Pain Is the 5 Vital Sign

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Phillips DM. JAMA 2000; 284(4):428-9.

Pain. What
is it?
An unpleasant sensory and
emotional experience associated
with actual or potential tissue
damage, or described in terms
of such damage.
International Association for the
Study of Pain

The Pain Continuum

Insult

Time to resolution

Acute pain

Normal, time-limited response

to noxious experience
(less than 3 months)

Usually obvious tissue damage

Serves a protective function
Pain resolves upon healing

Chronic pain

Pain that has persisted beyond

normal tissue healing time
(usually more than 3 months)

Usually has no protective function

Degrades health and function
Acute pain may become chronic

Chapman CR, Stillman M. In: Kruger L (ed). Pain and Touch. Academic Press; New York, NY: 1996; Cole BE. Hosp Physician 2002; 38(6):23-30;
International Association for the Study of Pain. Unrelieved Pain Is a Major Global Healthcare Problem.
Available at: http://www.iasp-pain.org/AM/Template.cfm?Section=Press_Release&Template=/CM/ContentDisplay.cfm&ContentID=2908. Accessed:
July 24: 2013;
National Pain Summit Initiative. National Pain Strategy: Pain Management for All Australians.
Available at: http://www.iasp-pain.org/PainSummit/Australia_2010PainStrategy.pdf. Accessed: July 24, 2013;
Turk DC, Okifuji A. In: Loeser D et al (eds.). Bonicas Management of Pain. 3rd ed. Lippincott Williams & Wilkins; Hagerstown, MD: 2001.

Pain Categories

1. Somatogenic pain is pain with cause (usually kno

localised in the body tissue
a/ nociceptive pain
b/ neuropatic pain

2. Psychogenic pain is pain for which there is no kno

physical cause but processing of sensitive inform
in CNS is disturbed

Psychological Pain = Psychogenic Pain

Psychological pain
Pain specifically attributable to the thought
process, emotional state, or personality of the
patient in the absence of an organic or
delusional cause or tension mechanism.
International Association for the
Study of Pain

Case from Clinic (1)

A 52 yrs old woman complained headache since
3 years ago. She had already checked to a
neurologist, a TNT-Specialist and internist and did
some examinations.
The previous physician did not find any problems
and the examinations ruled out any underlying
disease, except the pain still existed
She could not described the pain specifically,
come and go but very annoying. She realized
that the pain intensity was related to stress

Psychiatry and Pain

Diagnosis of Pain in Psychiatry (DSM)
DSM I (1952)
Psychophysiological disorders
Psychoneurotic Disorders

DSM II (1968)
Hysterical neurosis

III (1980)
Psychogenic Pain
incompatible or INXS
Etiologically related

III-R (1987)
Somatoform pain
Dropped etiology part

Psychiatry and Pain

DSM IV
Pain Disorder
Pain=predominant focus
Substantial distress/impairment
Psych factors have role
Onset or expression

Not malingering/factitious disorder

DSM 5 : Somatic Symptoms Disorder and Its

Related Disorder.
Somatic Symptoms Disorder with predominant pain

PPDGJ and Pain

Dalam diagnosis gangguan jiwa menurut PPDGJ 3 terdapat

diagnosis gangguan nyeri sebagai bagian dari gangguan
somatoform yaitu F. 45.4 . GANGGUAN NYERI YANG MENETAP.
Nyeri pada satu atau lebih tempat anatomis
Nyeri menyebabkan penderitaan yang bermakna secara klinis atau
gangguan dalam fungsi sosial, pekerjaan, atau fungsi penting lain.
Faktor psikologis dianggap memiliki peranan penting dalam onset,
kemarahan, eksaserbasi atau bertahannya nyeri.
Gejala atau defisit tidak ditimbulkan secara sengaja atau dibuat-buat
(seperti pada gangguan buatan atau berpura-pura).
Nyeri tidak dapat diterangkan lebih baik oleh gangguan mood,
kecemasan, atau gangguan psikotik dan tidak memenuhi kriteria
dispareunia.

Assessment of Pain

Immediate Pain
Physical Functioning
Psychological Factors
Pain Behaviors
Objective Correlates

The Cause of Psychogenic Pain

Theory 1:
Underlying psychological factors cause
psychogenic pain
anxiety disorder
depression

Theory 2:
Psychogenic pain results from some previous injury
that hasnt yet fully healed.

Theory 3:
Psychogenic pain causes existing pain to feel
worse than the situation actually warrants.

Symptoms of Psychogenic Pain

Constant discomfort despite taking medication
Difficulty describing the location, quality and
depth of pain
Non localized pains that encompass larger
parts of the body
Worsening pain independent of any underlying
medical condition.
All above symptoms exist in absence of any chronic disorder
with physical cause

Case from Clinic (2)

A 45 yrs old man with history of major
depressive disorder in his 30s.
He complained that the symptoms of depression
were coming back recently
He also complained aches all over his body
The man was diagnosed with MDD with somatic
as a predominat symptoms
Notes : Approximately two thirds of patients with depression in
primary care present with somatic symptoms
(Tylee, et al, J Clin Psychiatry. 2005; 7(4): 167176)

Psychiatric Disorder and Pain

DEPRESSION
Approximately 60% of patients with depression present pain at the
moment of the diagnosis
The presence of depressive disorder may increase the risk of developing
a musculoskeletal pain, headache and chest pain 3 years later on.
Elderly patients with depression are at increased risk for cervical, lumbar
and hip pain.
Depression prevalence was 12 times in individuals with three or more
pain-related symptoms, as compared with patients without pain.
Patients with chronic pain suffered from major depression between 8%
and 50%

Pain and psychiatry: a critical analysis and pharmacological review. Marazziti, et al,
Clinical Practice and Epidemiology in Mental Health 2006, 2:31

Psychiatric Disorder and Pain

ANXIETY
Patients with different painful syndromes showed an increased risk of
anxiety syndromes or disorders (50% have anxiety symptoms and 19%
have a panic disorder or generalized anxiety disorder)
A prospective study involving 1007 young adults found that a history
of headache was associated with a higher of panic disorder
Anxiety disorders are associated with high somatic
preoccupation levels and physical symptoms.
In a study of panic disorder, at least 40% patients described chronic
pain symptoms and more than 7% took pain relievers daily

PAIN in Psychosomatic Patient

Unpublished survey. Conducted by

Dr Andri for educational and promoting mental health
purpose only. Data were collected using
ww.surveymonkey.com. Bias of the result is one of the
weakness of this survey

Multimodal Treatment of Pain Based on

Biopsychosocial Approach
Lifestyle management

Stress management

Sleep hygiene

Physical
therapy

Interventional pain
Pharmacotherapy management

Occupational therapy

Education
Complementary therapies

Biofeedback

Gatchel RJ et al. Psychol Bull 2007; 133(4):581-624; Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research.;
National Academies Press; Washington, DC: 2011; Mayo Foundation for Medical Education and Research. Comprehensive Pain Rehabilitation Center Program Guide. Mayo
Clinic; Rochester, MN: 2006.

Barrier to Psychiatric Approach

A referral to psychiatrist may mean to the
patient:
- The pain is not real
- Physicians are giving up on them
- Physicians have failed to diagnose the
underlying disease
- Physicians refer only when they think no
organic pathology could be detected

Psychiatric Treatment Approach

Interdisciplinary approach with other specialists
Acknowledge the symptoms : the pain is real
Supportive therapy and cognitive therapy: How
can I live with this pain? ; How can I adapt
with it?
If commorbid with mental disorder, Treat it Well
Drugs that psychiatrist usually use :
SNRI (duloxetine), Amytriptiline, Pregabalin

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