Psychological Issues in the Pain Patient

Before leaving the topic of chronic pain, some discussion of the psychiatric aspects need to be explored. I am reminded of my Austrian born psychoanalytic Professor Dr. Mulfelder, who knew Sigmund personally. One of Dr. Mulfelder's favorite recollections, quoting Dr. Freud with a smile " sometimes a cigar is just a cigar, but sometimes a cigar is a penis". What does this have to do with the topic of pain? Well, sometimes pain is just pain, but sometimes it signifies something much more. When it does, the physician must be aware of the various psychodynamics' or he will be unable to treat pain successfully.

Our language is replete with aphorisms which bespeak the interrelationship between mind and body "your a pain", "that's a headache", "what a heartbreak". However with the pain patient, he takes it a step further and tends to interpret emotional reactions in the context of pain. Instead of "I'm sad", "I'm lonely", "I'm afraid", he says "it hurts". In other words, psychological symptoms become extrapolated into complaints of pain and expressed in that fashion. Eighty percent of of chronic pain patients have significant psychological components; anxiety, depression, mood swings, paranoia, and characterological defects. Chronic pain dominates their mental life . Every activity becomes viewed through the lens of their pain. "I'd like to play with the children, but I know that I'd suffer for it", I wish that I could go to the Mall, but the walking will kill me". Needless to say that for the serious mental disorders, psychotropic medications will help. Anti-depressants, anti-anxiety, neuroleptic agents all have a major roll in the treatment of chronic pain patients. However, one must also have an understanding and awareness of underlying issues that may be present.

The psychiatrist, Dr. George Engel, in his classic paper "Psychogenic" pain and pain prone patient", discussed the underlying psychoanalytic issues which pervaded some pain patients. He noted that pain as a child would often times be followed by comforting by a loved person, and to a certain extent relief of the pain. This becomes an important determinant in the tender loving relationship for the pain patient. Also to a child, pain and punishment often become linked. He found that there was a prominence of conscious and unconscious guilt with pain serving as a relatively satisfactory means of atonement in some patients. Pain also becomes closely associated with aggression and power. A child quickly discovers the effects of inflicting pain on others and on himself. A strong aggressive drive, which is not fulfilled, can then be experienced as pain instead. High incidence of physical abuse in parental relationships or in relationships with parents such that later on in life, there becomes a development of pain as a replacement for the loss, when a relationship is threatened or lost. Because of feelings of low self esteem and inadequacy, he becomes intolerant of success and a propensity to solicit pain as evidence of the large number of painful injuries, operations and treatments. These are just some of the psychoanalytic themes which are present in some patients. They need to be identified, interpreted and worked through, if pain management is ever to be successful.