Psychology, Psychiatry and Chronic Pain

204 Pages·1992·2.876 MB·English

by  Stephen P. Tyrer (Eds.)

Psychology, Psychiatry
and Chronic Pain
Edited by
Stephen P. Tyrer
Consultant Psychiatrist
Pain Relief Clinic
The Royal Victoria Infirmary
Newcastle upon Tyne, UK
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T T E R W O R TH
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First published 1992
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British Library Cataloguing in Publication Data
Psychology, Psychiatry and Chronic Pain
I. Tyrer, Stephen P.
616.89
ISBN 0 7506 0573 1
Typeset by Lasertext, Stretford, Manchester
Printed in Great Britain at the University Press, Cambridge
Contributors
P. Chandarana MB, ChB, ABPN, FRCP(C)
Associate Professor of Psychiatry, University of Western Ontario,
London, Ontario, Canada
J. E. Charlton MBBS, DObst, RCOG, FRCAnaes
Consultant Anaesthetist, Department of Anaesthesia, Pain Relief
Clinic, The Royal Victoria Infirmary, Newcastle upon Tyne, UK
P. T. James BSc, MPhil, CPsychol, AFBPsS
Department of Clinical Psychology, Pain Relief Clinic, The Royal
Victoria Infirmary, Newcastle upon Tyne, UK
G. Mendelson MBBS, MD, FRANZCP
Honorary Senior Lecturer, Monash University Department of
Psychological Medicine, Melbourne, Australia; and Consultant
Psychiatrist, Pain Management Centre, Caulfield General Medical
Centre, Caulfield, Victoria, Australia
H. Merskey DM, FRCP, FRCP(C), FRCPsych
Professor of Psychiatry, University of Western Ontario, London,
Ontario, Canada; and Director of Education and Research,
London Psychiatric Hospital, London, Ontario, Canada
L. M. Smith BSc (Hons), MCSP
Head of Therapy Services, West Dorset General Hospitals NHS
Trust
J. W. Thompson MBBS, PhD, FRCP
Director of Studies Honorary Physician, St. Oswald's Hospice,
Newcastle upon Tyne; Emeritus Consultant Clinical
Pharmacologist, Newcastle Health Authority; Emeritus Professor of
Pharmacology, University of Newcastle upon Tyne, UK
viii Psychology, Psychiatry and Chronic Pain
S. P. Tyrer MA, MB, BChir, LMCC, DPM, FRCPsych
Consultant Psychiatrist, Department of Psychiatry, Pain Relief
Clinic, The Royal Victoria Infirmary, Newcastle upon Tyne, UK
Foreword
This book is written in response to urgent needs at a time of growing
crisis. The very phrase, chronic pain, merges in its meaning with
intractable pain since neither condition would exist if safe powerful
remedies were available. There are at least three reasons why the
crisis grows. First, many of these pains occur in older people who
make up a larger and larger fraction of our population, largely because
of the success of the very same doctors who now fail to cure the pains
of medically produced old age. Second, we have grown a community
who no longer suffer in silence, and why should they be silent in a
society which urges them to work, to be active and to participate.
This means that private suffering is translated into public display
which produces guilt and embarrassment in their friends and doctors
who hide their impotence in a froth of frustration, anger and
withdrawal. Third, and most peculiarly, the very real modern success
in defeating certain types of pain emphasizes the pitiful failure of the
cure of other types. We may tend to forget that there really have been
huge successes for which those responsible should be very proud.
Postoperative pain is an example of intelligent use of old recipes and
of patient involvement and of new ideas which can transform a period
of writhing discomfort into relative calm. The pains of terminal cancer
have been abolished for the great majority of patients by the brilliant
mobilization of humanity and thought over the past 50 years. Even
as dramatic a condition as trigeminal neuralgia usually responds
within a day to carbamazepine. One can therefore easily see the
motivation of patients and professionals who now wish to advance
from clear victories to conquer the remaining enemy.
First we must recognize how medicine has attacked a problem over
the past 200 years. The first stage was to identify a causal pathology.
Each disease was tracked down by the medicinal Sherlock Holmes to
point a finger of accusation at the true criminal, be it bacterium, virus,
cell, gene or molecule. In this Conan Doyle school of medicine,
secondary characters were identified and placed on one side until the
χ Psychology, Psychiatry and Chronic Pain
fundamental villain, the real Dr Moriarty, was nailed. In the eighteenth
century, Heberden described a condition as precisely as any of us
could do today but gave it the vague name of angina pectoris, pain
in the chest. The reason for his vagueness was that he could not
identify the causal local pathology. He examined the hearts of those
who had died with extreme angina but he was not certain that he
could detect a specific disorder of the heart to which he could ascribe
the origin of the pain. We will return to Heberden's problems but,
suffice it to say, over the next 200 years every structure in the chest;
heart, lungs, blood vessels, nerves and joints, were labelled as the
cause until, in the 1930s, P. D. White and Sir Thomas Lewis gave us
the accepted explanation of today that ischaemic cardiac muscle
causes angina pectoris. This set the scene for the doctors duty when
faced with a patient in pain, which is to search for the pathology.
They are very good at it. This patient has appendicitis. This patient
has a broken leg. However there were serious problems which began
to appear in this clearly successful process. Pain may not be associated
with evident pathology. Certain types were so common that they
could not be dismissed since even the doctors themselves suffered
from them. The obvious example is the headache, subdivided into
tension and migrainous types. Since they had to have a localized
pathological cause the former was ascribed to muscle cramp and the
latter to blood vessel dilatation or spasm. A hundred years on and it
is now possible to measure with great precision the state of muscles
and blood vessels and the fact that there is no correlation between
these measurements and the headache has hardly dented the muscle
tension and vascular origin dogma. Similarly, the ubiquitous back
pain problems could be attributed to clear and classical spinal
pathology; disc herniation, infection, tumour, stenosis, arthritis and
arachnoiditis. In a larger and larger proportion of low back pain
patients, none of these pathologies could be identified. Worse, a series
of painful syndromes began to be identified for which the hard nosed
could identify no pathology. These now include, temporomandibular
joint syndrome, atypical facial neuralgia, whip lash syndrome, fibro-
myalgia, repetitive strain syndrome, tenosynovitis, the majority of low
back pain patients and post encephalitic myalgia.
Behind the honourable and successful search for localized pathologi-
cal causes for abnormal symptoms, there was a more profound
seventeenth century alternative. If someone reported a sensory experi-
ence which did not match the reality of the state of their body or the
external world, they suffered a disorder of their mental world. This is
Cartesian dualism in the raw. It is considered in every doctor's
consultation room and in this book. Interestingly, Descartes himself
was challenged by a Marquise with exactly this question when she
asked him to explain a phantom limb. Descartes gave a much more
subtle answer than many of those in this book who claim to be his
Foreword xi
loyal disciples. He explained that the mind was the slave of the body
mechanisms and that the mind could not distinguish between a 'true'
message and one delivered by a corrupted mechanism. This moves us
350 years on to understand a specific type of intractable pain
where there has been obvious nerve damage in the periphery as
in amputation, causalgia, Sudek atrophy, post herpetic neuralgia,
arachnoiditis and spinal cord injury. If pain persists after all signs of
the original peripheral damage has subsided, should we attribute the
pain to a mental aberration as do some of the authors of this book
or to the generation of 'false' signals as do others. The unravelling of
this issue is exactly the crucial topic of this book. Of course the basic
dualism of either body or mind may be incorrect since intermediate
solutions to the question may be the most useful for those who suffer
chronic pain.
Therefore let us leave the depths of these complex issues and return
to the simple well known fact that abrupt cardiac ischaemia may
produce a period of acute angina and death. There are also 'silent'
fatal heart attacks where post mortem examination shows that a series
of major unreported previous episodes of severe cardiac ischaemia had
occurred. In patients with angina of effort, no clear correlation can
be established between measured coronary circulation and angina. In
the 1950s, 10 patients had sham operations and 10 had ligation of
their internal mammary arteries for angina and both groups showed
equal favourable pain responses over the next six months. Patients
with osteoarthritis have clear precisely definable lesions of their joints
and a limitation of movement and pain. The relation between these
three is variable as is their response to joint replacement and to the
many forms of drug treatment. These variations are the issues which
make a book of this type so crucial for the future of our understanding
of pain and, above all, for the well being of these patients.
We are hopefully beyond the crude dualism of the question 'Is it
in the body or in the mind?' or in more fancy words, 'Is it sensory or
affective?' or 'Is it real or cognitive-attentive-discriminative?' However,
we may have to say to a patient Ί do not have the foggiest idea why
you are in pain. You and I have to work on that question and in the
meantime I have some useful things to tell you about how to live
with this awful condition by teaching you methods of survival and
coping and distraction and control.'
Patrick D. Wall FRS, DM, FRCP
Department of Anatomy and Developmental Biology
University College London, UK
Preface
Sufferers with chronic pain have a severe handicap to bear. Chronic
pain is demoralizing and debilitating and it is not surprising that in
this condition almost half of patients with chronic pain attending
pain relief clinics have measurable psychiatric symptoms, mainly those
of depression. Despite this, the majority of pain clinics do not have a
regular service by psychologists or psychiatrists. There is more
psychological input into pain clinics, but in the UK less than 5% of
pain clinics have any dedicated sessions from psychiatrists.
This book is aimed at all those who work with individuals with
chronic pain, so that they will be better able to assess and treat the
psychological and psychiatric complications of this condition. It is
not an academic textbook, rather it is intended to be a practical guide
to help professionals not working in the mental health field about
factors that affect the emotional state of chronic pain sufferers. It
should therefore be of value to all doctors working with patients with
chronic pain, to nurses, physiotherapists, occupational therapists,
pharmacists, hypnotists and alternative therapists involved in this
area. The psychologist or psychiatrist intending to work with patients
with chronic pain and those who have some experience of the subject
but wish more knowledge should also benefit from this volume. The
intelligent pain sufferer should also find something of personal value
from this work. The language used is intended to be free of jargon
and should be understandable to the lay person.
The book is divided into two sections concerned with description
of the issues involved in the psychological and psychiatric issues in
chronic pain and in the second part, with assessment and intervention.
In addition to description of the main emotional factors involved
in patients with chronic pain, there are chapters on particular
psychiatric and psychological problems involved in specific illnesses
and on compensation.
The second section on assessment and intervention describes what
treatment methods are available to help those with emotional
xiv Psychology, Psychiatry and Chronic Pain
problems arising from chronic pain. There are chapters on psycho-
tropic drugs, cognitive and behavioural therapy in chronic pain, and
hypnosis. Chapters are also included on physiotherapy and the
exhibition of transcutaneous electrical nerve stimulation (TENS) and
acupuncture. A final chapter is concerned with how services can be
organized within a chronic pain clinic.
A book with multiple authors from three different continents is
difficult to organize in a comprehensive way. The fact that it has been
achieved is in no small part due to the diligent attention of Vicky
Woodruff, Gillian Simpson and Valerie Marsh who have together
assembled the manuscript. Dr Trian Fundudis, Dr Marion Michie,
Dr David Sanders and Dr Mark Tyrer have helped considerably in
reading over selected passages in the book and offering valuable
suggestions. Above all, I would like to thank my co-authors for their
cooperation in assembling this volume. Finally, I am indebted to my
wife who has put up nobly with my early morning risings and my
evening irritability in order to get this work completed.
Stephen Tyrer
Newcastle upon Tyne
1
Basic concepts of pain
S. P. Tyrer
The experience of pain is known to virtually all mankind. There are
some people with certain neurological illnesses who are unable to feel
pain but these are few and far between. So all of us, when describing
and talking about 'pain', have a clear concept of what feeling is
exhibited when we use the word. But do we? The experience of a
sharp pain following a cut or burn is different in quality and
description from the chronic, nagging pain of rheumatoid arthritis. The
intermittent severe pain of gall-bladder colic, although incapacitating
and intense when it occurs, does not have the long-term debilitating
effects of the pain arising from chronic cancer or progressive arthritis.
So each of us mean different things when we talk about pain and we
cannot assume that others understand what we mean when we
describe it.
The differences in the exhibition of pain described above are, to a
large part, dependent upon the intensity and duration of the pain. In
particular, chronic unremitting pain with little or no possibility of
release must be one of the most distressing experiences known to
man. The experience of pain dominates all waking life, it interferes
with thinking and prevents all but the most simple of constructive
activities. It disturbs sleep, impairs appetite, affects morale and may
disorganize the functioning of every part of the body. It is largely
with the problem of chronic pain that this book is concerned. Acute
pain, although not free of psychological or psychiatric difficulties, is
not usually associated with serious mental health effects.
Incidence
The incidence of chronic pain is enormous. In Britain about 2.2
million people a year see a doctor about a back problem. This is
almost 5% of the adult population. However, the incidence of chronic
backache at any one time is almost certainly higher than this. A