my presentation provide how can we approach patient with chronic pain, when we suspect psychiatric cause for chronic pain any how we explain chronic psychogenic pain and how we manage.

1. Pain from psychiatric point of
view
Dr Ibrahim Talha
Specialist Of Psychiatry
NPC

2. Main points in my presentation
• Definition of pain and why we talk about pain
• Experience and neuroanatomy of pain
• How can we start helping patient with chronic pain
• Pain of psychiatric origin and how can we differentiate
between psychiatric and organic pain
• Explanation of pain of psychiatric origin
• General rules of management of chronic pain
• conclusion

3. What's pain?
• Pain is an unpleasant sensory and emotional experience.
• Pain is an unpleasant phenomenon that is uniquely experienced by each
individual.
• It cannot be adequately defined, identified, or measured by an observer
• In most of the situations pain is associated with actual or potential tissue
damage(acute pain).
• In other situations there's no clear cause for pain, and of long duration
more than expected (chronic pain).
Chronic pain is complex topic
1.Subjective complaints that can not be measured, can not be confirmed
2.Affects all aspect of the patient life are affected and can worsen the patient
pain so we need for team work

4. Why we talk about pain?
• Pain is very common complain
Condition Number of sufferers Source
Chronic pain 100 million Americans Institute of Medicine of The
National Academies
Diabetes 25.8 million Americans
(diagnosed and estimated cases)
American diabetes association
Coronary Heart Disease
(heart attack and chest
pain)
16.3 million Americans American heart association
Stroke 7.0 million Americans American stroke association

5. Why we talk about pain. Continued
• Pain is complain of both sex and all ages
• Pain affects the individual productivity and quality of life
Impact on Quality of Life.
• (59%) overall enjoyment of life.
• 77%) reported feeling depressed.
• 70% have trouble concentrating.
• 74% their energy level is impacted by their pain.
• 86% reported an inability to sleep well

6. Why we talk about pain?. Continued
Pain affects the national income badly, the
American society losses at least $150-$250 billion
dollars annually(cost of health care and lost
productivity).
Person with pain are at high risk for psychiatric
co-morbidities

7. The experience of pain
Three systems interact usually to produce
pain
• Sensory :Discriminative system that process information about
strength ,intensity,quality,temporal and spatial aspects of pain
• Motivational: affective system(positive emotions and negative
emotions) that determines the individual´s approach-avoidance
behaviours.
• Cognitive: evaluative system (depends mainly on the previous
experience and learned behavior), it may block ,modulate or
enhance the perception of pain.

8. Neuroanatomy of pain
There is three portions of the nervous system responsible for the sensation , perception and processing of pain ,these portions
are divided into :
• Afferent pathways
• CNS
• Efferent pathways
The afferent portion is composed of:
a-Nociceptors (pain receptors
b-Afferent nerve fibres
c-Spinal cord network: From there the impulse is carried through the spinothalamic tract to the brain. The two divisions of
spinothalamic tract are known:
1.The neospinothalamic tract : it carries information to the midbrain, thalamus and post central gyrus (where pain is perceived).
2.The paleospinothalamic tract: it carries information to the reticular formation, Pons, limbic system, and mid brain and
responsible about, affective ,cognitive and autonomic responses associated with pain .

9. 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
• Acute and chronic pain
Acute pain :it is pain that occurs acutely in reaction to tissue damage by thermal
,chemical ,or mechanical injury so it is protective mechanism that alerts the
individual to a condition or experience that is immediately harmful to the
body
• Onset - usually sudden
• Relief - after the chemical mediators that stimulate the nociceptors, are
removed.

10. Responses to acute pain
(Stimulation of autonomic nervous system
• increased heart rate
• diaphoresis
• increased respiratory rate
•  blood sugar
• elevated blood pressure
• pallor or flushing,
• dilated pupils
• nausea occasionally occurs

11. Psychological and behavioural
response to acute pain
• Fear
• General sense of unpleasantness or unease
• Anxiety

12. Chronic pain is:
Persistent or intermittent usually defined as lasting at
least 6 months
The cause is often unknown, often develops insidiously,
often is associated with a sense of hopelessness and
helplessness.
Depression often results

13. Psychological response to chronic pain
•
Intermittent pain :produces a physiologic response similar to acute pain.
Persistent pain :allows for adaptation (functions of the body are normal but the
pain is not relieved).
SO Chronic pain produces significant behavioural and psychological changes
The main changes are:
1-depression
2-Limitation of activities and mobility in an attempt to keep pain
3-sleeping disorders
4-preoccupation with the pain

14. How can we help patient with chronic
pain?
1) The first step to deal with pain is identification of
pain.
2) Identification aims to recognition of the pain
syndrome.
3) This will be achieved through history taking,
examination and doing the necessary
investigations that may help in diagnosing the
pain syndrome .

15. How to identify pain?.. Continued.
B-Through examination we should determine :
anatomical distributions of pain, vitals signs, if there's
tenderness, neck signs, any swellings, eye, ear or teeth
signs, a abdominal signs
C-Investigations that may be done like MRI.CT,bone
density, blood picture, sickling,ESR,CRP,rhemuatid
factor, csf tapping in selected cases
D-Mental state examination should be part of
examination of patient with chronic pain.

16. Analysis of the findings
 After we collect data we should be able to identify the pain syndrome.
 This help in management of pain
For example:
1. sudden head pain, throbbing and associated with neurological signs
like neck stiffness and lateralization(subarachnoid hemorrhage)
2. Chronic headache in young obese female with no significant finding
other than papilledema(BIH)
3. Chronic pain in elderly, affecting joint, with periods of exacerbation and
not remission(arthritis).
4. Chronic head pain in female, throbbing in character ,affect half of the
head, remission and exacerbation, family history(migraine)

17. Why I'm here?…
 Some types of pain after analysis cannot be identified and
correlation of the pain with organic cause can't be done or
 Complaints are more than what expected for the organic
findings and pain persists for months and years with no good
response to ordinary ways of management
This means we missed something???
• psychiatric primary illness
• development of psychiatric co-morbidities which interfere
with pain response to management.

18. Pain of psychiatric origin
Psychogenic pain, also called psychalgia or somatoform pain
•It is pain caused, increased, or prolonged by mental, emotional, or
behavioral factors
• headache, back pain, and stomach pain are sometimes diagnosed
as psychogenic if no organic cause and psychiatric correlation found
•Sufferers are often stigmatized, because both medical professionals and
the general public tend to think that pain from a psychological source is
not "real" because of absence of clear cause, anatomy or character
•However, psychiatrists consider that it is distressing and annoying and
has bad consequences on the quality of life and productivity of the
individual like other type of pain

19. Differences between psychiatric and
organic pain
Some differences between psychiatric and organic pain:
• No specific cause, no specific anatomy ,no specific character
• So Psychiatric pain is more diffuse and less localized and does not
follow an anatomical distribution.
• History of current or previous mood disorder
• psychogenic pain persists (chronic ) and increase without evidence of
increased tissue damage., whereas physical pain may ebb and flow
and be worsened or relieved by specific measures
• Psychogenic pain is difficult for the patient to describe qualitatively,
while organic pain sufferers will use terms like ‘burning’ for skin,
‘shooting’ for nerve pain and so on.

20. Primary psychiatric disorders with pain
presentation
Somatoform Disorders
 Physical complaints without organic basis
 Psychological factors and conflicts seem
important in initiating, exacerbating, and
maintaining the symptoms
 Symptoms or magnified health concerns are not
under conscious control
 Somatization & somatoform pain disorder.

21. Explanation of pain of psychiatric origin
•Most of the cases have psychiatric illness
like depression, anxiety or somatization
disorder but the underlying pathology
can be attributed to interaction between
biological and psychological
disturbances

22. Biological base of chronic pain
Reduction in the level of mediating
neurotransmitters nor epinephrine (NE)
and serotonin (5-HT)
decreased opiate output in patient with
chronic pain
Disturbance in sodium channel

23. Psychological base of chronic pain
• Pain response is considered an alarm triggered
by the brain in response to noxious stimuli
• The pain response should force the person to take action to
avoid exposure to noxious stimuli and avoid more harm
• Our disturbed emotions,thoughts,behavior and social
support by others, can be perceived by our brain as noxious
stimuli and can lead to persistent feeling of pain

24. Psychological base of chronic pain
continued.
• Emotional factors: emotions are powerful source of information(fear, anger and frustration)as
strong negative emotions suggest that something is really wrong and can increase suffering
• Thoughts: the brain takes thought about pain in account especially self defeating thoughts, ex: my life
is ruined, I can not stand, I am completely miserable, my pain is really horrible
• Behavior: our brain takes our behavior into account as behavior is type of feedback informing the
brain about the severity of physical problem, ex: asking for help for even simple tasks, completely giving
up activities you used to enjoy, turning down invitation involving minor physical activity, staying in bed
all day
• Social responses: even the family and friends may be trying their best to be helpful to you, they can
sometimes convey negative messages such as you are burden, you are unable to manage your life, you
need lots of extra help, you are not in control of your pain.
So if we corrected our emotions, thoughts, behavior and if our family and friends
learned how to help us without sending negative messages this can lead to marked
improvement of chronic pain..

25. What to do?
Chronic pain either symptom of psychiatric
disease or the cause of psychiatric co
morbidity needs team work
Establishing chronic pain management clinic
Different specialties should be existent in one
place to facilitate discussion and putting plan

26. Criteria of the team
Everyone in the team should have patience
Provide understanding for the patient
Able to understand the patient negative emotions,
behavior and thoughts and able to do change for that
as this will help patient so much to cope properly
with his pain.
Detection of life threatening problems like suicide
Family and friends educations

27. Role of psychiatrist
Psychiatrist can evaluate the patient and can identify
and determine that if the pain is primary or secondary.
Can provide
medications(antidepressants,anxiolytics,mood
stabilizers)
Can advice and perform ECT.
Psychologists are important for providing support and
psychotherapy for modifying the patient emotions,
behavior and thoughts.

28. Conclusion
• Pain is common complain including sensory and emotional
components ,very annoying and interfere with work, social
life ,enjoying the life ,sleep and may force patient to commit
suicide
• chronic pain may be part of psychiatric disease or
complicated by psychiatric illness which worsen the pain due
to disturbed emotions, thoughts and behavior
• Patient with pain must be examined and investigated well
before diagnosis as psychogenic pain.

29. Conclusion. Continued
• Psychogenic pain is not following the known anatomical
pathways for pain but still real pain.
• Management of chronic pain needs team work and
psychiatrist can help by confirmation of diagnosis, and
management including advices and even medications
• Variety of drugs can be used to manage pain including
,antidepressants, mood stablizers,anxiolytics and even ECT
brain

30. •Any questions?
…….
Thank you all