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.

Chronic Pain

Acute pain is often an indication that something needs immediate attention. However, chronic pain, those pains that have been thoroughly investigated but tend to recur with a variety of triggers, may often have a much more diverse psychosomatic make up.
Once a body has experienced acute pain of injury or disease, a neurological program remains available thereafter for the body to communicate 'dysfunction' more readily along the established pathways.
However this 'dysfunction' may be biological, psychological, sociological or spiritual. Psychosomatic medicine has delineated that men, for instance, subjected to physical abuse such as beatings across the back are most likely later in life to experience more of their anxiety and depression as bodily sensation, such as 'back aches'. Similiarly women sexually abused and vaginally traumatized early in life will be more likely at later times in life to express loneliness as pelvic discomfort.
The rationale for this is that neurologically a number of circuits were originally brought into play for the original acute injury or disease and later these same circuits can be used for the expression of psychological, sociological and spiritual discomfort. The mind is efficient.
To this end chronic pains while requiring an index of suspicion as a site for new physical disease often benefit more from less investigation, certainly less invasive investigation and more actual therapy.
An example is found in the acute back injury which is greeted with the recommendation of days of rest and no work initially but later when recurrence is noted, the recommendations drastically changes to 24 hour rest and then increasing exercise. Increasingly suicidal behaviour, acutely se en as a cry for help and need for massive life preserving intervention, later when it is chronic and recurrent is seen as a behaviour that requires education and redirection rather than responding as if this were the first suicidal episode. Suicide in this instance is a response to 'emotional pain".
Phantom limb pain is real however it may reflect emotional pain such as loss of a loved one or irritation and frustration with the inability to achieve one's goals.
Nothing is ever 'all in your head' but even fractures and amputations are experienced 'in your head'. The brain is the central physical processor and the mind is the overall understanding of all factors at play.
The DSMIV differentiates Pain Disorders into two, one where there is no physical basis noted, and another where a physical basis is noted but there is also a psychological and emotional overlay.
Treatment of chronic pain has advanced lightyears from where it was only 25 years ago. Much work has demonstrated that the degree of the chronic pain is directly associated with depth and quality of sleep. Pain often disrupts sleep and the next day anxiety and sleep loss are experienced as greater pain. So much of modern medicine focusses on addressing sleep in patients with pain disorders. Medications such as trazadone, gabapentin, mirtazepine are used for sleep and pain disorders.
Whereas in the past the tendency was to 'take away the pain' today pain is understood as beneficial and it's removal entirely can lead to serious side effects. Nerve severing studies found that people who'd had this neurological treatment to an arm for instance suddenly were at major risks for serious burns because they couldn't feel pain to react to. To that end today the pain is 'controlled' rather than eliminated.
In the past opiates were the mainstay of pain management. Today they are pre empted by first use of acetomenophen, nonsteroidal anti-inflammatories, and ASA's compounds. These are commonly today used in combination rather with three different pills from the different classes preferred over three times the dosage of just one medication. It was found these combinations of medications enhance the pain relief as each works on different sites in reducing pain but more importantly side effects are dramatically lessened as each has very different side effect profiles. ASA causes blood clotting to be reduced with no effect on the liver while Acetominophen causes liver enzymes to increase with no effect on the blood clotting. Therefore using two together one can get twice the pain relief with half the side effects.
Antidepressant medications and atypical major tranquillizers have been used as well more often to modulate pain control. Amitriptylline, a trycyclic antidepresssant has long been the treatment of choice for such conditions as fibromyalgia. Medications like cipralex and cymbalta address the depression commonly associated with pain. It was long ago noticed that combining coffeine with pain medications made them more potent. The antidepressants specifically work like this but for a longer period.
The opiates are for sure still used and yet the recognition was that people who took opiates could enter a pain free dream like state and be at increased risk for hurting themselves because of poorer judgement and lack of pain reception. This was especially true with musculoskeletal injuries. In contrast opiates have been seen as more beneficial in chronic 'organ' pain.
Exercise is central to pain management because commonly pain results in decreased exercise and risk of the consequences of this, obesity, disuse atrophy, and other side effects. Further, exercise is it's own antidepressant and the uplifting benefits help with maintaining and positive outlook which is central to the successful management of chronic pain.