Saturday, February 4, 2012

Somatization and Chronic Pain

People don't like to hear that their pain is 'all in their head'.  Rarely do people say this but those with issues almost invariably translate that 'some' of their pain is 'mental' as 'you don't validate' my pain.  This merely confirms that a lot of people with 'chronic pain' have a dual diagnosis a) they have pain b) they are crazy.
The fact is, without a head, a person would not have pain. The brain is the central processor of pain.  When I had the pleasure of assisting neurosurgeons with the skull cap off the patient anesthetized and awake I witnessed the surgeon touching various structures and the patient reporting pain in different parts of their body.
When I hypnotised patients who had pain or didn't have pain I could alter their perception of their pain by my hypnotic inductions and suggestions. I actually did surgery on people I hypnotised so not only could a person's pain be affected by their brain their perception of their pain could be greatly modified by their mental state.
A classic study done in the Vietnam era was a comparison of young men in the field who lost a leg by stepping on a grenade versus young men in New York who lost a leg by a sheering injury in a car accident. Theoretically if pain was external in the limb the grenade wound would require more pain medication to address it than the sheering car injury wound.  This was because grenade explosions creating 'dirty wounds' involving far more nerve endings and far greater trauma than the slicing injuries of motor vehicle accidents.  As it turned out the young men in New York required a quantum factor more  pain medication, for argument sake say 10 x more, than the Vietnam soldiers. It was highly significant and very dramatic and not what people expected and not because soldiers are tougher.
People experience dependent on a variety of factors and a major one is the psychiatry of the pain and the belief associated with the pain.
Further people who have difficulty expressing their feelings, those who have hidden trauma and a variety of other psychological constructs will often experience pain greater than those with less complicated lives.  Men who were physically abused as children taken much longer to heal following back injuries.
There's a matter of secondary gain. If a person is paid for being unwell they may in fact take the 'sick role' for a long time. This is overt secondary gain and may give rise to 'malingering' where a person will present with physical illness for the express purpose of getting financial advantage.
In factitious disorder the person presents with physical disease including pain and often dizziness not overtly for financial benefit but for some other secondary gain.  An example is a person who was cared for in childhood when they were sick and neglected when not. This person may 'milk the mercy' out of an injury or illness or pain as a means of getting attention later in life having unconsciously learned this was an acceptable way of emotional communication.
Some people can't express anger and instead have a 'pain in the neck' or a 'back ache'.  Historically most men have heard some joke about women not wanting to have sex because they have the 'proverbial headache'.
These are all aspects of 'somatization'.  Somatization simply suggests that psychological factors are experienced through the periphery nervous system. People have no difficulty accepting that the hands can feel and send feeling messages to the brain. However they have difficulty with the idea that brain messages can be transmitted to the hands in illness. Having treated patients with amputations I've had a man who when angry found his missing limb hurting him because he was 'clutching' his missing fist too hard.

Given the reality of this there's a tendency to treat chronic pain with psychiatric medication. The treatment of choice for fibromyalgia, a disorder originally called 'somatic depression' and originally described by psychiatrists not internists or surgeons, today still responds to the antidepressant medication amitriptylline.  The latest antidepressant medication which is actually 'labelled 'for pain therapy as well as depression and anxiety is 'cymbalta' or 'duloxetine.' This is today the treatment of choice for chronic pain of most kinds.

In addition individual and group therapies are used to address somatization and chronic pain with great success.  Exercise is also very beneficial.

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