Publications
APS Bulletin • Volume 16, Number 1, Winter 2006
Resource Reviews
John D. Loeser, MD, Department Editor
Psychosocial Aspects of Pain: A Handbook for Health Care Providers Progress in Pain Research and Management, Volume 27
Reviewed by Gerald M. Aronoff, MD
Robert H. Dworkin, William S. Breitbart, Seattle, IASP Press, 2004. Hard cover, 665 pages, ISBN 0-931092-48-5. Nonmembers $89, IASP members $69.
The goal of Psychosocial Aspects of Pain: A Handbook for Health Care Providers is “to serve as a comprehensive resource for healthcare providers who would like to become knowledgeable about the psychosocial, psychiatric, and social aspects of pain.” The book addresses the many deficiencies of the traditional biomedical treatment model and discusses the research supporting the biopsychosocial model as the treatment of choice.
The book is divided into five parts. The chapters in part I review biological, psychological, and social influences on pain and discuss psychosocial models of their interaction. There is an excellent and concise discussion of pain neurophysiology, functional brain imaging studies, and consciousness studies in persons with pain to help explain the role of cognitive factors in the human pain experience and in the modulation of pain. Research discussing the influence of family and culture on pain emphasizes the importance of pain clinicians taking detailed developmental, family, and psychosocial histories. The section on biopsychosocial models of pain emphasizes the multidimensional process involving genetics and various types of learning on shaping the pain experience and the likelihood that patients will cope adaptively or maladaptively.
Part II discusses methods for evaluating the numerous factors that influence patients’ experience of both acute and chronic pain, emphasizing the importance of being aware of the many factors that might bias information that clinicians obtain about pain. Gallagher and Verma review the evidence on mood and anxiety disorders in chronic pain and emphasize that to effectively manage most patients with chronic pain, clinicians must learn how to identify, diagnose, and treat common comorbidities such as anxiety and depression. Somatoform disorders are fairly common with pain complaints and although psychiatric and other behavioral practitioners are trained in their evaluation, most other physical medicine specialties often do not recognize them and are unfamiliar with their treatment. Guidelines are suggested. This section concludes with an excellent chapter that should be mandatory reading for all interventional pain practitioners.
Part III discusses specific aspects of treating pain patients and emphasizes the importance of integrating principles from clinical psychology and psychiatry into treatment protocols regardless of our primary specialty. The first chapter by Mark Sullivan emphasizes the importance of recognizing that the goals for pain treatment should not only be to target the pain but also to evaluate and treat the emotional distress (suffering), improve function, and assist the patient in maintaining or improving quality of life. Making an accurate diagnosis is important, but he notes that at times it is equally or more important to take a patient-centered approach geared toward understanding the personal meaning of the pain or illness for the patient being treated. There is an excellent section on the importance of integrating cognitive-behavioral pain management strategies into the treatment of patients with persistent pain.
The chapters in part IV review several types of chronic pain that often present particularly complex challenges for clinicians. The first chapter in this section discusses fibromyalgia from a patient-oriented perspective. There is discussion of various treatment approaches and recognition that fibromyalgia patients represent a heterogeneous group requiring biopsychosocial evaluation as well as patient acceptance of responsibility for self-management. The chapter on complex regional pain syndromes notes that although this is fundamentally a neuropathic pain disorder, the resulting pain syndrome is most appropriately viewed as a complex biopsychosocial problem that should be treated using the aggressive multidisciplinary approach. The section on irritable bowel syndrome (IBS) notes that there is substantial comorbidity with a number of other chronic pain syndromes and that “IBS patients with one of more of these comorbid conditions are more anxious, depressed, somatically focused, and pain sensitive than are IBS patients without such comorbidities.” The section on recurrent headache disorders notes the importance of training patients in self-management approaches, use of cognitive-behavioral strategies, and recognition of psychosocial issues that can complicate chronic headaches.
Part V discusses pain in special populations. The chapter on identifying and treating patients with drug-abuse problems provides an excellent discussion of opiophobia on the part of medical practitioners as well as patients that often results in the undertreatment of chronic pain causing patients to experience needless suffering. Patrick McGrath presents an excellent chapter in which he takes an evidence-based approach to the psychosocial and psychiatric aspects of pain in infants, children, and adolescents and frames this in the context of biological aspects of pain. The chapter on psychosocial aspects of pain in older people discusses aging as a pain-modulating factor.
Part VI discusses special issues, including the influence of coping styles and personality traits on pain, and notes that while no one personality style or disorder is pathognomonic for a chronic pain condition, personality traits can have a significant bearing on whether pain patients are able to cope with pain (and with stress) adaptively or not. The chapter that deals with compensation claims for chronic pain acknowledges that there are unique complexities in assessing claimants with chronic pain and in making causal relationships between alleged traumatic incidents and residual chronic pain complaints. However, the author also cautions readers against assuming that symptoms involve malingering or symptom embellishment for personal gain. The chapter on risk factors for chronic pain in patients with acute pain and their implications for prevention discusses the evidence to support the conclusion that “severe acute pain, biomedical risk factors, psychological distress and mental disorders, and psychosocial stressors such as poor social support, stressful life events, and psychological trauma may all contribute to an increased risk of chronic pain in patients with acute pain.” Howard Fields wrote the final chapter in this text, “Placebo Analgesia.” He reviews the considerable confusion about the use of this term, cautions clinicians to never deceive a patient in clinical practice by knowingly using placebos, but also acknowledges that inherent in our authoritarian position vis-à-vis the patient, the expectation that we share with the patient that certain treatments are expected to give pain relief can exert a powerful analgesic affect.
The book’s authors met all of their stated goals. This volume should be mandatory reading for all pain practitioners and also those who provide primary care and ancillary care because so many patients present with pain among many other symptoms. These patients are often treated with a biomedical approach or with the assumption that there must be an underlying medical or physical cause for their symptoms despite a strong body of evidence supporting the role of psychosocial stressors contributing to many of their ongoing complaints. The book is well written, well edited, and evidence based. If the readers integrate some of the concepts developed in this text, it will not only improve their patient care but will make their clinical practice more rewarding.
Dr. Aronoff is Medical Director of Carolina Pain Associates and is Adjunct Associate Professor at the Duke University School of Medicine.
Dr. Loeser is Professor of Neurological Surgery and Anesthesiology at the University of Washington in Seattle.