Reintegrating psychiatry into pain-management programs

ROBERT L. HENDREN, D.O. NEAL E. KRUPP, M.D.

Reintegrating psychiatry into pain-management programs The authors describe traditional and modem approaches to the management of patients with chronic pain. They recommend a reintegration of psychiatry into pain-management programs net only for patients with nonorganic pain but also for those with mixed (psychogenic and organic) pain problems. Case histories are included.

ABSTRACT:

The treatment of patients with somatic pain is not a new challenge to psychiatry.I.5 In the past, success depended primarily upon physical, pharmacologic, and/or psychotherapeutic victory over the responsible psychiatric disorders.6 Delusional suffering, depressive equivalents, somatized anxiety, and conversion reactions succumbed to appropriate psychiatric treatment. Painful "excuses" for alcoholism and other addictions were vanquished by attacking the cause rather than the symptom. Pain from interpersonal sources subsided once the patient's interper-

sonal conflicts had been resolved. Mixtures of psychological and organic pain responded less often and less well, however; and problems compounded by significant organic disorder and disability proved largely resistant. 7 In the treatment of these disorders, frustration of psychiatrist and patient alike sometimes led to mutual avoidance8 ; in other cases, wellmeant medical and surgical attempts to provide relief only further complicated these already baffling pain puzzles. In recent years, newer approaches to the treatment of

Dr. Hendren is resident in psychiatry. Mayo Clinic. Rochester, Minn. Dr. Krupp is consultant in psychiatry. Cleveland Clinic Foundation. Reprint requests to Dr. Krupp, The Clinic Center, 9505 Euclid A ve, Cleveland. OH 44106. APRIL 1979 • VOL 20 • NO 4

chronic, mixed pain have earned success and enthusiasm.9 Proliferating pain-management centers have utilized physical, behavioral, pharmacologic, and biofeedback modalities to return previously "untreatable" patients to active, productive, and satisfying lives. 1o Many, if not most, of these would probably have been "failures" if treated by traditional psychiatric methods.' 1-18 And in many cases, it was the likelihood of such failure that led to near-total disparagement and neglect of psychiatry in such centers. Unfortunately, "new" is no more perfect than "old," as is evident in the increasing number of treatment failures in non psychiatric painmanagement programs. Partly to blame are poor patient selection procedures, which court inevitable failure, sometimes with medicolegal overtones. Also, even when selected wisely, patients sometimes stop short of success for psychiatric reasons. And· even when there is apparent success, it can be shortlived: the patient, returning horne, rediscovers the same needs for pain

Psychiatry and pain management

that antedated successful treatment. These observations suggest that it is time to blend the new and old by once again using psychiatric insights and intervention-this time to complement the new techniques and arrive at a total, comprehensive program for the management of problematic pain. '9

The Center The Mayo Clinic Pain Management Center admitted its first patients in October 1974. Although its founder and director was a psychiatrist, his specialty was not distinguished publicly from the other participants-physiatrist, clinical psychologist, physical therapist, occupational therapist, program coordinator, and selected nursing personnel. From its inception, the pain-management staff usually included one or more psychiatric residents who had elected this service. Nevertheless, conscious care was taken that the Center not be identified as a treatment facility for "psychiatric patients." Patients were selected only after complete diagnostic evaluation demonstrated the existence of a significantly disabling, organically based pain problem that had lasted at least six months and for which no "curative" medical or surgical treatment was possible. Patients with progressive malignancy, or patently poor motivation (including medicolegal prospects) were not admitted. 18 Although most patients were interviewed in advance by the director or other psychiatrists who were well informed about the program, a few were admitted on direct referral from other medical and surgical consultants. The program's goal was to help the patient and his or her family cope more effectively with the pain. 230

Without the complications of analgesia addiction, the patient learned to "neglect" the pain, to minimize secondary tension, to use muscles previously weakened by disease, and to pursue satisfying activity. The process included gradual withdrawal from narcotics and/or analgesics, physical and occupational therapy, the learning of biofeedback and relaxation techniques, and intensive interaction with the staff and other patients who applauded progress enthusiastically (positive reinforcement) and largely ignored pain complaints and behavior (extinguishing by nonreinforcement). Spouses and/ or other important family members were required to participate during the last three days of the threeweek program in order to "carry over" the process into the home. In this milieu the majority of patients did well, most of them learning to "live with" their pain successfully. In some dramatic instances, true "cures" (total relief of pain) occurred in the course of the program. Unfortunately, others participated poorly, complained loudly (especially at having their complaints ignored), resisted actively, antagonized staff and peers, and quit prematurely. A few (whose paranoid tendencies had been overlooked) even pursued medicolegal retaliation, fortunately unsuccessfully. Others, after apparent therapeutic success, experienced return of full symptoms sooner or later after discharge. These problems prompted the following gradual adaptations in the program: • The group therapy, previously devoted mainly to behavioral goals, was expanded to deal with interpersonal and intrapersonal problems as well.

• The "psychiatric" component of the program was openly acknowledged. • All prospects began to be admitted routinely to the open psychiatric unit for thorough preliminary evaluation and observation when it became evident that inappropriate patients were not being eliminated in the outpatient screening process. Gradually, as selected psychiatric modalities were introduced, the program became more successful, with fewer "failures." The three case histories reported below illustrate three types of patients treated at the Center. Case 1 A 52-year-old unemployed man, who had sustained a work injury eight years earlier, suffered from severe disabling low back and leg pain unresponsive to a wide range of medical and surgical treatments. No further medical or surgical evaluation was recommended by Mayo Clinic examiners. Supported by Workmen's Compensation payments and an employed, "understanding" wife, 14 years his junior, the patient focused almost entirely on his painful disability, though his desire to be more active seemed sincere. Despite the apparent contraindication of continuing compensation, evaluators were influenced by his entreaties and by circumstantial data suggesting that he feared losing his younger wife if he did not "get better." His first two days in the Center featured extraordinary enthusiasm, activity, and apparent progress. On the third day, however, he refused to get out of bed, and when strongly encouraged to do so, he angrily demanded dismissal. He judged the program a failure because the staff lacked appropriate sympathy and understanding. His abrupt and angry leavetaking had the particularly disturbing result of seriously-and adverselyaffecting the enthusiasm and hopefulness of many other patients for several

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days after he left the pain center. In this case, even careful preevalu~ ation failed to detect a patient whose own failure was projected upon the program, with disruptive effects on many. Adherence to a known contraindication (that is, compensation) would have eliminated him but, unfortunately, his spoken motivation and unconfirmed suspicions about his marital situation overruled prudence.

Case 2 Another patient illustrates the emergence of psychiatric difficulties that were treated successfUlly within the context of the pain-management program. A 44-year-Old engineer complained of lower chest pain lasting eight years. It had begun at home shortly after a chQlecystectomy; aggravated by most physical activities, the pain caused him marked limitation in function. Although he continued to work, most of his time at home was spent in bed, with his attentive, sympathetic wife assuming all household duties. Medical examination indicated the organic contribution of scar tissue and adhesions. During his clinic evaluation, the man denied any personal or marital problems. The patient participated cooperatively and actively in all aspects of the program. In group theraRY, he complained spontaneously of intense anxieties about his job security and about the domineering qualities of his mothering wife. During her participation in the program, he was able to confront her with her overpowering need to take care of him. She was able to accept that assertion, and in subsequent sessions (group and conjoint) they were able to work through a number of other marital difficulties. For this patient, the pain-management program reduced his somatic preoccupation, enhanced his physical activities, and improved his confidence in his body and himself. In addition, he and his wife were able to APRIL 1979· VOL 20· NO 4

renegotiate a more equal and, it is to be hoped, more satisfying marriage.

Caie3 Sometimes the patient gives clues of traditional psychiatric disorder, but nevertheless needs, and qualifies for, admission to the Pain Management Center. An attractive 47-year-Old housewife had been troubled seriously with low back pain for 11 years. A spinal fusion had failed to provide any relief. By the time of her Mayo Clinic examination. her participation in family activities and household duties had gradually reduced to almost nothing. Her personal and sexual relationship with her husband was strained and distant. She was using analgesics chronically and excessively. During her preadmission psychiatric evaluation, she denied anxiety or depression. Her behavior toward the psychiatrist was coy, seductive, and sometimes childishly petulant. The possibility of a primary conversion reaction was outweighed, however, by the apparent organic substrate and by the fact that she had gained nothing from a previous course of psychotherapy. She made progress in the pain-management program and in all parameters measured. She and the staff were immensely pleased. Shortly before her husband was to arrive, however, her pain complaints recurred and she became hostilely dependent, especially toward male members of the staff. Conjoint interviews with her husband revealed serious and chronic marital discord, related importantly to her own intrapersonal conflicts between dependency and rivalry. Both the patient and her husband acknowledged their newly discovered problems and made plans to pursue further psychotherapy. At the time of discharge she was fully mobile, active, and sociable, no longer requiring any medication. Although she still had pain, it was no longer disabling. In this case, fortunately, psychiatric

features did not distract the staff from the patient's other qualifications for admission to the pain-management program. Predictably, she profited from the physical, pharmacologic, and behavioral therapies. Emergence of psychodynamic issues, precipitated by her husband's arrival, threatened the gains she had made but were dealt with effectively to the benefit of both patient and husband.

Discussion Traditional psychiatric therapies have proven valuable in the treat· ment of functional (nonorganic) pain problems. Occasionally they help with "mixed" pain problems, but they are seldom helpful when the organic component is substantial and chronic. Modern painmanagement programs, featuring a multidisciplinary but nonpsychiatric approach, are effective in enabling a large number of chronically disabled, addicted, demoralized, and infantilized patients to return to active, productive lives through teaching them "to live with their pain." Continuing experience with the modem approach, however, suggests that if psychiatry is added to make the programs more comprehensive and effective, these benefits can result: (I) selection of appropriate patients can be enhanced; (2) certain problems can be avoided, aborted, or handled more successfully; (3) previously unknown emotional disorders can be revealed or recognized; (4) con· comitant psychotherapy can be afforded; and (5) appropriate postdischarge therapies can be encouraged. In sum, integrating the "old" and "new" approaches increases the effectiveness of any program that is dedicated to dealing .with the difficult problem of chronic pain. 0 231

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REFERENCES 1. Freud S: Mourning and melancholia, in Riviere J (trans): Collected Papers. London, Hogarth Press, 1925, vol 4, pp 152-170. 2. Freud S: Complete Psychological Works, vol 2, Studies in Hysteria. London, Hogarth Press, 1955 3. Engel GL: "Psychogenic" pain and the pain prone patient. Am J Med 26:899-918,1957 4. Merskey H, Spear FG: Pain: Psychological and Psychiatric Aspects. London, Bailliere Tindall and Cassell, 1967. 5. Rangell L: Psychiatric aspects of pain. Psychosom Med 15:22-37,1953. 6. Kapp FT: Psychogenic pain. in Friedman A, Kaplan H, Sadock B (eds): Comprehensive Textbook ot Psychiatry. ed 2, Baltimore, Williams & Wilkins Co, 1975, vol 2, pp 1704-1708 7. Sternbach RA, Woll SR. Murphy RW, et al: Traits of pain pafients: The low back "loser." Psychosomatics 14:226-229, 1973. 8. Maruta T, Swanson DW, Swenson WM: Low back pain patients in a psychiatric popula-

tion. Mayo Clin Proc 51(7):57-61,1976. 9. Bonica JJ: Organization and function of a pain clinic, in Arias A, el al (eds): Recent Progress in Anesthesiology and Resuscitation. Amsterdam, Excerpta Medica. 1975, pp 46-50 10. Bonica JJ, Albe-Fessard D (eds): Advances in Pain Research and Therapy. vol 1. Proceedings 01 the First World Congress in Pain. Florence. t975. New York, Raven Press. 1976. 11. Fordyce WE, Fowler RS, Lehmann JF, et al: Operant conditioning in the treatment of chronic pain. Arch Phys Med Rehabil 54:399-408,1973 12. Fordyce WE: Pain viewed as learned behavior. in Bonica JJ (ed): International Symposium on Pain, Advances in Neurology, IV. New York. Raven Press, 1974, pp 415-422. 13. Fordyce WE: Treating chronic pain by contingency management. in Bonica JJ (ed): International Symposium on Pain, Advances in Neurology, IV. New York, Raven Press. 1974, pp 583-589.

14. Greenhoot JH, Sternbach RA: Conjoint trealment of chronic pain, in Bonica JJ (ed): International Symposium on Pain, Advances in Neurology, IV. New York, Raven Press, 1974, pp 595-603 15. Janowsky DS. Sternbach RA: The patient with pain, in Abram HS (ed): Basic Psychiatry for the Primary Care Physician. Boston. Little, Brown & Co. 1976. 16. Sternbach RA: Pain Patients: Traits and Treatment. New York, Academic Press. 1974. 17. Swanson DW. Swenson WM, Maruta T, et al: Program for managing chronic pain. I. Program description and characteristics of patients. Mayo Clin Proc 51(7):401-408. 1976. 18. Swanson DW. Floreen AC, Swenson WM: Program for managing chronic pain. II. Short term results. Mayo Clin Proc 51(7):409-411. 1976 19. Shantield SB. Killingsworth RN: The psychiatric aspects of pain. Psychiatr Ann 7(1):2430.1977.

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