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.Her moodis depressed, and her affect is congruent.Her thought processes are log-ical, and her thought content is negative for suicidal or homicidalideation, delusions, or hallucinations.¤' What is the most likely diagnosis for this patient?¤' What is the best approach for this patient?282 CASE FILES: PsychiatryANSWERS TO CASE 32:Pain DisorderSummary: A 42-year-old woman has unremitting back pain for 6 monthssince she was knocked down.The pain is right-sided, located near L4 and L5.There are no exacerbating or alleviating factors, and the pain does not radiate.The patient is nonfunctional since the event.No fractures were found at thetime of the accident a diagnosis of back strain was made.Further workupsover the past 6 months show no anatomic or physiologic reason for continuedpain.The patient has a history of domestic violence and on multiple occasionswas treated in the emergency department for bruises and lacerations.Theresults of her mental status examination are noncontributory to the diagnosis.¤' Most likely diagnosis: Pain disorder.¤' Best approach: Validate the patient s experience of pain.Explain the roleof psychological factors as a cause and consequence of pain.Considerantidepressants and referral to a pain clinic.ANALYSISObjectives1.Recognize pain disorder in a patient.2.Understand the chronicity, approach, and treatment options for patientswith pain disorder.ConsiderationsThis patient has chronic back pain (for 6 months or longer) that is unac-counted for by a general medical condition.As a result, she is distressed andunable to function.There are no data suggesting that the condition was pro-duced intentionally or is being feigned.It is possible (based on her history ofdomestic violence) that the accident triggered memories of the psychologi-cal trauma she previously experienced and thus has a role in the severity ofher current pain.The patient does not exhibit signs or symptoms of any otherdisease that might better account for the pain.Table 32 1 lists the diagnosticcriteria for pain disorder.CLINICAL CASES 283Table 32 1 DIAGNOSTIC CRITERIA FOR PAIN DISORDER*Pain at one or more sites that is severe enough for a clinical evaluation; it is the patient sprimary complaint.The pain is very distressing to the patient and/or causes significant functionalimpairment.The clinician judges that psychological factors play an important part in the initiation,worsening, or severity of the pain.The pain cannot be explained by another axis I condition such as major depression or apsychotic disorder, nor can it be solely the pain of dyspareunia.*The disorder is considered acute if it lasts for less than 6 months, chronic if longer.APPROACH TOPain DisorderDEFINITIONSBIOFEEDBACK: A relaxation technique by which patients are trained toinduce physiologic changes (most frequently the induction of alpha waves onan electroencephalogram [EEG] or vasodilatation of peripheral capillaries)that result in a relaxation response.DYSPAREUNIA: Painful sexual intercourse.PAIN DISORDER: One of several somatoform disorders listed in the Diagnosticand Statistical Manual of Mental Disorders, Fourth edition, text revision (DSM-IV-TR)that is distinguished by a primary complaint of pain that is not explained byphysical factors; psychological factors are significant in the clinical picture.Pain is a very common complaint in medicine and occurs more often in olderpatients (fourth and fifth decade of life) and in those who are likely to havejob-related physical injuries.A number of psychodynamic factors can beinvolved, including inability to express emotions verbally, an unconsciousneed to obtain attention by suffering physical pain, or an unconscious needfor punishment.Individuals also learn this form of help-seeking in a familythat models and reinforces the behavior.284 CASE FILES: PsychiatryCLINICAL APPROACHDifferential DiagnosisPain is a very common complaint in medicine and occurs more often in olderpatients (fourth and fifth decade of life) and in those who are likely to havejob-related physical injuries.It is important that the patient undergo anevaluation for all medical or surgical illnesses that could cause the pain.Patients with depression and/or anxiety can sometimes present with a primarycomplaint of pain; however, on evaluation, the depressive symptoms predom-inate.Patients with hypochondriasis can complain of pain symptoms, but themain clinical feature is a conviction that they have a serious medical illness.Patients with factitious disorder intentionally produce an injury or illness inorder to assume the sick role.Patients who are malingering can consciouslypresent false reports of pain in order to achieve secondary gain (such as financialcompensation, evading the police by being hospitalized).Patients with paindisorders often use substances to relieve distress, which can mask the paindisorder or some other medical or surgical illness.TREATMENTIn treating a patient with pain disorder, the clinician must accept that thecondition is often chronic and that the goal of pain relief can be unrealistic;providing gradual improvement of functioning is a more reasonable approach.Although the physician must validate the existence of the patient s pain,education about the contributing effect of psychological factors is important.The use of antidepressants can be an effective pharmacologic approach; bothtricyclics and selective serotonin reuptake inhibitors (SSRIs) have beenshown to be helpful.These agents work by decreasing comorbid depressionor by exerting an independent analgesic effect.Analgesic medications aregenerally not helpful, and the patient has usually tried this approach beforeseeking treatment.Narcotic analgesics should be avoided given their abuseand withdrawal potential.Biofeedback is helpful in certain pain disorders,specifically headaches and muscle tension.Hypnosis and nerve stimulationare also used.Psychodynamic psychotherapy focused on the impact of thedisorder on the patient s life can be helpful.For treatment-resistant individ-uals, comprehensive pain clinics (either inpatient or outpatient) should beconsidered.CLINICAL CASES 285Comprehension Questions32.1 A 63-year-old woman returns to her family physician with continuingheadaches for 9 months.She describes the pain as  constant.alwayswith me, around her entire scalp.She does not appreciate much vari-ation throughout the day, and she cannot name any aggravating oralleviating factors.Although she occasionally feels light-headed whenin severe pain, she denies photophobia, visual changes, nausea, orvomiting.She is especially upset about the headaches as she retired inthe past year and has been unable to visit her infant granddaughter.Complete neurologic examinations, computerized tomography, magneticresonance imaging, laboratory studies, and lumbar punctures have beenunremarkable.Which of the following is her most likely diagnosis?A.Factitious disorderB.HypochondriasisC.MalingeringD.Pain disorderE.Somatization disorder32.2 Which of the following would be the most useful approach for thepatient in question 32.1?A [ Pobierz caÅ‚ość w formacie PDF ]