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Steven A. King: Chapter 38. Pain Disorders, in Gabbard’s Treatments of Psychiatric Disorders, 4th Edition. Edited by Glen

10. Gabbard. Copyright ©2009 American Psychiatric Publishing, Inc. DOI: 10.1176/appi.books.9781585622986.260284.

Printed 5/10/2009 from www.psychiatryonline.com

Gabbard’s Treatments of Psychiatric Disorders > Part VII. Somatoform and Factitious Disorders >

Chapter 38. Pain Disorders

INTRODUCTION

Pain is one of the most common problems for which patients seek care. As a result of the ubiquity

and potential complexity of pain, a wide range of treatments have been employed with varying

degrees of success. Although pain is still frequently thought of as primarily a physical problem,

there is often no clear correlation between physical pathology and the presence and severity of pain

(Deyo and Weinstein 2001; Jensen et al. 1994).

In DSM-IV and DSM-IV-TR, the primary diagnosis that addresses pain is pain disorder (American

Psychiatric Association 1994, 2000). This diagnostic category is subclassified as pain disorder

associated with psychological factors and pain disorder associated with both psychological factors

and a general medical condition. An additional category—pain disorder associated with a general

medical condition—is included for differential diagnostic purposes but is not considered to be a

mental disorder. The categories are further divided into acute and chronic pain based on the length

of time the pain is present.

Although many of the treatments are the same for both acute and chronic pain, there is a

fundamental difference in the therapeutic goals. In acute pain, the primary goal is to relieve the

pain. In contrast, for chronic pain it is important to address not only the pain but also the patient’s

level of functioning, with the goal of managing the pain and reducing its impact on the patient’s life

rather than curing it.

Unfortunately, there are relatively few studies on the diagnosis of DSM pain disorder and its

treatment. However, because it appears that a significant number of patients have this disorder and

that most have pain disorder associated with both psychological factors and a general medical

condition (Anooshian et al. 1999; King 1995b), it can be extrapolated that therapeutic modalities

that have demonstrated efficacy for pain that would fit this diagnosis are the optimal choices for

management of this disorder.

PSYCHOLOGICALLY BASED MODALITIES

Psychologically based treatment approaches are considered a vital part of both acute and chronic

pain management. A wide variety of psychotherapies have been reported to be beneficial for pain,

including many forms of individual, group, and family therapies. The most commonly used

approaches fall into two major categories: 1) operant conditioning and 2) cognitive-behavioral

therapies (CBTs), including biofeedback, relaxation training, and hypnosis (National Institutes of

Health Technology Assessment Panel 1996).

Operant conditioning is based on the concept that certain operant or learned behaviors develop in

response to environmental cues. Common examples among pain patients include complaints of pain

and reluctance to indulge in certain activities. The anticipated response to pain is often receiving

medication and being excused from work or normal daily tasks. The goal of operant conditioning is

to reinforce the positive or “healthy” behaviors and to diminish the destructive behaviors that

maintain the patient’s pain.

CBT involves identifying and correcting the patient’s distorted attitudes, beliefs, and expectations.

The goal of this CBT is first to make the patient more aware of factors that exacerbate and diminish

the pain and then to help the patient modify behavior accordingly. A variety of therapeutic

modalities, including biofeedback, relaxation therapy, and hypnosis, may be used to achieve this

(Barrows 2002). Hypnosis and relaxation therapy appear to be especially beneficial for thePrint: Chapter 38. Pain Disorders

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management of acute pain.

The application of each of these techniques to the management of pain has been studied to varying

degrees, and controversy still remains concerning which approach is most efficacious. Reviews of

the literature have reported that operant therapy is useful in decreasing patients’ medication use

and increasing their activity levels (Linton 1986; Turner and Chapman 1982a, 1982b; Vlaeyen

2005). In contrast, CBT was observed to be helpful in reducing pain complaints.

PHARMACOLOGICAL MANAGEMENT

The mainstay of the management of both acute and chronic pain is the use of analgesic

medications. Many medications from a wide variety of classes have been utilized as analgesics. The

following discussion focuses on the most commonly used analgesic medications: opioid analgesics,

nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen, antidepressants, and

anticonvulsants.

Opioid Analgesics

Opioid analgesics can provide relief for a wide variety of pain conditions. Although they are well

accepted for the treatment of acute pain, including posttraumatic and postoperative pain and

cancer-related pain, their use in the management of chronic pain remains more controversial

(Acute Pain Management Guideline Panel 1992; American Pain Society 2003; Jacox et al. 1994).

This controversy primarily centers around concerns that extended use may lead to abuse and

psychological dependence or addiction (American Academy of Pain Medicine et al. 2004).

It has been clearly demonstrated that opioids can be safely and effectively used for the

management of chronic pain (Federation of State Medical Boards 1998). However, there appears to

be some degree of risk for patients to abuse and become dependent on them. This is more likely to

occur among patients with a previous history of substance abuse and dependence, but even

patients without such a history can still develop these problems. Although the number of patients

who will have problems remains unclear, two studies indicate that abuse of and dependence on

opioids initially prescribed for pain are not uncommon. In a study of 59 patients with chronic pain

and no detectable history of substance abuse or dependence disorder, Bouckoms et al. (1992)

found that 27% abused these medications and 24% developed addiction. The authors were unable

to identify any predictive factors for those who developed these problems. Hoffman et al. (1995), in

a study of 414 patients with chronic pain, reported that 12.6% had current psychological

dependence on opioid analgesics and 2.9% were in remission for this problem. Patients for whom

opioids are indicated to manage their pain should receive them but should be monitored on an

ongoing basis to determine whether abuse or dependence is occurring.

There are two major classes of opioids currently available: 1) the mu-receptor agonists, which

include morphine, methadone, fentanyl, hydromorphone (Dilaudid), hydrocodone (Vicodin, Lortab,

Norco), and codeine; and 2) the mixed agonists-antagonists, which bind at some mu receptors and

block others and are kappa-receptor agonists (Inturrisi 2002; Stein et al. 2003). Although at one

time it was speculated that medications in the latter class were less likely to be abused, there is

nothing to support this, and overall it appears that the mu-receptor agonists provide better

analgesia. Oxycodone (Percocet, OxyContin) may exert its analgesic effects by binding to both

kappa and mu receptors.

Traditionally, opioid analgesics have been viewed as being on a continuum from mild to strong.

How valid this concept is remains open to question, because several of what are considered

“milder” opioids are metabolized to “stronger” ones. For example, codeine is metabolized to

morphine and hydrocodone to hydromorphone (De Leon et al. 2003; Lotsch et al. 2002; Virani et al.

1997). To some degree, the concepts of milder and stronger are related to the fact that those that

are considered the milder opioids are often prescribed in formulations that also contain nonopioids

such as acetaminophen and aspirin, which have dosage ceilings, unlike the mu-agonist opioids and

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For treatment of acute pain, patients may initially require what are generally considered the

strongest opioids, including morphine and hydromorphone. It is generally recommended that milder

opioids (e.g., oxycodone, hydrocodone, or codeine) be tried first for chronic pain and cancer-related

pain before proceeding to a stronger medication (Jada and Browman 1995). When opioids are used

chronically, a hyperalgesic state in which the pain threshold is lowered may result, and therefore

pain may gradually increase. Increasing the dosage in these situations will worsen rather than

improve the pain (Balantyne and Mao 2003; Moore and Dimsdale 2002). Although opioids are

sedating medications, they can affect sleep architecture and may exacerbate sleep problems

commonly associated with both acute and chronic pain.

For a more detailed discussion of the use of opioid analgesics, see King 2003.

Nonsteroidal Anti-Inflammatory Drugs and Acetaminophen

NSAIDs and acetaminophen are the most widely used analgesic medications. Despite this, the

mechanisms by which they provide pain relief are still unclear. All NSAIDs prevent prostaglandin

synthesis by inhibiting cyclooxygenase (COX), and it appears their anti-inflammatory actions are

related to this. However, acetaminophen does not work through this mechanism, and it is uncertain

whether this mechanism is responsible for the analgesia provided by NSAIDs. These medications

can provide excellent analgesia for a wide variety of pain conditions and appear to be especially

useful for the management of musculoskeletal pain.

There are two major classes of NSAIDs available: the nonselective COX-1 and COX-2 inhibitors,

including ibuprofen and naproxen, and the newer selective COX-2 inhibitors (FitzGerald et al.

2001). Although all NSAIDs are equally analgesic, it is believed that the selective COX-2 inhibitors

may be associated with less gastrointestinal toxicity and do not inhibit platelet functioning to the

same degree as the nonselective NSAIDs (Dalen 2002; Gajraj 2003; Juni et al. 2002). Three

selective COX-2 inhibitors were approved by the U.S. Food and Drug Administration (FDA):

celecoxib (Celebrex), valdecoxib (Bextra), and rofecoxib (Vioxx). However, the latter two

medications were subsequently taken off the market due to concerns about side effects, primarily

an increased risk of myocardial infarctions and strokes, and only celecoxib remains available (Topol

2005). Meloxicam, which is primarily a COX-2 inhibitor, is also still on the market.

Antidepressants

There is an extensive body of research supporting the analgesic properties of antidepressants

(Saarto and Wiffen 2005). Virtually all of the literature indicates that the drugs that inhibit both

serotonin and norepinephrine reuptake (serotonin norepinephrine reuptake inhibitors, or SNRIs)

are markedly better analgesics than antidepressants that have different modes of action, including

the selective serotonin reuptake inhibitors (SSRIs) (Ansari 2000). The increased bioavailability of

serotonin and norepinephrine may result in a descending inhibitory effect on pain transmission both

centrally and peripherally. The SNRIs appear to be efficacious for a wide range of painful

conditions, most notably neuropathic pain, including diabetic neuropathy and postherpetic

neuralgia, osteoarthritis and rheumatoid arthritis, fibromyalgia, migraine headaches, and irritable

bowel syndrome (Clouse 1994; Dworkin et al. 2003; Goldenberg 2004; King 1995a).

Although amitriptyline has traditionally been considered to be most analgesic of the

antidepressants, it appears that all the tricyclic antidepressants (TCAs) are equally analgesic. The

two newest SNRIs, venlafaxine and duloxetine, also appear to provide pain relief equal to that

offered by the TCAs, and in 2004 duloxetine became the first antidepressant approved by the FDA

for the treatment of any pain condition when it was approved for the management of diabetic

peripheral neuropathic pain (Goldstein et al. 2005). Venlafaxine has also been demonstrated to

provide significant relief for this condition and other neuropathic pain (Sindrup et al. 2003). An

obvious advantage of both duloxetine and venlafaxine is that they have much more benign

side-effect profiles than the TCAs and therefore can be prescribed for a wider patient population,

including geriatric patients for whom TCAs are often contraindicated.

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Anticonvulsants have been demonstrated to be effective for the management of neuropathic pain.

Older anticonvulsants, including phenytoin, carbamazepine, and sodium valproate, were reported to

provide analgesia, but their use was limited due to side effects (McQuay et al. 1995; Wiffen et al.

2000). The newer anticonvulsants have been found to provide as much, if not more, analgesia than

the older ones with fewer side effects; in most cases they therefore have replaced them as

analgesics (Backonja 2002; LaRoche and Helmers 2004).

At the current time, four anticonvulsants have been approved by the FDA as analgesics: gabapentin

(Neurontin) for postherpetic neuralgia pain, pregabalin for postherpetic neuralgia pain and diabetic

neuropathic pain, topiramate for prophylactic treatment of migraine headaches, and carbamazepine

for trigeminal neuralgia. The first three are newer-generation anticonvulsants. The use of

carbamazepine for trigeminal neuralgia reflects the fact that, for unknown reasons, it provides

more analgesia for this condition than any other medication (Backjona 2004; Irving 2005).

How the anticonvulsants exert their analgesic effects remains unclear. A primary mechanism

appears to be related to the calcium channel blockade effects of at least some of these medications,

including gabapentin and pregabalin (Frampton and Foster 2005).

Other Analgesic Medications

In addition to the medications discussed earlier, several others have been approved as analgesics

by the FDA. Lidoderm is FDA approved only for the management of postherpetic neuralgia (Barbano

et al. 2004). However, it appears to be beneficial for other pain conditions. Because it is a topical

analgesic, it is only useful for fairly localized pain. It does have a significant advantage in that it is

essentially without side effects and therefore can be used safely in patients whose health problems

may contraindicate the use of systemic analgesics.

Triptan medications, including eletriptan (Relpax), sumatriptan (Imitrex), and zolmitriptan

(Zomig), are useful for the acute treatment of migraine headaches. These drugs are serotonin

agonists. There is limited information comparing one medication in this class with any of the others

with regard to efficacy, so it is therefore best to try one and then change if relief does not occur

(Goadsby et al. 2002; Tepper 2001). Because of their serotonergic actions, there is the possibility

that prescribing one of these medications to a patient taking an SSRI could lead to the development

of serotonin syndrome (Boyer and Shannon 2005). However, the current literature indicates that

this a rare occurrence and that taking an SSRI is not a contraindication to also using a triptan

medication (Nappi et al. 2003). Tepper et al. (2003) studied 240,268 patients who had filled a

prescription for a triptan at least twice in a 6-month period. Although 20% of these patients had

also filled prescriptions for an SSRI, there were no reported cases of serotonin syndrome.

Ziconotide (Prialt) is a newer medication made from a synthetic form of snail venom that appears

to work by blocking calcium channels (Staats et al. 2004). It is FDA approved for chronic intractable

pain but is currently available only for intrathecal administration.

Capsaicin (Zostrix) is a topical pain medication made from chili peppers available in

over-the-counter preparations. It is useful for joint pain and localized musculoskeletal pain.

Multiple mechanisms of action have been proposed to account for its analgesic effects. Originally it

was thought that its analgesia was related to an inhibition of substance P, a neuropeptide involved

in pain transmission. However, more recent research indicates it may block the vanilloid peripheral

pain receptors (Argoff 2003).

Muscle relaxants are often utilized for the management of chronic pain. These include antispasticity

agents such as the benzodiazepines, most notably diazepam, baclofen, cyclobenzaprine, and

tizanidine. Whether these drugs actually relax the muscles and provide analgesia or simply relax

the patient due to their sedating effects remains the subject of controversy (Turturro et al. 2003).

Because cyclobenzaprine is chemically related to the TCAs, which indicates it may have some

analgesic effect, I recommend trying this muscle relaxant first if it is felt that one of these

medications is indicated. Extended use of benzodiazepines can lower pain threshold; therefore,Print: Chapter 38. Pain Disorders

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their use is generally contraindicated for patients with chronic pain (Dellemijn and Fields 1994).

OTHER TREATMENT MODALITIES

Among the other therapies found to be beneficial are various surgical interventions, nerve blocks,

trigger point injections, acupuncture, physical therapy, and transcutaneous electrical nerve

stimulation (TENS). The provision of each of these therapies requires clinicians with specific

training and experience. As with the psychologically based modalities, support in the literature for

the efficacy of each of these therapies is variable. The best recommendation is that in the absence

of a medical emergency, conservative therapies should be tried before more invasive ones such as

nerve blocks and surgery. Therapeutic interventions such as physical therapy, acupuncture, and

TENS carry little risk of side effects or worsening of the patient’s pain (National Institutes of Health

1997; Ottoson and Lundeberg 1988).

As the interest in pain has grown over the last quarter of the twentieth century and the beginning

of the twenty-first, various forms of pain services, clinics, and treatment centers have been

created. These vary from true multidisciplinary establishments to those offering single forms of

treatment provided by one or more clinicians. Unfortunately, the type of therapy provided often is

based less on what the patient needs than on what the clinician offers. Even when a truly

multidisciplinary treatment team is present, the team may fail to recognize the differences between

patients, and the clinicians may attempt a “one size fits all” treatment approach (Turk 1990).

Patients appear to be much better served when a variety of modalities are available.

Because of the importance of improving the functioning of patients with chronic pain, the best

multidisciplinary pain programs offer services that focus on this goal. Central to such programs are

physical therapy, occupational therapy, and behaviorally oriented therapies. Although patients may

prefer programs in which treatment is done on them, lasting improvement appears to depend on

health care professionals teaching patients how to cope with and manage their own pain and on

patients being willing to do this.

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