Symposium on Psychiatry in Internal Medicine
Pain The Most Common Psychosomatic Problem
Thomas N. Wise, M.D. *
The symptom of pain is one of the most common complaints that the practicing physician encounters. Of 550 consecutive admissions to the general medical clinic at the Johns Hopkins Hospital, 40 per cent of the chief complaints involved the specific complaint of pain. Pain, no matter how vague, is often "the ticket of admission" to a physician's office. This discomfort can indicate an impending rupture of an appendix, the onset of an acute myocardial infarction, the imminence of giving birth, or a serious psychologic disorder. Unfortunately, pain is not an objective physiologic sign such as a pulse rate, respiratory rhythm, or focal neurologic defect with gross pathologic changes. Pain can be defined as "an unpleasant experience which we primarily associate with tissue damage or describe in terms of tissue damage."8 Yet, it is always a subjective symptom whether it is caused by an observable fractured limb or a hallucinatory delusion. This complaint cannot be directly observed, but only inferred from the patient's self report. Although an individual's relative response can be measured by giving equally noxious stimuli to different individuals, pain is expressed by the patient's self report or observed reaction indicating "something hurts." The "either/or" dichotomy of psychogenic versus real organic pain merely confuses the issues and concepts of pain perception and treatment. One cannot always separate the mind from the body. Psychogenic pain often has organic concomitants. Similarly, organic pain is never without an emotional reaction. The individual with a compound fractured femur is clearly anxious and fearful, both concurrent psychological symptoms. The very language of pain exemplifies this interface. Just as "pain in the neck" underscores the interpersonal aspects of a relationship, so do the frequently used idioms "heartache," "hurt lover," or "this pain is going to drive me crazy" demonstrate that pain is a combination of psychological and interpersonal phenomena. "Chairman, Department of Psychiatry, The Fairfax Hospital, Falls Church, Virginia; Assistant Professor of Psychiatry and Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland; Associate Professor of Psychiatry, Georgetown University
Medical Clinics of North America-Vol. 61, No. 4, July 1977
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V ARIABLES MODIFYING THE RESPONSE OF PAIN The basic biologic utility of pain allows organisms to perceive danger within their environment. As primitive organisms recoil from noxious stimuli in a basic stimulus-response pattern, so do more complicated species. As one progresses along the phylogenetic scale, many intervening factors arise which modify and attenuate this basic action-reaction system. An individual's cultural background, the society in which he resides, the interpersonal relationships he possesses, the interpsychic meaning of a pain stimulus and the real impersonal organic problems, all color one's response to pain. Cultural Factors Cultural aspects can complicate an individual's reaction to a painful stimulus. The couvade syndrome is the phenomena in which expectant fathers complain of nausea and abdominal pain. This can occur in increasing intensity when the woman begins labor. "Couvade," French for brood or hatch, is seen most clearly in those cultures in which women show minimal distress during pregnancy and often will continue with strenuous physical activity even during early labor. In these instances, their mates will take to bed and groan as though in great pain. It must be emphasized that the expectant father does not consciously imitate his wife's pregnancy but unconsciously reacts to the pregnancy by psychological acquisition of abdominal pain as if he were experiencing the pain of labor himself. Although clearly described in primitive settings, at least 11 per cent of expectant fathers in industrial societies experience abdominal pain without demonstrable organic factors. 12 Social Factors Specific ethnic groups react differently to uniform noxious stimuli. Sternbach has studied four specific groups: the Italian, Jewish, Irish, and Old American ethnic entities. Although the minimal amount of pain which an individual is able to perceive appears to be the same among the various groups, their tolerance to increasing levels of pain varies. The Italian and Jewish subgroups were not able to tolerate the levels of electric shock that their Irish and Old American counterparts were able to sustain. When the Jewish and Italian members of the investigation were told of this, the differential finding to pain vanished on repeat testing. 10 It appears that the specific cultural or ethnic milieu creates expectations which the individual uses as a role model and thus reacts as expected. Specifically, certain individuals will immediately seek medical care if they feel discomfort while others will complain but do nothing. Still others will stoically tolerate substantial discomfort. Interpersonal Factors In addition to cultural or social factors, the interpersonal situation of an individual greatly modifies his response to pain. This can be shown experimentally in animals. Certain species of dogs have been raised in isolation so that they are deprived of their normal environmental stimuli
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of bodily knocks and scrapes that they would experience from their litter mates. When mature, these animals were unable to react normally to a variety of painful challenges. 7 In human beings, the interpersonal communicative aspects of pain are very important. Thomas Szasz has noted that the meaning of pain depends on its symbolic equivalent especially as a nonverbal message to important individuals around the patient. 11 The concept of secondary gain is viewed by Szasz as a communication for help which utilizes a primary somatic complaint in the case of pain. This begins at infancy when an infant's cry for help leads to a mother's attention. Engel has further elaborated the interpersonal meanings of pain by explaining the association of pain and punishment in early developmental periods to emphasize the interpersonal importance ofpain.4 CASE 1. A 41 year old woman was admitted for persistent abdominal pain. Past history revealed multiple surgical procedures as well as psychiatric hospitalizations for abdominal pain. Multiple medical therapies as well as various somatic psychiatric therapies were tried but the patient's complaints persisted. The present physical examination revealed no overt reason for her complaints. The patient's past history is significant in that she was from an affluent family. Her father was a very dynamic, often absent business man. Her alcoholic mother gave her little attention except when the patient was ill. The patient married at an early age in an apparent attempt to achieve independence. Her married life was beset by longstanding financial problems because of her husband's unsuccessful business career. On evaluation, the patient persistently focused on her abdominal pains and demanded relief. She then proceeded to elaborate upon various other painful conditions such as cramping in her legs and persistent headaches. The patient had a conspicuous absence of any feelings, either positive or negative, toward her husband, except that she was very aware of the longstanding hardships her multiple illnesses had been to him. In formulating an explanation for this patients' complaint, it became apparent that she expressed her hostility at her inattentive parents and her rage at her husband's lack of success by dominating his life with her complaints of pain. Since this was an unconscious process, the multiple surgical-medical procedures and brief organic psychotherapy was of little help. In essence, her husband and the medical community were slaves to her continued medical treatments and complaints.
Studying the interpersonal aspects of the meaning of her complaints are more helpful than denoting secondary gain phenomena in understanding such an individual. The concept of secondary gains can be pejorative and confuse the management of such an individual. In the case described, the necessary approach is to decrease the patient's pain medication and try to induce her into psychotherapy. This can be done by agreeing with her that pain is a real phenomena and an accurate perception but that her continued medical treatments will not totally cure her complaints. Only by accepting her complaints as real, but approaching her as an adult, is there any hope for relief of such problems. The other approach would be to focus on her rehabilitation directly, not the underlying emotional causes. Homogeneous pain units at the Johns Hopkins Hospital and the University of Seattle provide these treatment approaches. 7 Other interpersonal aspects besides that of pain and punishment can be present. Engel has noted that, as in the above case, pain is involved in early human relationships. From infancy onward, the reduction of pain
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and the attention received when an individual is sick can be a pleasurable experience, such as the concern that the mother gives a crying infant. Pain also is involved with aggression and power in that the bully, by the threat or actual infliction of pain upon others, can achieve dominance. Pain and sexuality also can become interwoven. The painful aspect of sexual functioning is dominant over erotic drives in sadomasochistic perversions. Thus, pain can be very important in the interpersonal milieu from birth. Whenever the physician confronts an individual with pain, he becomes one part of the interpersonal communication of the meaning of this symptom. It is important to note that pain develops in certain periods and settings. Engel goes on to explain that pain occurs when external circumstances fail to satisfy the unconscious needs to suffer. Pain can occur when a real or fantasized loss occurs. This is symbolically noted in the idea of a "heartache" but can occur when individuals experience family losses or anniversaries of deaths or separations. Finally, pain can occur in the presence of intense, aggressive, or forbidden sexual feelings which are unconscious and become translated into a pain-prone situation. Only when the physician takes a full history in an open-ended manner will he often perceive the specific social or personal nuances which occur in the setting of the specific complaint. 6 The specific meaning of a painful stimuli is also a very important variable which will determine how the individual will react to this noxious stimuli. Beecher's work on soldiers severely wounded in battle demonstrates this principle. He discovered that wounded infantry men brought into combat hospitals did not complain of pain severe enough to require the administration of narcotics that patients normally would need in a postoperative civilian setting. When interviewed, the wounded soliders denied having pain from their extensive wounds or ignored the uncomfortable sensation that they perceived. 1 Beecher noted that the soliders openly declined analgesics, whereas many civilians would plead for injections of morphine. He concluded that the wounded soliders were thankful to have escaped alive from the battlefield and that the injury meant a ticket home. This was in contradistinction to the surgical patient for whom an operation is a depressing, frightful event. Individuals, however, who receive instructions in what to expect postoperatively will require less narcotics than those uninformed. 3 The middle-aged man who has chest pain from a muscle strain but whose best friend has just had a myocardial infarction will immediately focus on that meaning of the pain because of his recent concerns about his own health. One commonly sees an athlete play an entire sports event with a sprained ankle or a fractured limb, noticing only after the end of the contest that he has severe pain. The ability to focus on a task is an important modifier of the perception of pain. Attention can greatly alter one's response to noxious stimuli. The common phenomenon of hypnosis is essentially focalized attention. When hypnotized, individuals can often tolerate severe pain. Children engaged in the production of fantasies such as describing an imaginary cartoon on a wall can tolerate painful suturing procedures. Painful emotions such as anxiety or depres-
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sion, in contradistinction to focal attention, can exacerbate pain. To subdue anxiety by tranquilization or suggestion can allow an individual to tolerate increasing amounts of pain. 2 Thus, the phenomenon of pain is the resultant of many variables which coalesce to create the chief complaint. The impersonal factor, the actual organic nature of the pain, such as metastatic bone pain or the pain of gall bladder disease, will clearly play a major role in the pain complaint. Other levels are also important such as the cultural background of an individual, the interpersonal aspects of the complaint, as well as the personal idiosyncratic meaning of the pain itself. The physician who assesses any complaint of pain must always keep in mind each level, the biologic, organic aspects and the modifying aspects of an individual's cultural, social, and intrapsychic meanings.
SPECIFIC DISEASE ENTITIES There are psychiatric disorders which are commonly found in individuals whose persistent complaints of pain lead to no clear organic etiology. These psychiatric difficulties can prevent an individual with a genuine organic problem from maximum rehabilitation or can be the genesis of the further somatic concern. The specific psychological difficulties most often seen in pain patients are those of the conversion reaction, depression, adolescent adjustment reactions, and schizophrenia. Conversion Reaction Conversion in itself implies a mental mechanism whereby an emotional complaint is converted or transformed into a somatic symptom. This refers to an emotional defense mechanism and not a specific disease. Those individuals who have a hysterical neurosis have conversion phenomena which constitute the main symptom of the psychological difficulty. Pain is the most commonly utilized conversion phenomenon seen presently.13 The use of pain as a conversion symptom is different than the more dramatic voluntary muscular symptoms seen in the past. The patient with the pain complaint is more acutely distressed and will often seek medical aid for the problem. As noted, the use of conversion symptoms covers many psychiatric entities. The psychiatric diagnosis of hysterical neurosis refers to that condition wherein the primary symptom is a symbolic transformation of an emotional difficulty. The primary gain, the avoidance of emotional pain, is implicitly utilized to avoid the dysphoric affects of an unconscious conflict. Other symptoms often seen in hysteria are the presence of an hysterical character style, a marked "la belle indifference" in relating to painful complaint and a past history of conversion reactions. Individuals who utilize conversion mechanisms do not always have hysterical character types. CASE 2. A forty-seven year old man was seen because of persistent back pain. The patient noted that he had incurred a work-related injury 4 years prior to his evaluation and since that time had been unable to work. There was no evidence of
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any organic difficulties despite his protracted complaints of pain. He lived and led a quiet life, pursuing his hobby of gardening. This patient gave no evidence of malingering or consciously avoiding work. What was clear was that he was a very dependent individual whose work accident provided the unconscious opportunity to avoid a job which he found boring. He thus converted his wishes not to work into a persistent somatic complaint.
Depression Pain is often a major complaint of individuals who are depressed. Depression is the most common psychological condition found in the individual with a pain complaint. Depression can exacerbate whatever uncomfortable sensations are present or can be a primary condition wherein somatic complaints are a manifestation of the depressive syndrome itself. Depression is a psychological syndrome which is found on a continuum from minor feelings of sadness to severe symptoms of despair, hopelessness, and anxiety with major psychomotor retardation. Up to 20 per cent of individuals on a medical unit will have a depressive syndrome equivalent to those found in psychiatric settings. 9 The physician should be aware of symptoms of guilt, crying, loneliness, and anorexia which are characteristic of depressed medical patients. Also, the presence of recent real or symbolic loss often coexists in this syndrome with depression. Vegetative signs such as insomnia and diminished libido are seen as well. The physician should be aware that individuals from a lower socioeconomic class will often have somatic symptoms as the primary mode of expressing their mood.
Adjustment Reaction of Adolescence Adolescent adjustment reactions provide a setting in which complaints of pain occur. Adolescent difficulties are often based on the shifts from childhood to adult status. The adolescent will frequently have problems in coping with dependency needs and emerging sexuality. He will have associated difficulties in school or peer group problems in addition to persistent somatic complaints. CASE 3. A 16 year old girl had persistent abdominal complaints and nausea which were not explained by full organic evaluations and were not responsive to ongoing brief support and minor tranquilization. The patient was a very intelligent but controlled young woman who felt that no one really understood her or would listen to her. A product of a large family, the patient was unable to deal with the persistent anger which she had felt in trying to become her own person. Formal psychotherapy was directed toward evaluating and investigating her feelings of inadequacy and insecurity with her peers and her family. Her somatic symptoms disappeared when her emotional difficulties became more evident. The physician needs to understand and investigate the personal and family stresses that the adolescent is undergoing. He should be direct, tolerate his patient's distress, but communicate that he is aware that there are emotional factors in the patient's somatic complaints. The adolescent with pain complaints must be supported; invalidism needs to be prevented. The adolescent should have some face-saving opportunities and not be directly confronted with "it's all in your head." It is for this reason that psychotherapy concurrent with conservative medical management is often the best approach.
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Schizophrenia Finally, there are a small percentage of individuals with schizophrenia who present with complaints of pain. Schizophrenia is a major psychosis, the major symptoms of which are illogical thought processes and disorganized, bizarre behavior. Associated phenomena include personalized bizarre thinking, delusions, and paranoid hallucinations. The major task in treating an individual with schizophrenia is to utilize appropriate psychiatric treatment plus major tranquilizers such as phenothiazines. Psychological testing can be used as an aid in the diagnosing of such cases by revealing the psychotic thought disorder. Since schizophrenia is a chronic illness with major debilitation, a specialist in psychiatry should always be utilized in helping manage such an individual.
APPROACH TO TREATMENT The treamtent of the patient with a pain syndrome and a predominantly psychiatric disorder is obviously directed toward the underlying entity (Table 1). Most pain patients, however, have mixed pictures of organic as well as emotional factors. The essential clinical difficulty in treating these patients is that the problems are often chronic, psychosocial ones with coexistent organic factors. Patients, however, focus on acute and immediate cures. Individuals with pain syndromes can be placed at two ends of a continuum. First, there are those individuals with real, very painful conditions whose personality predisposes them to drug abuse or litigious behavior. In these cases there is a very clear cut and real organic etiology to their pain and discomfort. CASE 4. A 21 year old man, a former heroin addict, was in a full body cast and Stryker frame for a fractured vertebrae incurred during a work-related accident. The patient was initially in much pain but persisted in utilizing high doses of narcotic medication. He continued to complain that the nurses were not giving
Table 1. Areas of Interest in the History of Patients with Pain Syndromes Drug abuse Litigation, work compensation Symptoms of depression Vegetative signs-poor sleep, decreased libido, anorexia Lethargy Sad mood, crying spells Recent losses Manner and content of present illness Absence of concerned affect (la belle indifference) Disability greater than injury Meaning of complaint To patient To significant others
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him his medicines on time or that they were giving him less than he deserved. His past history was significant in that he was a former heroin abuser. The patient had aroused much anger in the treating staff and on one occasion threatened to harm a nurse. Here the basic management entailed a clear recognition on the part of the physicians that the patient did indeed experience pain. He also had to be clearly informed that he would receive a certain amount of medication which would help him tolerate his discomfort but that there would be a limit to this medication. This operationally meant that there would be no "p.r.n." medications and that he would receive regularly divided doses of a narcotic analgesic. The patient was also clearly informed that this medicine would be given in a divided schedule at a certain time period but that because of the nurses' schedule there might be 10 to 20 minutes overlap from the exact time that he would receive his shots. The nursing staff had to be included in this negotiation. A written contract was then drawn up where the patient clearly saw, in writing, the amount of medicine he was to receive and specifically the times when he would receive such drugs. A chart was kept next to his bed where both he and the nurse could sign when the medicines were given; thus, direct negotiations were set up whereby the patient was given a strict format for his medicines. He was able to tolerate this regimen because in fact the treating staff had fallen into his angry and childish behavior and had begun withholding medicines from him at times. The lack ofp.r.n. medication provided an opportunity for the patient to continue to complain and crave more medicines.
The other type of individual is that whose pain complaint is primarily without an organic basis and whose psychological difficulties foster drug abuse, needless medical procedures and multiple hospitalizations. CASE 5. A 25 year old divorced woman was hospitalized for persistent left lower quadrant pain of 8 months' duration. Despite her negative medical evaluation, the patient persisted in requesting an operation, as she noted "I want surgery to put my mind at ease." She believed that she had an ovarian cyst. Her past history revealed that she had had similar pain on her right side 4 years prior to her present admission which was treated with a laparotomy. The patient believed that she had had an ovarian cyst removed by misinterpreting the doctor's explanation of her prior surgery. Review of her past surgical procedure revealed that no pathology was found for the pain. Despite this fact, the patient had been relatively free of symptoms during the past 4 years. The patient's social history was important in that her present complaint developed around the time her second child was born. The first episode of pain occurred right after her first child was legally taken from her because of her inability to care for him. When seen the patient appeared to be in no acute distress but was quite hostile and angry. She adamantly refused to accept that her complaint of pain was related to psychiatric problems. Accordingly, she would not agree to follow-up psychiatric care. The patient was managed by a conservative medical approach with clear direction to her that the physicians could in no way do unnecessary surgery because it might harm her. The rule of "primum non nocere" was the psychiatric consultant's main message. The patient was also begun on a combination of Prolixin and Elavil and a gradual reduction of narcotic medication was instituted while she was in the hospital. * The patient was told that she would have to tolerate her pain. During the ensuing days the patient became quite angry over this approach but finally accepted follow-up by visiting the outpatient clinic. C~eful follow-up was done in the gynecology clinic and management was directed tdward alleviating of her discomfort and increasing her functioning. When her social difficulties became increasingly difficult, her admission of depression became clearer and she finally accepted outpatient psychiatric treatment. *Empirical evidence suggests this combination can modify the pain response. The exact mechanism is not known.
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Table 2. Treatment of Patients with Pain Syndromes 1. Listen to full history of pain complaint 2. Agree that the pain is real and distressing 3. Directly commiserate with patient that harmful or unjustified procedures cannot be done 4. Direct therapy toward less addictive medicine and increased functioning No p.r.n. medications Combined amitriptyline-fiufenazine medication Increase activity in graded manner Frequent outpatient follow-up visits
The underlying principles of managing these individuals includes the recognition by the staff that the physician need not be defensive when confronted by the request for a surgical procedure (Table 2). He must always be willing to remind the patient that he cannot justify a possibly dangerous procedure without any specific indication. By doing this he begins to ally himself with the healthy part of the patient. Furthermore, he clearly commiserates that the patient is uncomfortable and that his pain is subjectively real. He can then go on to urge the patient to tolerate some of the discomfort. By ongoing collaboration, the pain will at least be borne and the patient's functioning increased. This must be put in a positive manner, noting that the patient will increase his activities gradually and nothing can be done to hurt the patient. Also, direct confrontation about possible drug abuse can be utilized in this manner by stating that the medication that the patient is taking is clearly hazardous to his functioning. Furthermore, the physician should studiously avoid the use ofp.r.n. medication in these individuals and never utilize placebo or saline injections which are punitive and only temporary solutions.
SUMMARY The individual who complains of pain often has a combined emotional and organic experience. Pain is the resultant symptom of organic factors, personal and developmental phenomena, as well as social and cultural characteristics of the individual. The individuals who complain of pain often have chronic histories of difficulty and disability thus creating a difficult treatment problem. The physician who faces such individuals must attend the psychological, social, and organic entities in order to adequately manage and help rehabilitate these distressed individuals.
REFERENCES 1. Beecher, H. K.: Measurement of Subjective Responses. New York, Oxford University Press, 1959. 2. Chapman, C. R., and Feather, B. W.: Effects of diazepam on human pain tolerance and pain sensitivity. Psychosom. Med., 4 :330-340, 1973. 3. Egbert, L. D., Battit, G. E., Welch, C. E., et al.: Reduction of postoperative pain by encouragement and instruction of patients. New Eng. J. Med., 270:825--826, 1964.
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4. Engel, G. L.: Psychogenic pain and the pain-prone patient. Amer. J. Med., 26:899-917, 1959. 5. Fordyce, W. E.: Behavioral Methods for Chronic Pain and Illness. St. Louis, C. V. Mosby Co., 1976. 6. Kimball, C. P.: Techniques of interviewing. Ann. Intern. Med., 71 :147-153,1969. 7. Melzack, R., and Scott, T. H.: The effects of early experience on the response to pain. J. Comp. Physio!. Psycho!., 50:155-158, 1957. 8. Merskey, H., and Spear, F. G.: Pain: Psychological and Psychiatric Aspects. London, Bailliere, 1967. 9. Schwab, J. J., Bislow, M., Bron, J. M., et al.: Diagnosing depression in medical inpatients. Ann. Intern. Med., 67:695-707, 1967. 10. Sternbach, R. A., and Tursky, B.: Ethnic differences among housewives in psychophysical and skin potential responses to electric shock. Psychophysiology, 1 :241-246, 1965. 11. Szasz, T. S.: Pain and Pleasure. New York, Basic Books, 1957, pp. 86-87. 12. Trethowan, W. H., and Conlon, M. F.: The couvade syndrome. Brit. J. Psychiat., 57:111-115, 1965. 13. Zeigler, F., Imboden, J. B., and Meyer, E.: Contemporary conversion reactions. A clinical study. Amer. J. Psychiat., 116:901-909, 1960. Department of Psychiatry The Fairfax Hospital 3300 Gallows Road Fairfax, Virginia 22046
Pain The Most Common Psychosomatic Problem
Thomas N. Wise, M.D. *
The symptom of pain is one of the most common complaints that the practicing physician encounters. Of 550 consecutive admissions to the general medical clinic at the Johns Hopkins Hospital, 40 per cent of the chief complaints involved the specific complaint of pain. Pain, no matter how vague, is often "the ticket of admission" to a physician's office. This discomfort can indicate an impending rupture of an appendix, the onset of an acute myocardial infarction, the imminence of giving birth, or a serious psychologic disorder. Unfortunately, pain is not an objective physiologic sign such as a pulse rate, respiratory rhythm, or focal neurologic defect with gross pathologic changes. Pain can be defined as "an unpleasant experience which we primarily associate with tissue damage or describe in terms of tissue damage."8 Yet, it is always a subjective symptom whether it is caused by an observable fractured limb or a hallucinatory delusion. This complaint cannot be directly observed, but only inferred from the patient's self report. Although an individual's relative response can be measured by giving equally noxious stimuli to different individuals, pain is expressed by the patient's self report or observed reaction indicating "something hurts." The "either/or" dichotomy of psychogenic versus real organic pain merely confuses the issues and concepts of pain perception and treatment. One cannot always separate the mind from the body. Psychogenic pain often has organic concomitants. Similarly, organic pain is never without an emotional reaction. The individual with a compound fractured femur is clearly anxious and fearful, both concurrent psychological symptoms. The very language of pain exemplifies this interface. Just as "pain in the neck" underscores the interpersonal aspects of a relationship, so do the frequently used idioms "heartache," "hurt lover," or "this pain is going to drive me crazy" demonstrate that pain is a combination of psychological and interpersonal phenomena. "Chairman, Department of Psychiatry, The Fairfax Hospital, Falls Church, Virginia; Assistant Professor of Psychiatry and Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland; Associate Professor of Psychiatry, Georgetown University
Medical Clinics of North America-Vol. 61, No. 4, July 1977
771
772
THOMAS
N.
WISE
V ARIABLES MODIFYING THE RESPONSE OF PAIN The basic biologic utility of pain allows organisms to perceive danger within their environment. As primitive organisms recoil from noxious stimuli in a basic stimulus-response pattern, so do more complicated species. As one progresses along the phylogenetic scale, many intervening factors arise which modify and attenuate this basic action-reaction system. An individual's cultural background, the society in which he resides, the interpersonal relationships he possesses, the interpsychic meaning of a pain stimulus and the real impersonal organic problems, all color one's response to pain. Cultural Factors Cultural aspects can complicate an individual's reaction to a painful stimulus. The couvade syndrome is the phenomena in which expectant fathers complain of nausea and abdominal pain. This can occur in increasing intensity when the woman begins labor. "Couvade," French for brood or hatch, is seen most clearly in those cultures in which women show minimal distress during pregnancy and often will continue with strenuous physical activity even during early labor. In these instances, their mates will take to bed and groan as though in great pain. It must be emphasized that the expectant father does not consciously imitate his wife's pregnancy but unconsciously reacts to the pregnancy by psychological acquisition of abdominal pain as if he were experiencing the pain of labor himself. Although clearly described in primitive settings, at least 11 per cent of expectant fathers in industrial societies experience abdominal pain without demonstrable organic factors. 12 Social Factors Specific ethnic groups react differently to uniform noxious stimuli. Sternbach has studied four specific groups: the Italian, Jewish, Irish, and Old American ethnic entities. Although the minimal amount of pain which an individual is able to perceive appears to be the same among the various groups, their tolerance to increasing levels of pain varies. The Italian and Jewish subgroups were not able to tolerate the levels of electric shock that their Irish and Old American counterparts were able to sustain. When the Jewish and Italian members of the investigation were told of this, the differential finding to pain vanished on repeat testing. 10 It appears that the specific cultural or ethnic milieu creates expectations which the individual uses as a role model and thus reacts as expected. Specifically, certain individuals will immediately seek medical care if they feel discomfort while others will complain but do nothing. Still others will stoically tolerate substantial discomfort. Interpersonal Factors In addition to cultural or social factors, the interpersonal situation of an individual greatly modifies his response to pain. This can be shown experimentally in animals. Certain species of dogs have been raised in isolation so that they are deprived of their normal environmental stimuli
PAIN
773
of bodily knocks and scrapes that they would experience from their litter mates. When mature, these animals were unable to react normally to a variety of painful challenges. 7 In human beings, the interpersonal communicative aspects of pain are very important. Thomas Szasz has noted that the meaning of pain depends on its symbolic equivalent especially as a nonverbal message to important individuals around the patient. 11 The concept of secondary gain is viewed by Szasz as a communication for help which utilizes a primary somatic complaint in the case of pain. This begins at infancy when an infant's cry for help leads to a mother's attention. Engel has further elaborated the interpersonal meanings of pain by explaining the association of pain and punishment in early developmental periods to emphasize the interpersonal importance ofpain.4 CASE 1. A 41 year old woman was admitted for persistent abdominal pain. Past history revealed multiple surgical procedures as well as psychiatric hospitalizations for abdominal pain. Multiple medical therapies as well as various somatic psychiatric therapies were tried but the patient's complaints persisted. The present physical examination revealed no overt reason for her complaints. The patient's past history is significant in that she was from an affluent family. Her father was a very dynamic, often absent business man. Her alcoholic mother gave her little attention except when the patient was ill. The patient married at an early age in an apparent attempt to achieve independence. Her married life was beset by longstanding financial problems because of her husband's unsuccessful business career. On evaluation, the patient persistently focused on her abdominal pains and demanded relief. She then proceeded to elaborate upon various other painful conditions such as cramping in her legs and persistent headaches. The patient had a conspicuous absence of any feelings, either positive or negative, toward her husband, except that she was very aware of the longstanding hardships her multiple illnesses had been to him. In formulating an explanation for this patients' complaint, it became apparent that she expressed her hostility at her inattentive parents and her rage at her husband's lack of success by dominating his life with her complaints of pain. Since this was an unconscious process, the multiple surgical-medical procedures and brief organic psychotherapy was of little help. In essence, her husband and the medical community were slaves to her continued medical treatments and complaints.
Studying the interpersonal aspects of the meaning of her complaints are more helpful than denoting secondary gain phenomena in understanding such an individual. The concept of secondary gains can be pejorative and confuse the management of such an individual. In the case described, the necessary approach is to decrease the patient's pain medication and try to induce her into psychotherapy. This can be done by agreeing with her that pain is a real phenomena and an accurate perception but that her continued medical treatments will not totally cure her complaints. Only by accepting her complaints as real, but approaching her as an adult, is there any hope for relief of such problems. The other approach would be to focus on her rehabilitation directly, not the underlying emotional causes. Homogeneous pain units at the Johns Hopkins Hospital and the University of Seattle provide these treatment approaches. 7 Other interpersonal aspects besides that of pain and punishment can be present. Engel has noted that, as in the above case, pain is involved in early human relationships. From infancy onward, the reduction of pain
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and the attention received when an individual is sick can be a pleasurable experience, such as the concern that the mother gives a crying infant. Pain also is involved with aggression and power in that the bully, by the threat or actual infliction of pain upon others, can achieve dominance. Pain and sexuality also can become interwoven. The painful aspect of sexual functioning is dominant over erotic drives in sadomasochistic perversions. Thus, pain can be very important in the interpersonal milieu from birth. Whenever the physician confronts an individual with pain, he becomes one part of the interpersonal communication of the meaning of this symptom. It is important to note that pain develops in certain periods and settings. Engel goes on to explain that pain occurs when external circumstances fail to satisfy the unconscious needs to suffer. Pain can occur when a real or fantasized loss occurs. This is symbolically noted in the idea of a "heartache" but can occur when individuals experience family losses or anniversaries of deaths or separations. Finally, pain can occur in the presence of intense, aggressive, or forbidden sexual feelings which are unconscious and become translated into a pain-prone situation. Only when the physician takes a full history in an open-ended manner will he often perceive the specific social or personal nuances which occur in the setting of the specific complaint. 6 The specific meaning of a painful stimuli is also a very important variable which will determine how the individual will react to this noxious stimuli. Beecher's work on soldiers severely wounded in battle demonstrates this principle. He discovered that wounded infantry men brought into combat hospitals did not complain of pain severe enough to require the administration of narcotics that patients normally would need in a postoperative civilian setting. When interviewed, the wounded soliders denied having pain from their extensive wounds or ignored the uncomfortable sensation that they perceived. 1 Beecher noted that the soliders openly declined analgesics, whereas many civilians would plead for injections of morphine. He concluded that the wounded soliders were thankful to have escaped alive from the battlefield and that the injury meant a ticket home. This was in contradistinction to the surgical patient for whom an operation is a depressing, frightful event. Individuals, however, who receive instructions in what to expect postoperatively will require less narcotics than those uninformed. 3 The middle-aged man who has chest pain from a muscle strain but whose best friend has just had a myocardial infarction will immediately focus on that meaning of the pain because of his recent concerns about his own health. One commonly sees an athlete play an entire sports event with a sprained ankle or a fractured limb, noticing only after the end of the contest that he has severe pain. The ability to focus on a task is an important modifier of the perception of pain. Attention can greatly alter one's response to noxious stimuli. The common phenomenon of hypnosis is essentially focalized attention. When hypnotized, individuals can often tolerate severe pain. Children engaged in the production of fantasies such as describing an imaginary cartoon on a wall can tolerate painful suturing procedures. Painful emotions such as anxiety or depres-
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sion, in contradistinction to focal attention, can exacerbate pain. To subdue anxiety by tranquilization or suggestion can allow an individual to tolerate increasing amounts of pain. 2 Thus, the phenomenon of pain is the resultant of many variables which coalesce to create the chief complaint. The impersonal factor, the actual organic nature of the pain, such as metastatic bone pain or the pain of gall bladder disease, will clearly play a major role in the pain complaint. Other levels are also important such as the cultural background of an individual, the interpersonal aspects of the complaint, as well as the personal idiosyncratic meaning of the pain itself. The physician who assesses any complaint of pain must always keep in mind each level, the biologic, organic aspects and the modifying aspects of an individual's cultural, social, and intrapsychic meanings.
SPECIFIC DISEASE ENTITIES There are psychiatric disorders which are commonly found in individuals whose persistent complaints of pain lead to no clear organic etiology. These psychiatric difficulties can prevent an individual with a genuine organic problem from maximum rehabilitation or can be the genesis of the further somatic concern. The specific psychological difficulties most often seen in pain patients are those of the conversion reaction, depression, adolescent adjustment reactions, and schizophrenia. Conversion Reaction Conversion in itself implies a mental mechanism whereby an emotional complaint is converted or transformed into a somatic symptom. This refers to an emotional defense mechanism and not a specific disease. Those individuals who have a hysterical neurosis have conversion phenomena which constitute the main symptom of the psychological difficulty. Pain is the most commonly utilized conversion phenomenon seen presently.13 The use of pain as a conversion symptom is different than the more dramatic voluntary muscular symptoms seen in the past. The patient with the pain complaint is more acutely distressed and will often seek medical aid for the problem. As noted, the use of conversion symptoms covers many psychiatric entities. The psychiatric diagnosis of hysterical neurosis refers to that condition wherein the primary symptom is a symbolic transformation of an emotional difficulty. The primary gain, the avoidance of emotional pain, is implicitly utilized to avoid the dysphoric affects of an unconscious conflict. Other symptoms often seen in hysteria are the presence of an hysterical character style, a marked "la belle indifference" in relating to painful complaint and a past history of conversion reactions. Individuals who utilize conversion mechanisms do not always have hysterical character types. CASE 2. A forty-seven year old man was seen because of persistent back pain. The patient noted that he had incurred a work-related injury 4 years prior to his evaluation and since that time had been unable to work. There was no evidence of
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any organic difficulties despite his protracted complaints of pain. He lived and led a quiet life, pursuing his hobby of gardening. This patient gave no evidence of malingering or consciously avoiding work. What was clear was that he was a very dependent individual whose work accident provided the unconscious opportunity to avoid a job which he found boring. He thus converted his wishes not to work into a persistent somatic complaint.
Depression Pain is often a major complaint of individuals who are depressed. Depression is the most common psychological condition found in the individual with a pain complaint. Depression can exacerbate whatever uncomfortable sensations are present or can be a primary condition wherein somatic complaints are a manifestation of the depressive syndrome itself. Depression is a psychological syndrome which is found on a continuum from minor feelings of sadness to severe symptoms of despair, hopelessness, and anxiety with major psychomotor retardation. Up to 20 per cent of individuals on a medical unit will have a depressive syndrome equivalent to those found in psychiatric settings. 9 The physician should be aware of symptoms of guilt, crying, loneliness, and anorexia which are characteristic of depressed medical patients. Also, the presence of recent real or symbolic loss often coexists in this syndrome with depression. Vegetative signs such as insomnia and diminished libido are seen as well. The physician should be aware that individuals from a lower socioeconomic class will often have somatic symptoms as the primary mode of expressing their mood.
Adjustment Reaction of Adolescence Adolescent adjustment reactions provide a setting in which complaints of pain occur. Adolescent difficulties are often based on the shifts from childhood to adult status. The adolescent will frequently have problems in coping with dependency needs and emerging sexuality. He will have associated difficulties in school or peer group problems in addition to persistent somatic complaints. CASE 3. A 16 year old girl had persistent abdominal complaints and nausea which were not explained by full organic evaluations and were not responsive to ongoing brief support and minor tranquilization. The patient was a very intelligent but controlled young woman who felt that no one really understood her or would listen to her. A product of a large family, the patient was unable to deal with the persistent anger which she had felt in trying to become her own person. Formal psychotherapy was directed toward evaluating and investigating her feelings of inadequacy and insecurity with her peers and her family. Her somatic symptoms disappeared when her emotional difficulties became more evident. The physician needs to understand and investigate the personal and family stresses that the adolescent is undergoing. He should be direct, tolerate his patient's distress, but communicate that he is aware that there are emotional factors in the patient's somatic complaints. The adolescent with pain complaints must be supported; invalidism needs to be prevented. The adolescent should have some face-saving opportunities and not be directly confronted with "it's all in your head." It is for this reason that psychotherapy concurrent with conservative medical management is often the best approach.
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Schizophrenia Finally, there are a small percentage of individuals with schizophrenia who present with complaints of pain. Schizophrenia is a major psychosis, the major symptoms of which are illogical thought processes and disorganized, bizarre behavior. Associated phenomena include personalized bizarre thinking, delusions, and paranoid hallucinations. The major task in treating an individual with schizophrenia is to utilize appropriate psychiatric treatment plus major tranquilizers such as phenothiazines. Psychological testing can be used as an aid in the diagnosing of such cases by revealing the psychotic thought disorder. Since schizophrenia is a chronic illness with major debilitation, a specialist in psychiatry should always be utilized in helping manage such an individual.
APPROACH TO TREATMENT The treamtent of the patient with a pain syndrome and a predominantly psychiatric disorder is obviously directed toward the underlying entity (Table 1). Most pain patients, however, have mixed pictures of organic as well as emotional factors. The essential clinical difficulty in treating these patients is that the problems are often chronic, psychosocial ones with coexistent organic factors. Patients, however, focus on acute and immediate cures. Individuals with pain syndromes can be placed at two ends of a continuum. First, there are those individuals with real, very painful conditions whose personality predisposes them to drug abuse or litigious behavior. In these cases there is a very clear cut and real organic etiology to their pain and discomfort. CASE 4. A 21 year old man, a former heroin addict, was in a full body cast and Stryker frame for a fractured vertebrae incurred during a work-related accident. The patient was initially in much pain but persisted in utilizing high doses of narcotic medication. He continued to complain that the nurses were not giving
Table 1. Areas of Interest in the History of Patients with Pain Syndromes Drug abuse Litigation, work compensation Symptoms of depression Vegetative signs-poor sleep, decreased libido, anorexia Lethargy Sad mood, crying spells Recent losses Manner and content of present illness Absence of concerned affect (la belle indifference) Disability greater than injury Meaning of complaint To patient To significant others
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him his medicines on time or that they were giving him less than he deserved. His past history was significant in that he was a former heroin abuser. The patient had aroused much anger in the treating staff and on one occasion threatened to harm a nurse. Here the basic management entailed a clear recognition on the part of the physicians that the patient did indeed experience pain. He also had to be clearly informed that he would receive a certain amount of medication which would help him tolerate his discomfort but that there would be a limit to this medication. This operationally meant that there would be no "p.r.n." medications and that he would receive regularly divided doses of a narcotic analgesic. The patient was also clearly informed that this medicine would be given in a divided schedule at a certain time period but that because of the nurses' schedule there might be 10 to 20 minutes overlap from the exact time that he would receive his shots. The nursing staff had to be included in this negotiation. A written contract was then drawn up where the patient clearly saw, in writing, the amount of medicine he was to receive and specifically the times when he would receive such drugs. A chart was kept next to his bed where both he and the nurse could sign when the medicines were given; thus, direct negotiations were set up whereby the patient was given a strict format for his medicines. He was able to tolerate this regimen because in fact the treating staff had fallen into his angry and childish behavior and had begun withholding medicines from him at times. The lack ofp.r.n. medication provided an opportunity for the patient to continue to complain and crave more medicines.
The other type of individual is that whose pain complaint is primarily without an organic basis and whose psychological difficulties foster drug abuse, needless medical procedures and multiple hospitalizations. CASE 5. A 25 year old divorced woman was hospitalized for persistent left lower quadrant pain of 8 months' duration. Despite her negative medical evaluation, the patient persisted in requesting an operation, as she noted "I want surgery to put my mind at ease." She believed that she had an ovarian cyst. Her past history revealed that she had had similar pain on her right side 4 years prior to her present admission which was treated with a laparotomy. The patient believed that she had had an ovarian cyst removed by misinterpreting the doctor's explanation of her prior surgery. Review of her past surgical procedure revealed that no pathology was found for the pain. Despite this fact, the patient had been relatively free of symptoms during the past 4 years. The patient's social history was important in that her present complaint developed around the time her second child was born. The first episode of pain occurred right after her first child was legally taken from her because of her inability to care for him. When seen the patient appeared to be in no acute distress but was quite hostile and angry. She adamantly refused to accept that her complaint of pain was related to psychiatric problems. Accordingly, she would not agree to follow-up psychiatric care. The patient was managed by a conservative medical approach with clear direction to her that the physicians could in no way do unnecessary surgery because it might harm her. The rule of "primum non nocere" was the psychiatric consultant's main message. The patient was also begun on a combination of Prolixin and Elavil and a gradual reduction of narcotic medication was instituted while she was in the hospital. * The patient was told that she would have to tolerate her pain. During the ensuing days the patient became quite angry over this approach but finally accepted follow-up by visiting the outpatient clinic. C~eful follow-up was done in the gynecology clinic and management was directed tdward alleviating of her discomfort and increasing her functioning. When her social difficulties became increasingly difficult, her admission of depression became clearer and she finally accepted outpatient psychiatric treatment. *Empirical evidence suggests this combination can modify the pain response. The exact mechanism is not known.
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Table 2. Treatment of Patients with Pain Syndromes 1. Listen to full history of pain complaint 2. Agree that the pain is real and distressing 3. Directly commiserate with patient that harmful or unjustified procedures cannot be done 4. Direct therapy toward less addictive medicine and increased functioning No p.r.n. medications Combined amitriptyline-fiufenazine medication Increase activity in graded manner Frequent outpatient follow-up visits
The underlying principles of managing these individuals includes the recognition by the staff that the physician need not be defensive when confronted by the request for a surgical procedure (Table 2). He must always be willing to remind the patient that he cannot justify a possibly dangerous procedure without any specific indication. By doing this he begins to ally himself with the healthy part of the patient. Furthermore, he clearly commiserates that the patient is uncomfortable and that his pain is subjectively real. He can then go on to urge the patient to tolerate some of the discomfort. By ongoing collaboration, the pain will at least be borne and the patient's functioning increased. This must be put in a positive manner, noting that the patient will increase his activities gradually and nothing can be done to hurt the patient. Also, direct confrontation about possible drug abuse can be utilized in this manner by stating that the medication that the patient is taking is clearly hazardous to his functioning. Furthermore, the physician should studiously avoid the use ofp.r.n. medication in these individuals and never utilize placebo or saline injections which are punitive and only temporary solutions.
SUMMARY The individual who complains of pain often has a combined emotional and organic experience. Pain is the resultant symptom of organic factors, personal and developmental phenomena, as well as social and cultural characteristics of the individual. The individuals who complain of pain often have chronic histories of difficulty and disability thus creating a difficult treatment problem. The physician who faces such individuals must attend the psychological, social, and organic entities in order to adequately manage and help rehabilitate these distressed individuals.
REFERENCES 1. Beecher, H. K.: Measurement of Subjective Responses. New York, Oxford University Press, 1959. 2. Chapman, C. R., and Feather, B. W.: Effects of diazepam on human pain tolerance and pain sensitivity. Psychosom. Med., 4 :330-340, 1973. 3. Egbert, L. D., Battit, G. E., Welch, C. E., et al.: Reduction of postoperative pain by encouragement and instruction of patients. New Eng. J. Med., 270:825--826, 1964.
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4. Engel, G. L.: Psychogenic pain and the pain-prone patient. Amer. J. Med., 26:899-917, 1959. 5. Fordyce, W. E.: Behavioral Methods for Chronic Pain and Illness. St. Louis, C. V. Mosby Co., 1976. 6. Kimball, C. P.: Techniques of interviewing. Ann. Intern. Med., 71 :147-153,1969. 7. Melzack, R., and Scott, T. H.: The effects of early experience on the response to pain. J. Comp. Physio!. Psycho!., 50:155-158, 1957. 8. Merskey, H., and Spear, F. G.: Pain: Psychological and Psychiatric Aspects. London, Bailliere, 1967. 9. Schwab, J. J., Bislow, M., Bron, J. M., et al.: Diagnosing depression in medical inpatients. Ann. Intern. Med., 67:695-707, 1967. 10. Sternbach, R. A., and Tursky, B.: Ethnic differences among housewives in psychophysical and skin potential responses to electric shock. Psychophysiology, 1 :241-246, 1965. 11. Szasz, T. S.: Pain and Pleasure. New York, Basic Books, 1957, pp. 86-87. 12. Trethowan, W. H., and Conlon, M. F.: The couvade syndrome. Brit. J. Psychiat., 57:111-115, 1965. 13. Zeigler, F., Imboden, J. B., and Meyer, E.: Contemporary conversion reactions. A clinical study. Amer. J. Psychiat., 116:901-909, 1960. Department of Psychiatry The Fairfax Hospital 3300 Gallows Road Fairfax, Virginia 22046
