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Key Features

Essentials of Diagnosis

  • Chronic complaints of pain

  • Symptoms frequently exceed signs

  • Minimal relief with standard treatment

  • History of having seen multiple clinicians

  • Frequent use of several nonspecific medications

General Considerations

  • Components of the syndrome

    • Anatomic changes

    • Chronic anxiety and depression

    • Anger

    • An altered lifestyle

  • Importance of psychological factors increases over time

  • Often involves secondary gain for the patient via financial compensation or maintaining the sick role

  • Clinicians unwittingly reinforce the sick role, since the nature of medical practice is to respond to complaints of illness

  • It is counterproductive for the clinician to speculate whether the patient's pain is "real"

  • Acceptance of the problem must precede attempts to reduce symptoms and improve function

Clinical Findings

Symptoms and Signs

  • Patients often take multiple medications, stay in bed a great deal, and experience little joy in work or play

  • Typically, the anatomic problem related to the pain is irreversible

  • Marked decrease in pain threshold is apparent

  • Chronic anxiety and depression produce heightened irritability and overreaction to stimuli

  • Patients often have a preoccupation with the body and a need for reassurance

  • History of many interventions with unsatisfactory results

  • Treatment failures may provoke anger, depression, and exacerbations of the chronic pain

  • Relationships are impaired, including those with clinicians

  • Pressure on clinicians often leads to covert rejection of the patient, such as being unavailable or making referrals to other physicians

Differential Diagnosis

  • Somatic symptom disorders

  • Malingering

Diagnosis

  • See Essentials of Diagnosis

Treatment

Medications

  • Analgesics and sedatives are used only on a fixed-dose schedule to reduce their conditioning effects

  • Serotonin norepinephrine reuptake inhibitors (SNRIs), venlafaxine, milnacipran and duloxetine, and tricyclic antidepressants (eg, nortriptyline), in doses up to those used in depression may be helpful, particularly in neuropathic pain syndromes

  • Both duloxetine and milnacipran are approved for the treatment of fibromyalgia; duloxetine is also indicated in chronic pain conditions

  • Tricyclic antidepressants, venlafaxine, and duloxetine in doses used for depression can be helpful (Table 25–7)

  • Gabapentin and pregabalin can be helpful for neuropathic pain

Table 25–7.Commonly used antidepressants (listed in alphabetical order within classes).

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