Hong Kong J Psychiatry 2008;18:173-4


Chronic Pain

(In the series: Advances in Psychotherapy, Evidence-Based Practice – Vol. 11) Beverly J. Field, Robert A Swarm
Hogrefe, 2008
US$24.95; pp112; ISBN: 978-0-88937-320-4

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In western countries, chronic pain prevalence estimates in the general population range from 10 to 55%. Approximately 70 million Americans report chronic pain, with 10% having pain for more than 100 days per year. Chronic pain imposes tremendous costs on patients, employers, and the health care system. The American Productivity Audit estimated that 13% of the work force lost productive work time due to common pain conditions including headache, back pain, arthritis, and other musculoskeletal conditions, from August 2001 to July 2002.

Chronic Pain, written by 2 academics from the departments of anaesthesiology and psychiatry at the Washington University School of Medicine, St Louis, provides up-to-date information for those of us who have been overlooked in the management of pain. In traditional attempts to look for pathology and to treat symptoms, the role of psychology is often underestimated. Any chronic pain is best treated with a patient-focused and integrated approach.

From a clinical perspective, it is useful to classify pain: acute or chronic, nociceptive or neuropathic. While acute pain is usually associated with tissue damage, chronic pain is a result of complex systems. It is better understood as the integration of biomedical and physiological processes. Psychological factors play an important role in sustaining pain perception and coping. Chronic pain leads to a vicious cycle of depression, helplessness, guilt, and increased preoccupation with pain. It is accompanied by a multitude of negative behavioural responses like restricted activity, sleep deprivation, and social withdrawal. Misuse of opioid analgesics and alcohol complicate patients’ problematic behaviours. Patients with chronic pain often resist referral to mental health professionals. By the time they present to mental health services, many have already seen a number of physicians, some of whom may have implied that the pain is purely psychogenic. It can be challenging to establish a therapeutic alliance with patients who respond with defensiveness or hostility.

An overview and practice guides for the psychological evaluation of chronic pain are given in this book. The assessment should include: a careful review of the patient’s medical records; exploration of the patient’s beliefs, expectations, and negative cognitions related to pain; elicitation of symptoms of depression and anxiety; gauging of how well the patient and his / her family are adjusting to changes in family roles; elicitation of co-morbidities such as sleep disorders; and evaluation of the patient’s coping skills. Because of the complexity and multidimensionality of pain, single-modality treatments are not as effective as multimodal approaches. Psychological therapy is rarely used as the sole treatment modality. It is usually combined with analgesic medications, behavioural or psychological therapies, physical therapies, injections, and interventional procedures. The goal of treatment, in most cases, is not to cure or ‘fix’ the pain, but to reduce the severity and improve function. The manner in which patients respond emotionally and behaviourally to pain varies, depending on individual characteristics and external resources. Individuals with broad coping-skill repertoires, flexible responses to adverse circumstances, and supportive families and friends may be able to make adaptive adjustments to living with pain.

This book also discusses physical treatment in detail, describing a variety of opioid and non-opioid analgesics, the risks of analgesics like gastro-intestinal toxicity, analgesic tolerance, and the possibility of developing opioid tolerant hyperalgesia. The currently available analgesics have signifi- cant limitations in chronic pain management, including incomplete pain relief, adverse effects, and tolerance. Pain medications should only be considered after weighing the benefits against potential risks. The dosage must be titrated for each individual, to a level where it reasonably controls pain while producing minimal adverse effects. Adjuvant analgesics, including several anticonvulsants and antidepressants, are often used for treatment of neuropathic pain; they may have other beneficial effects such as relief of insomnia, control of irritability, and management of co- morbid depression and anxiety.

Much of the book is devoted to psychological interventions including: cognitive behavioural therapy, behavioural or operant therapy, and self-regulatory therapies such as biofeedback, relaxation, and hypnosis. Cognitive behavioural therapy encompasses a broad range of therapeutic approaches but usually includes: (1) education about theories of pain, (2) setting short- and long-term goals, (3) relaxation techniques to manage stress, reduce muscle tension, aid in distraction from pain, (4) identification and modification of pain-related cognitions, beliefs and fears, and (5) identification or strengthening of the patient’s social support network, and developing strategies for coping with setbacks and relapses. The patient’s treatment goals and expectations should be discussed during the first session and the therapist should work with the patient to develop a set of mutually acceptable goals. Unrealistic patient goals can sabotage treatment.

Apart from cognitive behavioural therapy, patients can benefit from learning how to use self-regulatory techniques. This book provides a clear description of various techniques: diaphragmatic breathing, progressive and passive relaxation, imagery, autogenic phrases, hypnosis, meditation, and biofeedback. All of them aim to reduce stress, increase physical relaxation, and focus attention. When relaxation is introduced, some may mistakenly assume that the therapist believes the pain is “in your head”, hence it is important to assure patients their pain is real. These techniques do not cure the pain, but help decrease the severity of chronic pain and enable patients to cope with the stress of living with chronic pain. The practical details provided enable readers with clinical backgrounds to translate the material into useful management approaches.

It is not uncommon to get referrals of patients with chronic pain from the physicians and general practitioners. Managing patients with chronic pain is challenging. This book provides a concise, comprehensive, and user-friendly discussion of assessment and treatment strategies for persons with chronic pain.

Dr Vivian Lim, MBBS, MRCPsych
Department of Psychiatry
Tai Po Hospital
Tai Po
Hong Kong

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