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Pain - PowerPoint PPT Presentation


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Pain. Physiology of Pain. Nociceptors Stimulus Transmission Termination Modulation. Physiology of Pain. Multiple Redundant Reciprocal Complex. Assessment of Pain. Immediate Pain Physical Functioning Psychological Factors Pain Behaviors Objective Correlates.

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physiology of pain
Physiology of Pain
  • Nociceptors
  • Stimulus Transmission
  • Termination
  • Modulation
physiology of pain3
Physiology of Pain
  • Multiple
  • Redundant
  • Reciprocal
  • Complex
assessment of pain
Assessment of Pain
  • Immediate Pain
  • Physical Functioning
  • Psychological Factors
  • Pain Behaviors
  • Objective Correlates
assessment immediate pain
Assessment: Immediate Pain
  • Intensity
  • Location
  • Affective Response
  • Composite Measures
assessment physical fx
Assessment: Physical Fx.
  • Impairment
  • Functional limitation
  • Disability
assessment psych factors
Assessment: Psych factors
  • Influence vs. causation
  • Mediation
  • Reinforcement
  • Resonators
  • Pain beliefs
assessment pain behavior
Assessment: Pain Behavior
  • Observation
  • Role of learning
composite pain scales
Composite Pain Scales
  • Attempt to measure one or more dimensions of the pain experience
slide15

History

Intensity

Comorbid

Quality

Objective Data

Side effects

assessment objective indicators
Assessment: Objective Indicators
  • Ex. Electromyography

“Well, Phil, after years of vague complaints and imaginary ailments, we finally have something to work with.”

diagnosis
Diagnosis
  • Categorization
  • DSM and Pain
  • Other Approaches to “Somatoform Pain”
categorization
Categorization
  • Acute versus Chronic
acute pain
Acute Pain
  • Not just time
  • Clearer association
    • Subtypes (ex. Recurrent?)
  • “nociceptive pain”
chronic
Chronic
  • Association?
  • Types
    • By presumed etiology
      • Neurologic pain
      • Ideopathic
    • By course
dsm iv

DSM-IV

The concept of Somatoform Pain

dsm and pain
DSM and pain
  • I (1952)
    • Psychophysiological disorders“
    • “Psychoneurotic Disorders”
  • II (1968)
    • Hysterical neurosis
dsm and pain24
DSM and pain
  • III (1980)
    • Psychogenic Pain
      • “incompatible” or “INXS”
      • Etiologically related
  • III-R (1987)
    • Somatoform pain
    • Dropped etiology part
dsm and pain25
DSM and pain
  • IV
    • Pain Disorder
      • Pain=predominant focus
      • Substantial distress/impairment
      • Psych factors “have role”
        • Onset or expression
      • Not malingering/factitious disorder
problems with dsm
Problems with DSM
  • Utility
  • How to judge?
    • Physical versus Psychological
    • Etiology
  • DSM-IV
    • Mind-body dichotomy remains
    • Division of pain based on this.
dsm iv pain tested
DSM-IV pain tested
  • Psychological vs. Psychological+Medical Distinction
    • No difference on
      • Pain measures
      • Intensity
      • Type
      • Level of disability

(Aigner et al, Compr Psychiatry 1999)

slide30
IASP

5 axis system

  • Anatomical region
  • Organ system
  • Temporal characteristics/patterns
  • Intensity, time since onset
  • Etiology
slide31
IASP
  • Psychological pain
    • “Pain specifically attributable to the thought process, motional state, or personality of the patient in the absence of an organic or delusional cause or tension mechanism.”
other approaches
Other approaches
  • Dimensional
    • Take into account various aspects of pain
      • Objective findings/physical etiology
      • Perceptual influences
      • Presentation
treatment of pain36
Treatment of Pain
  • Pharmacologic
  • Psychological
  • Other somatic treatments
  • Importance of Multimodal
  • Cormorbid treatments
  • Role of C/L Psychiatrist
pharmacological treatment
Pharmacological Treatment
  • “True” Analgesics
  • Everything Else

“Yes Billy, but Mr. Phillips pushes legal drugs.”

true analgesic
“True” Analgesic
  • NSAIDS
  • Opioids
  • Local agents
nsaids
NSAIDS
  • Mechanism
  • Indication
  • Side effects
nsaids40
NSAIDS
  • Standard
  • Acetaminophen
  • Ketorolac
  • COX-2 inhibitors
opioids
Opioids
  • Mechanism of action
  • Indication
  • Side effects
    • Common
    • Uncommon but problematic
combination opioid nsaids
Combination Opioid/NSAIDs

*caffeine † butalbital ‡agonist-antagonist

treatment approach46
Treatment Approach
  • MEC
  • Role of pharmacokinetic
    • Toxicity
    • Slow-release preps
concerns
Concerns
  • Tolerance
  • Dependence
  • Addiction
overvalued concerns
Overvalued Concerns
  • Addication
  • Overdose and death
  • Discipline

“Damn! I suppose this means another malpractice suit.!”

adjunctive and other meds
Antidepressant

Anticonvulsants

Local Analgesics

Antihistamines

Antipsychotics

Benzodiazepines

Stimulants

Cannabinoids

Placebos

Adjunctive and other meds
nonsurgical treatments
Nonsurgical treatments
  • Cutaneous Stimulation
  • Electrical Stimulation
  • Acupuncture
  • Exercise
surgical treatments
Surgical Treatments
  • Neural Blockade
  • Surgical lesions
  • Limitations
psychological treatments
Psychological Treatments
  • Psychoeducation
  • Hypnosis
  • Behavioral Treatments
behav txs
Behav Txs
  • Relaxation
  • Biofeedback
  • CBT
    • Focus
    • Goals
multidisciplinary pain treatment
Multidisciplinary Pain Treatment
  • Different levels
  • Features included
comorbid problems
Comorbid Problems
  • Depression
  • Anxiety
role of c l psychiatrist in pain eval
Role of C/L Psychiatrist in Pain Eval
  • “Problem Patient”
  • “Drug Seeker”
  • “Just in their heads”
  • “Pain out of proportion…”