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The Chronic Pain The Chronic Pain PatientPatient
Ten Practical Psychiatric Ten Practical Psychiatric PerspectivesPerspectives
A Presentation for A Presentation for SOMC Medical Education
Kendall L. Stewart, MD, MBA, DFAPAKendall L. Stewart, MD, MBA, DFAPAOctober 15, 2010October 15, 2010
1 These are among the most frustrating patients you will encounter.2Contrary to the conventional wisdom, they can also be among your most grateful and gratifying patients.
Why is this important?1
• This is a huge medical problem.
• Chronic pain is among the most common reasons patients visit physicians.
• This is the third largest health care problem in the world.
• More than 60 million Americans suffer from chronic pain.
• And its treatment leads to all kinds of other problems.
• You will see many of these patients, and they will frustrate you enormously.
• After listening to this presentation, you will be able to answer the following questions:– Why is this issue so
important?– What practical psychiatric
perspectives will assist you in managing these challenging patients?
– How can you implement these perspectives in your clinical practice?
– What are some of the treatment challenges?1
• Your ability to integrate these practical perspectives in your clinical practice will enhance your effectiveness.
1 Click on the hyperlinks in the presentation for additional information.
What are some practical psychiatric perspectives on managing chronic pain?
1. Ask whether the patient is confident that nothing has been missed.
2. Remember the “soma to psyche” connection.
3. Leave the drug management to the experts—unless you are one.
4. Suggest regular visits.5. Monitor drug usage carefully.6. Recommend appropriate daily
exercise.7. Encourage healthy distractions.8. Teach progressive relaxation.9. Suggest sensory override
techniques10.Encourage positive addictions.
Ask whether the patient is confident that nothing has been missed.
• So long as your patient believes something has been missed, you cannot begin working on the goal of living with the pain.
• Many of our patients like to go to the Cleveland Clinic for a second opinion.
• You will be humbled by the number of times consultants will find something significant that you have missed.
• New findings rarely produce a cure.
• But a comprehensive examination often provides an enabling sense of closure.
1 A local surgeon diagnosed diverticulitis and recommended surgery.
Remember the “soma to psyche” connection.
• Begin with the genuine acknowledgement that the patient is suffering.
• Remind them that you are there to help them “live with” their pain.
• After you have convinced the patient that you believe the pain is real, begin to tentatively explore the painful emotions that may be contributing to the pain experience.
• When your conversations are confined mostly to the psychic pain, avoid going back to the physical symptoms except to briefly document the intensity of the pain.
1 An elderly woman came in with the complaint that her head was burning.
Leave the drug management to the experts—unless you are one.
• This complex medical management is best left to one physician.
• Clarify your role up front.1,2,3
• Invite the patient to make an informed decision.
• Make a commitment to the prescribing physician that you will not prescribe.
• Then inform the patient of your commitment.
• When they test you—and they will—remind them of this commitment and their previous agreement.
1 Do this before you get frustrated and resentful.2A colleague of mine promised to call his patient every evening.3Then he moved away and left the patient to me.
Suggest regular visits.
• These patients often feel their physicians don’t take them seriously.
• They feel shunted to other specialists.
• They want a physicians they can depend on.1,2,3
• Seeing the doctor too frequently often becomes their positive addiction.
• Their visits to the doctor are often their principal social outlets.
1 I routinely now ask my patients when they would like to return.2They change the frequency depending on what is going on in their lives.3I reassure them that they can always call.
Monitor drug usage carefully.
• Ask your patients to keep a medication diary.
• Ask to see this at every visit.• Inquire about side effects.• Communication about what
you learn and observe with the other physicians on the team.
• This patients will sometimes ask you not to communicate with their other physicians.
• Don’t agree to this condition.1,2
1 Never, ever agree to confidentiality beforehand.2A borderline patient once asked me to keep her pill stash for her.
Recommend appropriate daily exercise.
• This remains a hard sell, but we must keep selling it.
• Those physicians who exercise regularly themselves are more likely to recommend exercise to their patients, and they are more credible persuaders.
• People with chronic back pain are very likely to overdo exercise at times.
• Daily exercise works best.• Combining exercise with some
other enjoyable activity is critical.1,2
1 I exercise two hours every day.2I combine exercise with thinking, classical music, reading my Kindle, and watching the news.
Encourage healthy distractions.
• Healthy distractions– Television1
– Reading– Music– Facebook™– Productive activities
• Unhealthy distractions– Alcohol– Pain medications– Rumination– Complaining– Eating– Consumptive activities
1 When my mother’s television went off, her pain increased dramatically.
Teach progressive relaxation.
• This simple exercise is highly effective.1
• It works best if you make a recording for your patient the first time.
• It is easily combined with meditation and self-hypnosis.
• Some people will become highly agitated due to a fear of loss of control.
1 This is also a great way to put yourself to sleep.
Suggest sensory override techniques.
• Heating pad• Heating rubs• Local cold compresses• Hot bath• Loud music1
• Vigorous exercise• Sex• Deep tissue massage• Other strong sensory
experiences1 My schizophrenic patients often drown out the voices this way.
Encourage positive addictions.
• Self-help groups can be very helpful—especially for recovering patients.1
• Religious people who worship regularly clearly lead more healthy, satisfying lives.
• A consuming passion for serving others is the best positive addiction.
• Some demanding hobbies such as coupon clipping, scrapbooking and genealogy can serve as positive addictions.
• Passions that produce strong negative emotions such as spectator sports or politics are not as helpful.
1 Those who become consumed with helping others are most likely to succeed.
The Psychiatric InterviewA Patient-Centered, Evidence-Based Diagnostic and Therapeutic Process
• Introduce yourself using AIDET1.• Sit down.• Make me comfortable by asking
some routine demographic questions.
• Ask me to list all of problems and concerns.
• Using my problem list as a guide, ask me clarifying questions about my current illness(es).
• Using evidence-based diagnostic criteria, make accurate preliminary diagnoses.
• Ask about my past psychiatric history.
• Ask about my family and social histories.
• Clarify my pertinent medical history.
• Perform an appropriate mental status examination.
• Review my laboratory data and other available records.
• Tell me what diagnoses you have made.
• Reassure me.• Outline your recommended
treatment plan while making sure that I understand.
• Repeatedly invite my clarifying questions.
• Be patient with me.• Provide me with the
appropriate educational resources.
• Invite me to call you with any additional questions I may have.
• Make a follow up appointment.• Communicate with my other
physicians.
1Acknowledge the patient. Introduce yourself. Inform the patient about the Duration of tests or treatment. Explain what is going to happen next. Thank your patients for the opportunity to serve them.
Where can you learn more?
• American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, 2000
• Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry, Third Edition, 20081
• Flaherty, AH, and Rost, NS, The Massachusetts Handbook of Neurology, April 20072
• Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry Clerkship, Second Edition, March 2005
• Klamen, D, and Pan, P, Psychiatry Pre Test Self-Assessment and Review, Twelfth Edition, March 20093
• Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007
• Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain, January 2008
• Median, John, Brain Rules: 12 Principles for Surviving and Thriving at Home, Work and School, February 2008
• Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous Patients,” 2000
• Jacobson and Jacobson, Psychiatric Secrets, 2nd Edition, 2001
Where can you find evidence-based information about mental disorders?1
• Explore the site maintained by the organization where evidence-based medicine began at McMaster University here.
• Sign up for the Medscape Best Evidence Newsletters in the specialties of your choice here.
• Subscribe to Evidence-Based Mental Health and search a database at the National Registry of Evidence-Based Programs and Practices maintained by the Substance Abuse and Mental Health Services Administration here.
• Explore a limited but useful database of mental health practices that have been "blessed" as evidence-based by various academic, administrative and advocacy groups collected by the Iowa Consortium for Mental Health here.
• Download this presentation and related presentations and white papers at www.KendallLStewartMD.com.
• Learn more about Southern Ohio Medical Center and the job opportunities there at www.SOMC.org.
How can you contact me?1
Kendall L. Stewart, M.D.Kendall L. Stewart, M.D.VPMA and Chief Medical OfficerVPMA and Chief Medical OfficerSouthern Ohio Medical CenterSouthern Ohio Medical Center
Chairman & CEOChairman & CEOThe SOMC Medical Care Foundation, Inc.The SOMC Medical Care Foundation, Inc.
1805 27th Street1805 27th StreetWaller BuildingWaller Building
Suite B01Suite B01Portsmouth, Ohio 45662Portsmouth, Ohio 45662
740.356.8153740.356.8153
[email protected] [email protected] [email protected]@yahoo.com
www.somc.orgwww.somc.orgwww.KendallLStewartMD.comwww.KendallLStewartMD.com
1Speaking and consultation fees benefit the SOMC Endowment Fund.
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Sarah Porter, DOSarah Porter, DOSOMC FP 2006SOMC FP 2006
Kevin Kammler, DOKevin Kammler, DOOUCOM 1993OUCOM 1993
