This document discusses the physiology, assessment, diagnosis, and treatment of pain from multiple perspectives. It addresses the complex physiological mechanisms underlying pain transmission and modulation. It explores approaches to assessing pain, including immediate symptoms and factors like physical/psychological functioning. Diagnosis is discussed, comparing the DSM conceptualization of somatoform pain to other dimensional models. A variety of pharmacological, psychological, surgical, and multidisciplinary treatment options are outlined. The role of the psychiatrist in addressing comorbid problems and consulting on complex "problem patients" experiencing chronic pain is also summarized.

1. Pain

2. Physiology of Pain
 Nociceptors
 Stimulus
Transmission
 Termination
 Modulation

3. Physiology of Pain
 Multiple
 Redundant
 Reciprocal
 Complex

4. Assessment of Pain
 Immediate Pain
 Physical Functioning
 Psychological Factors
 Pain Behaviors
 Objective Correlates

5. Assessment: Immediate Pain
 Intensity
 Location
 Affective Response
 Composite Measures

10. Assessment: Physical Fx.
 Impairment
 Functional limitation
 Disability

11. Assessment: Psych factors
 Influence vs. causation
 Mediation
 Reinforcement
 Resonators
 Pain beliefs

12. Assessment: Pain Behavior
 Observation
 Role of learning

13. Composite Pain Scales
 Attempt to measure one or more
dimensions of the pain experience

15. History
Intensity
Quality
Objective
Data
Comorb
id
Side
effects

16. Assessment: Objective Indicators
 Ex. Electromyography
“Well, Phil, after years of vague
complaints and imaginary ailments, we
finally have something to work with.”

18. Diagnosis
 Categorization
 DSM and Pain
 Other Approaches to “Somatoform Pain”

19. Categorization
 Acute versus Chronic

20. Acute Pain
 Not just time
 Clearer association
 Subtypes (ex. Recurrent?)
 “nociceptive pain”

21. Chronic
 Association?
 Types
 By presumed etiology
 Neurologic pain
 Ideopathic
 By course

22. DSM-IV
The concept of Somatoform Pain

23. DSM and pain
 I (1952)
 Psychophysiological disorders“
 “Psychoneurotic Disorders”
 II (1968)
 Hysterical neurosis

24. DSM and pain
 III (1980)
 Psychogenic Pain
 “incompatible” or “INXS”
 Etiologically related
 III-R (1987)
 Somatoform pain
 Dropped etiology part

25. DSM and pain
 IV
 Pain Disorder
 Pain=predominant focus
 Substantial distress/impairment
 Psych factors “have role”
 Onset or expression
 Not malingering/factitious disorder

26. Problems with DSM
 Utility
 How to judge?
 Physical versus
Psychological
 Etiology
 DSM-IV
 Mind-body dichotomy
remains
 Division of pain based
on this.

27. True psychogenic pain

28. DSM-IV pain tested
 Psychological vs. Psychological+Medical
Distinction
 No difference on
 Pain measures
 Intensity
 Type
 Level of disability
(Aigner et al, Compr Psychiatry 1999)

29. Other approaches to diagnosing
pain

30. IASP
5 axis system
I. Anatomical region
II. Organ system
III. Temporal characteristics/patterns
IV. Intensity, time since onset
V. Etiology

31. 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.”

32. Other approaches
 Dimensional
 Take into account various aspects of pain
 Objective findings/physical etiology
 Perceptual influences
 Presentation

35. Treatment of Pain

36. Treatment of Pain
 Pharmacologic
 Psychological
 Other somatic treatments
 Importance of Multimodal
 Cormorbid treatments
 Role of C/L Psychiatrist

37. Pharmacological Treatment
 “True” Analgesics
 Everything Else
“Yes Billy, but Mr. Phillips pushes legal drugs.”

38. “True” Analgesic
 NSAIDS
 Opioids
 Local agents

39. NSAIDS
 Mechanism
 Indication
 Side effects

40. NSAIDS
 Standard
 Acetaminophen
 Ketorolac
 COX-2 inhibitors

41. Opioids
 Mechanism of action
 Indication
 Side effects
 Common
 Uncommon but problematic

42. Some Typical Opioids
Oral Paren Tran
Morphine √ √
Propoxyphene (Darvon) √
Hydromorphone (Dilaudid) √ √
Meperidine (Demerol) √ √
Methadone √ √
Oxymorphone (Numorphan) √
Fentanyl (Duragesic, Actiq) √* √ √
Oxycodone (Percoset, Oxy--) √

43. Combination Opioid/NSAIDs
Narcotic +Acet +ASA +Ibu
Dihydrocodone DHC plus*
Propoxyphene Darvocet,
Wyegesic
Codeine Tylenol w/ Codeine #2-
4, Fiorecet*†
Fiorinal*†
Hydrocodone Vicodin, Hydrocet,
Lorcet, Lortab, Zydone
Vicoprofen
Oxycodone Percocet, Tylox Percodan
Pentazocine‡ Talacen
*caffeine † butalbital ‡agonist-antagonist

44. Relative Potency
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0.20
0.40
0.60
0.80
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45. Treatment Approach

46. Treatment Approach
 MEC
 Role of pharmacokinetic
 Toxicity
 Slow-release preps

47. Concerns
 Tolerance
 Dependence
 Addiction

48. Overvalued Concerns
 Addication
 Overdose and death
 Discipline
“Damn! I suppose this means
another malpractice suit.!”

50. Adjunctive and other meds
 Antidepressant
 Anticonvulsants
 Local Analgesics
 Antihistamines
 Antipsychotics
 Benzodiazepines
 Stimulants
 Cannabinoids
 Placebos

51. Nonsurgical treatments
 Cutaneous Stimulation
 Electrical Stimulation
 Acupuncture
 Exercise

52. Surgical Treatments
 Neural Blockade
 Surgical lesions
 Limitations

53. Psychological Treatments
 Psychoeducation
 Hypnosis
 Behavioral Treatments

54. Behav Txs
 Relaxation
 Biofeedback
 CBT
 Focus
 Goals

55. Multidisciplinary Pain Treatment
 Different levels
 Features included

56. Comorbid Problems
 Depression
 Anxiety

57. Problems of dual diagnosis

58. Role of Psychiatrist in Pain Mgmt

59. Role of C/L Psychiatrist in Pain
Eval
 “Problem Patient”
 “Drug Seeker”
 “Just in their heads”
 “Pain out of proportion…”