When Psychology Trumps Percocet

Is it all in my head?

Posted Oct 20, 2008

It is not unusual that a patient with chronic pain finds it more than a little difficult to find a physician who has empathy for the patient with chronic pain. However, even if the patient with chronic pain discovers a physician who understands and cares, that does not necessarily accomplish a significant amount in terms of helping the patient.

The next step can be somewhat daunting, because it is one which requires initiative on the part of the patient. It is asking a person to develop a strategic plan. Many of us find planning too rigorous an activity, and it becomes more if so much energy is being expended to fight an illness. However, there has to be an approach, the goal of which is to lessen the pain that already exists, while simultaneously averting a secondary, more psychological diagnosis, such as depression.

This plan must be coordinated and comprehensive, and should include the following obvious and not-so-obvious items:
1. medications to treat the pain and lessen the impact on the psyche (this would include analgesics and psychotropic drugs-such as anti-depressants);
2. local administration of pain-relieving techniques and drugs (for example, epidural injections or the placement of "neurostimulators" for those with back pain;
3. ancillary physical modalities, such as acupuncture, massage, or physical therapy;
4. psychological intervention to work through the mental pain of chronic illness and/or chronic pain, and how the patient's pain impacts the interactions with others.

Of course, the patient will have to be receptive to having at least some of the responsibility for recognizing when physical pain begins to usher in psychological pain. For example, is there uncontrollable crying and sadness? Is there a sense of hopelessness? Is there confusion and irritability, along with unprovoked anger?

But if potential recognition of psychological symptoms is delayed, whether it be through denial or repression, the recovery will not only be delayed, but may well be compromised. There should be no sense of shame when dealing with the emotion of chronic pain. And if there is shame, then the patient with chronic pain should make every effort to fight off the sense of resentment should, say, a family doctor also recognize changes in affect and personality--and refer his patient to a mental health specialist.

Too often, the reaction to such intervention is anger because the "Doctor thinks it's all in my head". Well, it is often not all in one's "head"; but the human head is complicated and subject to all kinds of side-tracking, as it were. At some time or another, we all need a little gentle guidance to get back on track; a psychologist or psychiatrist is only one way of accomplishing that.

In fact, psychological evaluation is often part of the regimen when a patient is referred to a Pain Clinic. Pain and suffering create emotional distress, which almost invariably has an impact on the workplace and family life. Recovery can be impacted.

A multi-faceted approach with a multi-disciplinary philosophy will yield a more complete understanding of the patient, which is crucial for the treating team; and it might stumble upon an epiphany or two, which is just as crucial for a patient's sense of self-worth. No matter the angle by which this is viewed, the patient garners the greater benefit.