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The Psychological Letter®
Building on Complaints of Pain
January, 1998
Among the factors which
influence the experience and management of pain are external events,
pressures, demands and events (the exogenous factors) and those which
are caused by the nature of care received (the iatrogenic factors). It
is believed that pain arises from a combination of physical,
psychological, behavioral, social and cultural influences. The
experience of pain, and the expression of that experience, is complex.
"It is now widely recognized that purely physical treatment for
chronic pain based on the disease model has a low success rate."
In the course of care of the patient with chronic pain, diagnostic
studies are ordered, diagnoses are made, the patient and family are
informed, treatment is suggested, and referrals are made. While the
goal of each of these actions are in the best interest of the patient,
each is vulnerable to misjudgment, error and potential contribution to
magnification of symptoms by the patient.
The concern becomes whether there are times when too many rather than
too few studies are ordered, inappropriate prescription of medications
occur, overzealous and extended treatment is offered and/or
inappropriate information and recommendations are made to the patient.
In a recent study in England (Kouyanou et al, 1997) 27% of patients
studied were considered "over-investigated" for their pain
problems. This included multiple hospitalizations, multiple CT scans,
multiple MRIs and other diagnostic studies in excess of that needed to
form a diagnostic conclusion.
Forty-seven percent of patients were determined to have been
over-treated in terms of the number of surgeries, the repeated courses
of the same injections, greater than four referrals for P.T. and
greater than five forms of of treatment ranging from acupuncture to
chiropractic to osteopathic care.
Almost fifteen percent of the patients studied were determined to have
been prescribed medication on a pain-contingent (rather than fixed
schedule) basis. Forty-six percent reported that they had been
provided with no specific information on how to take their medication.
Almost fifteen percent were taking two or more analgesics from the
same class. Several studied were taking two anxiolytics, two
antidepressants from the same class, and twenty-six percent of the
chronic pain patients were prescribed long term narcotic
analgesia.Greater than two thirds of the patients studied were
inappropriately recommended for bed rest in response to pain.
Thirty-nine percent had been provided at least one simplistic
explanation as to the cause of their pain.
One-quarter of patients studied reported that at least one doctor
involved in their care had directly disputed the validity of their
pain; twelve percent told that the pain was "all in (their)
mind."
Of those patients who were seen as having pain as their primary
problem, in reality, almost half had a mood disorder as the primary
problem, twenty-five percent had a somatization disorder and
approximately sixteen percent had histrionic personality disorder.
Whether referring to number of diagnostic studies excessively ordered,
inappropriate prescribing practices provided, inaccurate information
given the patient, misdiagnosis of condition and/or mismanagement of
the condition, roughly forty percent of those studied felt that the
primary provideThere is increasing belief that the focus of treatment
should be upon active exercise and rehabilitation models, that the
problems that arise in chronic pain management are rehabilitation
problems and that conceptualizing pain symptoms as medical events will
not result in viable treatment strategies.r was not familiar with
their case history.
Chronic pain may, for some patients, be an expression of underlying
psychological disorder. Iatrogenic problems are greater for those
patients for whom the psychological problems are not recognized. [The
interested reader should refer to: Kouyanou, K, Pither, C. E., &
Wessley, S. (1997) Iatrogenic Factors and Chronic Pain. Psychosomatic
Medicine, 59, 6, 597-604].
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