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  • Chronic complaints of pain.

  • Symptoms frequently exceed signs.

  • Minimal relief with standard treatment.

  • History of having seen many clinicians.

  • Frequent use of several nonspecific medications.


A problem in the management of pain is the lack of distinction between acute and chronic pain syndromes. Most clinicians are adept at dealing with acute pain problems but face greater challenges in treating a patient with a chronic pain disorder. Patients with chronic pain frequently take many medications, stay in bed a great deal, have seen many clinicians, have lost skills, and experience little joy in work or play. Relationships suffer (including those with clinicians), and life becomes a constant search for relief. The search results in complex clinician-patient relationships that usually include many medication trials, particularly sedatives, with adverse consequences (eg, irritability, depressed mood) related to long-term use. Treatment failures can provoke angry responses and depression from both the patient and the clinician, and the pain syndrome is exacerbated. When frustration becomes too great, a new clinician is found, and the cycle is repeated. The longer the existence of the pain disorder, the more important become the psychological factors of anxiety and depression. As with all other conditions, it is counterproductive to speculate about whether the pain is “real.” It is real to the patient, and acceptance of the problem must precede a mutual endeavor to alleviate the disturbance.


Components of the chronic pain syndrome consist of anatomic changes, chronic anxiety and depression, anger, and changed lifestyle. Usually, the anatomic problem is irreversible, since it has already been subjected to many interventions with increasingly unsatisfactory results. An algorithm for assessing chronic pain and differentiating it from other psychiatric conditions is illustrated in Figure 25–1.

Figure 25–1.

Algorithm for assessing psychiatric component of chronic pain. (Reproduced with permission from Eisendrath SJ. Psychiatric aspects of chronic pain. Neurology. 1995;45:S26–S36.)

Chronic anxiety and depression produce heightened irritability and overreaction to stimuli. A marked decrease in pain threshold is apparent. This pattern develops into a preoccupation with the body and a constant need for reassurance. Patients may start avoiding usual behaviors when they first develop the pain and chronic avoidance of usual physical functioning can lead to the development of chronic pain. The pressure on the clinician becomes wearing and often leads to covert rejection of the patient, such as not being available or making referrals to other clinicians.

This is perceived by the patient, who then intensifies the effort to find help, and the typical cycle is repeated. Anxiety and depression are seldom discussed, almost as if there is a tacit agreement not to deal with these issues.

Changes in lifestyle involve some of the pain behaviors. These usually ...

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