Chronic pain

Patients suffering from long-term pain are a special problem, especially those with back pain who seem to be on a merry-go-round of failed multiple treatments and complex psychosocial problems. These patients are frequently treated in pain clinics. As family doctors we often observe an apparently normal, pleasant person transformed into a person who seems neurotic, pain-driven and doctor-dependent. The problem is very frustrating to the practitioner, often provoking feelings of suspicion, uncertainty and discomfort.

De Vaul et al. 14 list five subgroups of patients where perplexing pain presents as the major symptom. 3

1. Pain as a symptom of depression

2. Pain as a delusional symptom of psychosis

3. Pain as a conversion symptom of hysterical neurosis

4. Pain as a symptom of an unresolved bereavement reaction

5. Pain as a symptom of a 'need to suffer'

Patients who somatise their symptoms present one of the most difficult challenges to our skills and usually require a multidisciplinary team approach. Management involves:

• thorough medical assessment

• psychological assessment

• detailed explanations to the patient and family about treatment

• rational explanations about the cause of the pain

• management of associated problems, e.g. depression, sexual dysfunction

• behavioural modification to encourage increased activity and a gradual return to normality

A useful explanation

The author finds the following account a most useful method of explaining perplexing continuing back pain or neuralgia to patients (where there is no evidence of a persisting organic lesion).

Part of the problem is that psychological factors continue to aggravate and maintain the problem even though the reason for the pain in the first place may have disappeared. It is a similar problem to a person who has had a painful leg amputated. Even though it has been removed, the patient can still feel the leg and maybe even the pain. The patient has a 'phantom limb'. The nervous system, especially the brain, can play funny tricks on us in this way.

This means that even though the original disc injury has settled after several weeks, the body can still register the pain. This is more likely to occur in people who have become anxious and depressed about their problem. The pain continues. Someone once described it as a 'tension headache that has slipped down to the back'.

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