity. It is not surprising, therefore, that the presence of chronic pain is a significant risk factor for suicide (9—11). Thus, there is a great demand for psychiatrists to assist with the management of the pain patient. In some cases, the care of the pain patient may be entirely delegated to the psychiatrist.
In March 1998, the American Board of Psychiatry and Neurology (ABPN) collaborated with the American Board of Anesthesiology (ABA) and the American Board of Physical Medicine and Rehabilitation (ABPMR) to develop a Pain Management subspecialty examination to certify psychiatrists as specialists in pain management. The combined efforts of the Boards in creating a single certifying exam emphasized the interdisciplinary nature of pain management. Currently, efforts by the Accreditation Council for Graduate Medical Education (ACGME) are under way to establish the curriculum for multidisciplinary pain management fellowships. Parameters for specialty tracks in psychiatry and other fields are also being developed.
Subspecialty certification is appropriate for psychiatrists whose practices are largely devoted to pain management. We strongly believe that the general psychiatrist should also have training and experience to recognize and treat basic psychiatric issues associated with pain. With this in mind, the following outline for pain management training is proposed for use in a general psychiatry residency curriculum. The following reflects experiences in our residency training programs. This is not intended to be a definitive document, but rather a guide from which to develop a structured approach to the integration of pain management teaching into a residency program. It is hoped that exposure to pain management training can stimulate interests in further fellowship training and specialization after residency completion.
Training in the psychiatric aspects of pain management can be easily incorporated into the existing curriculum of any general residency training program. The pain management training proposed here can serve to enhance those aspects of interviewing, patient assessment, and treatment already addressed in the core curriculum. It is hoped that inclusion of pain management training will convey that such skills are not relegated solely to the specialist, but are a necessary component of comprehensive patient care.
Lectures provided to residents can lay the foundation for the contributions of the psychiatrist to pain management. Introductory lectures ought to address specific content areas, including the neuroanatomic and physiologic substrates of pain, commonly encountered pain disorders, psychiatric comorbidities of pain, the relationship between psychological states and pain, and treatment interventions.
Neuroanatomy and Neurophysiology
The basic neuroanatomic and functional features of pain may require review. This can include the basics of nociception, delineating the pathways from peripheral receptors to the spinal cord, thalamus, and somatosensory cortex. The role of pain-modulating systems and the autonomic nervous system in pain warrant inclusion. In addition, pathologic pain mechanisms can then be elaborated, including neuropathic pain, phantom pain, autonomic syndromes, and central pain syndromes. In general, the content described would provide a basic neurology review essential for any resident training in psychiatry.
However, pain is more than just a sensation. Given the reciprocal relationships between pain and affective states as well as pain and cognitive patterns (12), the pathways involved in pain processing warrant discussion because these appear to play an important role in the cognitive and emotional foundations of pain processing. Nociceptive, cognitive, and affective pathways involve common neurotransmitter systems, such as those for norepinephrine (NE) and serotonin (5-HT). By means of activation of autonomic arousal, other cascades of events can occur, leading to heightened pain (13,14).
There are a number of common pain states with which patients are likely to present for psychiatric evaluation and management. Often, pain patients are referred to psychiatric specialists because the complaints of pain exceed what is expected given the underlying disease, or because of concerns about treatment failure (15). Such patients raise concerns about treatment compliance, abuse and addiction, psychosocial factors contributing to the pain, and even malingering. However, to effectively discriminate between common pain disorders and those with unusual presentations, the trainee would require some familiarity with the features and diagnostic criteria of common pain states. Examples are provided in t1.
An exhaustive review of the disorders listed in t1 would be unwieldy for psychiatry residents. Instead, one or two disorders can be selected to serve as examples of how psychiatrists approach the assessment of pain disorders.
For the pain disorders selected, the focus should be on assisting residents with diagnosis (pertinent history and physical examination, imaging studies, laboratory tests), prognostic issues, psychological features, and concurrent psychiatric morbidity. The socioeconomic issues related to pain states also warrant attention, such as medical cost; impact on family and social roles; issues of employment, disability, and compensation; and secondary gains.
Discriminating between pain disorders and other somatoform or psychiatric disorders would be of particular benefit to psychiatry residents; for example, distinguishing somatization disorder from irritable bowel and chronic pelvic pain. Determining to what degree aspects of organically based pain are psychologically mediated can be particularly useful as well. Discussion of diagnostic techniques may therefore be germane to assessments of specific pain complaints and may clarify the psychosocial components of pain.
Psychiatric Comorbidities and Relationship Between Psychological States and Pain
Psychiatry residents may benefit most from discussions of the impact of chronic pain disorders on psychological functioning. Common psychiatric comorbidities in chronic pain include depression, anxiety, somatoform disorders, and substance use disorders (16—18). Certain Axis II disorders are associated with chronic pain; paranoid, histrionic, dependent, and borderline personality disorders are among the most common (16). Estimates of comorbid psychiatric disorders vary depending on whether one examines patients in clinic or community samples (19—22). It is plausible that psychiatric comorbidity is a factor influencing who seeks treatment.
Depression is the most commonly described psychological disturbance associated with chronic pain (17,23—26), and it appears to intensify the experience of pain (27). Pain may interfere with important activities, reducing self-efficacy. In addition, the impact on relationships can lead to social isolation. Helplessness because of the inability to manage pain and other aspects of life may predispose one to depression. Conversely, depression and subjective reporting of pain-associated disability are correlated (28—30). Depressed patients tend to rate pain intensity higher than patients without current depression or a history of depression (31—33).
In response to pain, anxiety may mobilize self-preserving and self-protective measures. On the other hand, excess anxiety can become incapacitating and can lead to higher pain intensity ratings (34—36).
Substance abuse is frequently a concern in the treatment of chronic pain patients. There is often a concern that dependence on opiate analgesics may result from long-term treatment of chronic nonmalignant pain (37). Additionally, patients with current or prior substance abuse histories prompt concerns regarding possible treatment strategies. Often, such patients are undertreated for pain (38). Psychiatrists may be able to work with these patients, optimizing pain treatment, contracting for appropriate use of opiate analgesics and avoiding their diversion, and coordinating pain treatment with concurrent substance abuse treatment.
Pain is a common feature in somatization and is the salient feature of Pain Disorder. Early versions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) dichotomized organic and psychogenic pain states, considering only the latter to be characteristic of psychopathology. This dichotomy was a remnant of the outdated biomedical reductionistic model of medical disorders, which has now been replaced with the more heuristic biopsychosocial perspective. DSM-IV now recognizes that even organically based pain complaints can have severe psychosocial components contributing to the functional deficits of the disorder (39). The taxonomy of diagnostic criteria offered in DSM-IV is broader than in previous DSM versions and is more consistent with the complexities and ambiguities of current pain conceptualizations (40).
Residents need to acquire an understanding of the treatment modalities available for patients with pain. Here, discussions will focus on pharmacologic and psychotherapeutic treatment strategies.
A variety of psychotherapeutic approaches can be employed in treating pain patients (41—43). Efficacy data are limited by small sample sizes, lack of homogeneous groups, variable dependent measures, and a lack of comparisons among different therapeutic modalities (44). Nonetheless, therapy can reduce some of the distress associated with pain and can foster adaptation. Cognitive-behavioral, psychodynamically oriented, and supportive therapies may have effects on cognitive and emotional components of pain (44—47). Behavioral therapy may reduce incapacitating and problematic pain behaviors (41). Couples/marital and family therapies may be necessary to reduce some of the distress in the home caused by pain or contributing to pain (48). In addition, residents should acquire familiarity with the utility of adjunctive techniques (hypnosis, biofeedback, and relaxation training) that may reduce some of the physiologic components of pain (44,49—53).
To facilitate collaborative endeavors with physicians in other specialties, psychiatric residents should become familiar with use of pharmacologic interventions customarily employed by those practitioners, such as steroids, opiates, and non-narcotic analgesics (54—57). Special attention should be directed toward concerns regarding side-effect profiles and toxicity, drug interactions, tolerance, drug abuse and dependence, and the specific indications for various types of medications and medication classes. Because several psychiatric drugs are employed in pain management, an overview of the indications for and risks of these agents warrants attention.
Tricyclic antidepressants (TCAs) have been the most extensively studied psychotropics as regards their utility in pain (58,59). TCAs appear to have analgesic effects apart from their antidepressant effects (60—62). Useful analgesic doses tend to be lower than those required for antidepressant effect. The efficacy of the TCAs may be related to NE and 5-HT reuptake inhibition, and those agents that influence both, such as amitriptyline and imipramine, produce more analgesic effects than more serotonergically selective agents such as clomipramine (63). Clearly, in cases of comorbid depression or anxiety higher doses may be required.
The analgesic effects of newer antidepressants have been less extensively studied than those of the TCAs. There is controversy concerning the usefulness of the selective serotonin reuptake inhibitors trazodone and nefazodone (64). In some studies, the effect of the antidepressant was no better than placebo (65—67), while in others, analgesic effects were reported (68,69). Antidepressants with broader neurotransmitter spectra of activity (e.g., venlafaxine and bupropion) may have greater utility for pain reduction (62,70—72).
Anticonvulsants have demonstrated effectiveness in management of neuropathic pain and trigeminal neuralgia, and also in migraine prophylaxis (73—75). TCAs are generally considered first-line treatment for neuropathy (76). However, in cases of intolerable TCA side effects or comorbid psychiatric conditions such as bipolar disorder, the anticonvulsants may be a better alternative.
Anxiolytics may have utility in pain associated with anxiety. Classically, benzodiazepines prove beneficial in sleep disturbances and in those disorders in which anxiety-related muscle tension precipitates or exacerbates pain (e.g., tension headache). Abuse liability, physical dependence, and risks of physical withdrawal raise concerns about use (77). In some patients, coadministration of benzodiazepines may interfere with opiate analgesia (78). Studies on the utility of buspirone in pain have been limited (79,80).
Antipsychotic use has been largely confined to delirium accompanying general medical conditions and aggressive attempts at managing pain. However, high-potency antipsychotic agents may be useful in neuropathic pain (81). Often in such investigations, assessment of the efficacy of antipsychotic agents has been obscured by the coadministration of antidepressants. The risks of antipsychotic use outweigh potential benefits in managing pain. The role of atypical antipsychotics is unclear; only one animal study suggested that risperidone reduces opiate analgesic requirements (82).
Stimulants have been employed to offset the sedation produced by analgesics and may potentiate the effectiveness of analgesics in relieving pain (83,84). In addition, stimulants may improve attention and reduce dysphoria that can accompany opiate analgesic use (85).
Pain in Special Populations
Principles of pain management require modification in special populations (e.g., during pregnancy and nursing, and among pediatric or geriatric populations). Such specialized topics can be supplemental for most residents in a general residency training program. On the other hand, residents pursuing fellowships in Child Psychiatry or Geriatric Psychiatry may find these specialized topics complementary to their traditional training programs (86,87).
Consultation With Nonpsychiatric Colleagues
Psychiatrists may be enlisted to address multiple aspects of care pertaining to patients with pain. Nonpsychiatric physicians may refer patients to the psychiatrist on consultation-liaison services, in specialized pain clinics, and in outpatient psychiatric settings. Because pain is pervasive, the settings in which patients present will likewise be diverse.
Critical to consultation is the clear, concise, and effective communication of clinical information to nonpsychiatrists in a manner that facilitates patient care. Toward this end, psychiatry residents will need to collect relevant medical data, interview patients (and collateral informants when indicated), and arrive at a differential diagnosis among medical, neurologic, and psychiatric disorders.
Nonpsychiatrists may not appreciate what psychiatrists can offer to the pain patient. Hence, liaison efforts may be required to educate our nonpsychiatric colleagues about the important therapeutic contributions of psychiatry in pain management. Toward this end, residents will need to become familiar with, and assured of, their skills in working with medical and surgical colleagues.
Psychotherapy supervision can foster competencies in interviewing and assessment of pain patients and can they increase sensitivity to pain-related issues. The focus of supervision can be to facilitate elicitation of complete pain histories and pertinent psychiatric histories (t2). In this way, a trainee will develop an adequate psychiatric differential diagnosis, including the presence of underlying depression or anxiety, defense mechanisms and coping strategies, and the impact of changing social roles on the ability to deal with pain.
In the course of psychotherapy supervision, it is hoped that residents acquire the ability to recognize the reciprocal relationships among pain and emotions, cognition, defenses, and behavior. Pain specialists maintain the position of simultaneous and mutual roles of pain sensation and psychological underpinnings of pain.
In addition to the sensory aspects of pain (where it is and what it feels like), pain also involves an affective dimension. Levels of pain-related distress are above normative means and clinically significant among chronic pain patients. Affective states most directly associated with pain are anger, fear, and sadness (88). Affective experiences influence the perception of and response to pain, and can also exacerbate pain. For example, anger is commonly associated with chronic illness (89) and may have an adverse effect on chronic pain. Suppressed anger and inappropriately discharged anger can adversely affect pain levels (89—92).
Of relevance to psychotherapeutic interventions are the patient's cognitions associated with pain (i.e., beliefs about the meaning of the pain and about future pain) as well as interpretations of how pain affects the patient's life, functioning, and relationships. Cognitive patterns that are particularly problematic in pain patients include a tendency to catastrophize, overgeneralize, selectively abstract, and personalize aspects of pain and/or the person's environment (93—96). Such cognitive styles are likely to reduce self-efficacy, hamper development of effective coping, drain support systems, accentuate unpleasant emotional states, and exacerbate pain.
In the course of receiving psychotherapy supervision, residents may need guidance on facilitating patient identification of unpleasant emotions, tolerating emotions, recognizing negative thought processes, and substituting more effective cognitive approaches and interpretations of pain (42,44). Such measures, in conjunction with pain-relieving therapeutic techniques such as relaxation and imagery, hypnosis, and biofeedback, can foster enhanced self-efficacy while reducing helplessness and hopelessness (49,51,52,97,98).
Defenses can affect pain perception and pain behavior. Passive aggression, isolation of affect, projection, and projective identification can adversely affect the patient's ability to cope, exasperate treatment providers, and exhaust available support systems. Thus, substituting more adaptive coping skills would be an appropriate focus in therapy. For example, alexithymia—the inability to identify and communicate feelings (99)—can be troublesome among patients with chronic pain. Observed in those with asymbolic and concrete thinking, alexithymia can produce significant impairments in self-regulation, particularly when emotions are experienced in the extreme. Unable to identify emotions and situational triggers, the alexithymic patient is incapable of thinking through possible courses of action. As a result, the patient may transiently dissipate unpleasant emotions by focusing on pain symptoms (more socially "acceptable" than addressing injury or other feelings), acting out, or using analgesics to numb unpleasant affect (100).
Because of the complexities inherent in the experience of pain, subjective assessments of it, and reactions to it, psychometric testing may be helpful to the trainee in determining which psychotherapeutic interventions may best address the needs of the pain patient. Psychometric testing can clarify the cognitive styles and defenses that contribute to the patient's distress (101), may predict responsiveness to treatment (102), and can clarify the psychosocial aspects of the pain experience (103).
Goals of therapy should include enhancing self-efficacy as well as developing the functional adaptations and coping strategies of patients with pain. Residents should also demonstrate an ability to educate their patients about working with treating physicians in other disciplines to foster compliance, address helplessness and hopelessness regarding unremitting pain, and address the impact of pain on family roles, relationships, work capacity, and disability (44,48, 104—106).
Transference and countertransference issues arising within the context of therapy with pain patients will also likely warrant significant attention in supervision. For example, residents may need to recognize the power of transference arising from the provision of medications. Likewise, they will need to examine their reactions to distancing defenses such as the rejection of help.
The training proposed here is intended to 1) foster residents' sensitivity to the issues of pain; 2) heighten awareness of the psychological factors affecting pain; and 3) develop skills to empower patients to develop strategies to deal with their pain. Ultimately, it is hoped that training will provide residents with tools to develop appropriate psychotherapeutic, psychopharmacologic, and general pharmacologic interventions for pain patients. The competencies acquired in the format discussed here complement the skills imparted to residents in the existing curriculum.
There are several potential obstacles to overcome in implementing the proposed training in pain management. First, concern may arise that training in pain management will lead to undesirable fragmentation and subspecialization of services. To overcome this perception, it may be important to emphasize that teaching the proposed curriculum complements existing training in the core curriculum, thereby enriching resident experiences and fostering the development of clinical skills required for good clinical care. In this way, Pain Management will not be seen as nonessential subspecialization, but as part of a multifaceted approach to optimal patient care. In addition, training in pain management not only provides excellent training opportunities to residents, but also addresses an ever-increasing societal demand for attention to and treatment of pain.
Second, pain management training may be viewed as fundamental to consultation-liaison training but as having no place in other realms of psychiatric training. While it is true that issues of pain management become prominent when dealing with the medical or surgical patient, it is important to recognize that pain from general medical conditions can be present in psychiatric inpatients, outpatients, patients in substance abuse treatment programs, and others. Therefore, understanding and refining techniques of history-gathering, assessment of physical and laboratory findings, and development of treatment techniques warrants the attention of psychiatrists, even those who do not anticipate pursuing advanced training in consultation-liaison psychiatry. Psychiatrists often receive referrals from general practitioners, internists, and surgeons. Many patients may be viewed as having emotional sequelae of ineffective pain control, unreasonable expectations regarding pain remission, and/or social and occupational limitations resulting from inadequate pain control. Therefore, for the psychiatrist to be effective and to facilitate collegial relationships, familiarity with common pain syndromes, diagnostic testing, and treatment approaches is likewise warranted.
Third, resistance to the implementation of pain management training may arise because of concerns regarding lack of faculty experts in the field. Certainly, this may increase as more psychiatrists pursue certification in pain management. Since the examination is offered in conjunction with the ABPMR and ABA, it is hoped that information exchange, networking, and mentoring can occur among physicians in these disciplines. In addition, it is hoped that the American Psychiatric Association and affiliated medical associations will develop or cosponsor workshops, training programs, treatment guidelines, and symposia to stimulate interest in pain management and to foster research development in this area.
The demand for more comprehensive medical endeavors to address the problems encountered with chronic pain has been increasing. There are nearly two thousand pain specialty clinics within the United States (107). Most of these are multispecialty centers, involving the clinical expertise of specialists in several disciplines, including psychiatry. More recently, pain clinics operated by psychiatry departments have emerged (108). These settings have provided a niche for addressing pain management problems previously underrecognized and undertreated in centers run by nonpsychiatry specialties. Clearly, the demand for psychiatric expertise in the management of the chronic pain patient will increase. Residency programs will need to respond to the demand by providing the general psychiatry resident with the requisite training and skills.