pain



Psychogenic pain



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Introduction


Unless the patient has reasons for ‘malingering’ – the symptoms are simulated for compensation or litigation motives – pain is always indicative of some degree of dysfunction.1 In most instances, the dysfunction is physical. Sometimes, however, the pain is devoid of any organic basis. If the patient has an unconscious belief in the reality of the symptoms, a psychogenic disorder is likely. The pain is then labelled ‘inorganic’ or ‘functional’. There is an emotional illness and, although no peripheral tissue damage exists, the pain is as distressing as is somatic pain.


Pain is often the outcome of a combination of physical and psychological causes. It is a highly complex phenomenon: psychological factors affect the way people experience and express pain;2 conversely, chronic pain often results in secondary personal difficulties.3,4 Because pain is an abnormal affective state (though called into being by physical changes in the body), a heightened awareness may increase the severity of the symptoms. The patient may then present with irrational complaints that obscure genuine factors.5


The detection of disorders which have their origin in the patient’s mind or from the desire to elicit sympathy or compensation is simple if the patient is examined by the methods set out in this book. However, it is more difficult to assess those who present with an organic lesion with psychogenic overlap. Here, much patience and clinical experience will be required to unravel the complicated clinical picture.



Orthopaedic medicine and psychogenic pain



Importance of immediate diagnosis


After the first attendance it is important to decide whether the patient does or does not have an organic lesion; this may be more difficult in an organic lesion with strong psychogenic overlap but, if the physician is alert, strong suspicion is usually aroused. For the sake of both patient and physician, psychogenic pain ought to be detected at once. If active treatment is applied to a patient who is dissembling or who is enmeshed in a compensation claim, nothing but an allegation of making symptoms worse can be expected. Also, in pain of ‘inorganic’ origin, the treatment will be completely inefficient and endless – the malady does not worsen but it never improves either. This is not only extremely discouraging to the physician and therapist but will also worsen the patient’s mental state.


Conversely, it is unethical to regard the patient’s symptoms as being devoid of organic basis simply because a treatment is unsuccessful. The label ‘psychogenic pain’ can never become an excuse for the physician’s failure; it can only be given at the first interview and before any treatment is instituted.



Importance of a positive diagnosis


The diagnosis ‘psychogenic pain’ should be made on the discovery of positive inconsistencies during orthopaedic assessment and not as the result of supposition about possible psychological factors, such as anxiety, depression, stressful life situation or family dissatisfaction. A patient regarded as psychoneurotic can develop a genuine orthopaedic condition in parallel, and concentration on the psychological problem may distract the examiner from the organic cause of the pain. When there is an organic cause, thorough orthopaedic examination will reveal a simple and consistent pattern that markedly contrasts with the excessive nervous behaviour of the patient. The mechanofunctional aspects of the body are well defined and easy to interpret. In pain not of organic origin, the findings are self-contradictory and, given enough opportunity, the patient will sooner or later demonstrate inconsistencies.


To establish that there is not an organic basis for symptoms is extremely important in order to protect the patient from endless therapy or repeated surgery. However, to make an objective distinction between the different types of inorganic pain – whatever names they are given – is extremely difficult and requires further (psychological) assessment. An orthopaedic physician should beware of using diagnostic labels such as ‘hysterical’, ‘hypochondriac’, and ‘regressed’. Because such classification depends merely on the doctor’s sympathy or lack of it, it results in poor communication and engenders negative perceptions of the patient and a sense of pessimism regarding the prognosis.



Pitfalls for the examiner


The examiner must try to keep a balance between excessive scepticism and naïve trust. Not every statement should be accepted unconditionally but, conversely, not every patient with a symptom that differs from the usual should be regarded as suffering from an imaginary disorder. However bizarre the behaviour of the patient, the examiner should always face the clinical situation with an open mind that takes note of, and registers, the statements and findings. The diagnosis is then substantiated by the discovery of positive inconsistencies. The most important pitfalls are:



A patient with chronic pain who has seen several practitioners without benefit feels under suspicion or begins to have self-suspicion and develops the behaviour of a suspect. Strong emphasis on symptoms may occur with attention-seeking activity so as to convince the physician by exaggeration. However, it is not so much the current performance of the patient that may convince the physician that there is not an organic lesion but the remarkable sequence of events and the unlikely sensations that are described.


The examiner should also eschew the belief that a history or pattern not encountered previously does not exist: unknown is not the same as inconsistent. If the patient’s symptoms remain within segmental boundaries, the complaints are consistent and the diagnostic movements are the same at each examination, an organic lesion is very likely. Although the examiner may not be able to make a diagnosis it must be obvious that here is a genuine, even though unfamiliar, disorder.


A serious pitfall in the detection of psychogenic disorders is the bias of the examiner towards the patient.6 The doctor usually has initial sympathy for the patient who comes for help. However, dispassionate history and examination are essential. Only then is it possible to decide whether or not the patient’s symptoms are psychogenic. A great effort is sometimes required to be completely objective but for the patient’s sake it is essential. It is even more difficult for a doctor employed by an insurance company to remain unbiased; a detailed clinical approach is vital to establish facts and draw conclusions but is not partisan in a lawsuit (Cyriax:7 p. 454).


Sometimes nothing can be found during clinical examination. Although the patient has a clear and well-defined complaint, the functional examination remains completely normal. If nothing can be found to account for pain, the decision that the symptom is psychogenic should not be taken lightly. It is possible that the examination has not been sufficiently precise to detect the organic disorder or the lesion is organic but not of orthopaedic origin. After serious internal disorders have been excluded, it is then fair to admit to the patient that one has failed to arrive at a diagnosis.



Clinical examination in psychogenic pain


Diagnosis follows the demonstration of positive inconsistencies during both the history and clinical examination. Sometimes the history contributes to the diagnosis, sometimes the examination will be the criterion but usually it is the overall picture – the combination of history and clinical examination – that is most informative. Inconsistencies may be found between symptoms, between signs and between symptoms and signs.



History


The examiner first listens to the history as related by the patient. Some accounts immediately draw attention to a possible existence of psychogenic pain or at least to a good deal of over-reaction. The patient describes symptoms in a melodramatic way: ‘a spear going through my back’; the pain is ‘dreadful, torturing, agonizing’. The patient’s story is not a clear description of the symptoms but one of intense suffering, increasing disability and of ineffective treatments received.8


The examiner then asks precise questions, such as when did the pain start; how did it start; where was the pain first felt; to where did it spread? This technique of questioning is extremely helpful in defining the psychogenic causes. A patient with a genuine lesion may have difficulties in explaining himself, may be garrulous or apathetic, sullen or rambling, and fail to give a coherent account. Or, the invitation to give precise answers to precise questions will produce pleasure that at last a doctor will listen with interest and patience. A consistent report will then almost always be obtained, which quickly suggests the organic nature of the lesion. The response of patients with psychogenic symptoms is in strong contrast: because they do not know exactly what to say and refuse to commit themselves, precise answers are avoided. Pressed to describe the exact position of the symptoms they take refuge in very vague but exaggerated statements such as ‘whole leg pain’, ‘whole leg numbness’ and ‘the whole leg giving way’. No position makes the pain better, or it comes and goes in the most improbable way. There is a tendency to embark quickly on the degree of suffering and the way the pain has influenced social, family or sexual life. When brought back to the point, there is reluctance to supply answers, which may even turn to irritation when the examiner continues with precise questions on the exact position of the pain, its variation and its spread.


Sometimes suspicion arises when none of the current and recognizable patterns emerges – the ‘inherent likelihoods’ (see Ch. 4). The lack of inherent likelihoods should put the examiner on guard. The patient is then allowed to go on talking so that contradiction of earlier statements may emerge.



Inspection


The patient is observed on entering the room and sitting down. Walking, sitting and undressing may demonstrate that certain muscles are not paralysed and establish that a degree of movement exists at the joints of the lower limb. The facial expression should be compared with the degree of alleged suffering. The face of a well-nourished and healthy patient does not correspond with the contention: ‘I haven’t had a wink of sleep in two months’.

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Jun 5, 2016 | Posted by in ORTHOPEDIC | Comments Off on pain

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