Pain
Physiology of Pain Nociceptors Termination Modulation
Physiology of Pain Multiple Redundant Reciprocal Complex
Assessment of Pain Immediate Pain Physical Functioning Psychological Factors Pain Behaviors Objective Correlates
Assessment: Immediate Pain Intensity Location Composite Measures
Assessment: Physical Fx. Impairment Functional limitation Disability
Assessment: Psych factors Influence vs. causation Mediation Reinforcement Resonators Pain beliefs
Observation Role of learning
Composite Pain Scales Attempt to measure one or more dimensions of the pain experience
Assessment: Objective Indicators
Diagnosis Categorization DSM and Pain Other Approaches to “Somatoform Pain”
Categorization
Acute Pain Not just time Clearer association - Subtypes (ex. Recurrent?)
“nociceptive pain”
Chronic
DSM-IV The concept of Somatoform Pain
DSM and pain I (1952) - Psychophysiological disorders“
- “Psychoneurotic Disorders”
II (1968)
DSM and pain III (1980) - Psychogenic Pain
- “incompatible” or “INXS”
- Etiologically related
III-R (1987)
DSM and pain IV - Pain Disorder
- Pain=predominant focus
- Substantial distress/impairment
- Psych factors “have role”
- Not malingering/factitious disorder
Utility How to judge? - Physical versus Psychological
- Etiology
DSM-IV - Mind-body dichotomy remains
- Division of pain based on this.
True psychogenic pain
DSM-IV pain tested Psychological vs. Psychological+Medical Distinction - No difference on
- Pain measures
- Intensity
- Type
- Level of disability
Other approaches to diagnosing pain
IASP - Anatomical region
- Organ system
- Temporal characteristics/patterns
- Intensity, time since onset
- Etiology
IASP Psychological pain - “Pain specifically attributable to the thought process, motional state, or personality of the patient in the absence of an organic or delusional cause or tension mechanism.”
Other approaches Dimensional - Take into account various aspects of pain
- Objective findings/physical etiology
- Perceptual influences
- Presentation
Treatment of Pain
Treatment of Pain Pharmacologic Psychological Importance of Multimodal Cormorbid treatments Role of C/L Psychiatrist
Pharmacological Treatment “True” Analgesics Everything Else
“True” Analgesic NSAIDS Opioids Local agents
NSAIDS Mechanism Indication Side effects
NSAIDS Standard Acetaminophen Ketorolac
Opioids Mechanism of action Indication Side effects - Common
- Uncommon but problematic
Some Typical Opioids
Combination Opioid/NSAIDs
Relative Potency
Treatment Approach MEC Role of pharmacokinetic - Toxicity
- Slow-release preps
Concerns Tolerance Dependence Addiction
Overvalued Concerns - Addication
- Overdose and death
- Discipline
Adjunctive and other meds Antidepressant Anticonvulsants Local Analgesics Antihistamines Antipsychotics
Nonsurgical treatments Cutaneous Stimulation Electrical Stimulation Acupuncture Exercise
Neural Blockade Surgical lesions Limitations
Psychological Treatments Psychoeducation Hypnosis Behavioral Treatments
Behav Txs Relaxation Biofeedback CBT
Multidisciplinary Pain Treatment - Different levels
- Features included
Comorbid Problems
Role of Psychiatrist in Pain Mgmt
Role of C/L Psychiatrist in Pain Eval - “Problem Patient”
- “Drug Seeker”
- “Just in their heads”
- “Pain out of proportion…”
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