Psychogenic/idiopathic pain syndromes

Chronic Pain, Psychopathology, and DSM-5 Somatic Symptom Disorder

Unlike acute pain that warns us of injury or disease, chronic or persistent pain serves no adaptive purpose. Though there is no agreed on definition of chronic pain, it is commonly referred to as pain that is without biological value, lasting longer than the typical healing time, not responsive to treatments based on specific remedies, and of a duration greater than 6 months. Chronic pain that is severe and intractable has detrimental consequences, including psychological distress, job loss, social isolation, and, not surprisingly, it is highly comorbid with depression and anxiety. Historically, pain without an apparent anatomical or neurophysiological origin was labelled as psychopathological. This approach is damaging to the patient and provider alike. It pollutes the therapeutic relationship by introducing an element of mutual distrust as well as implicit, if not explicit, blame. It is demoralizing to the patient who feels at fault, disbelieved, and alone. Moreover, many medically unexplained pains are now understood to involve an interplay between peripheral and central neurophysiological mechanisms that have gone awry. The new Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, somatic symptom disorder overpsychologizes people with chronic pain; it has low sensitivity and specificity, and it contributes to misdiagnosis, as well as unnecessary stigma. Adjustment disorder remains the most appropriate, accurate, and acceptable diagnosis for people who are overly concerned about their pain.

Successful outcome after surgical management in two cases of the "painful variant" of Hashimoto's thyroiditis

OBJECTIVE

To describe two cases of the rare "painful variant" of Hashimoto's thyroiditis (HT) that were refractory to medical management and in which surgical intervention provided the definitive treatment.

METHODS

We thoroughly review the clinical history as well as the laboratory, imaging, and surgical pathology data in these cases, and follow-up of the clinical response over time is provided. The relevant literature is also discussed.

RESULTS

A 56-year-old woman, who had remotely undergone a left hemithyroidectomy and had been diagnosed with HT, sought further assessment because of neck pain and edema. Treatment with corticosteroids was partially successful but led to the development of Cushing's syndrome. A 32-year-old man had pain and swelling of the thyroid and was diagnosed with HT shortly thereafter. Levothyroxine treatment was unsuccessful. Both patients underwent thyroidectomy. Chronic lymphocytic thyroiditis (HT) with a variable degree of fibrosis was found on assessment of pathology specimens. The patients remained asymptomatic after the surgical procedure and did not require any further anti-inflammatory therapy.

CONCLUSION

In selected cases, surgical treatment may become necessary for effective and permanent control of symptoms and local signs in painful HT. Access to experienced endocrine surgeons is important in order to avoid postoperative complications because the thyroid gland may be small or fibrosed in this rare variant of HT.

Mind/body dualism in medicine: The case of chronic pelvic pain without organic pathology: a critical review of the literature

Chronic pelvic pain in the absence of organic pathology identifiable in medical terms is considered one of the most perplexing conditions that gynecologists confront. A critical analysis of the medical, psychiatric, and psychological literature on chronic pelvic pain without organic pathology reveals that the dichotomous construct of mind and body underpinning medical research and understanding is a barrier to the successful diagnosis and treatment of this condition, and indeed to the productive engagement of the health professional with the patient. The strict duality of the condition's etiology being understood in either physiological or psychogenic terms has been questioned at times over the last 40 years, but only recently has an "integrative model" been proposed. However, it is argued here that although the development of a multidisciplinary approach is important, only a radical deconstruction of the medical paradigm will truly address the problem and enable a real change in practice.

Problems women patients experience in the medical encounter for chronic pelvic pain: a New Zealand study

Women who have used the New Zealand health services for chronic pelvic pain have reported problems with diagnosis, communication with the doctor, lack of information, and inappropriate treatment. Six focus groups were conducted in which women talked about their experiences of using the health services for chronic pelvic pain. A discourse analysis of this material provided a conceptual basis for understanding the key dimensions structuring women's experience. Themes of particular concern were that (a) doctors negated the woman's own experience of the pain and its meaning to her and this negation affected her ability to take responsibility for her condition; (b) the medical "extraction" of symptoms through technology overshadows the woman's discursive interpretation of, and voicing of, her symptoms; and (c) the concept of "pelvic pain without organic pathology" implies an absence that becomes filled with the specter of neurosis or psychological problems.

Stress, depression and left-sided psychogenic chest pain

Ninety men between the ages of 20 to 65 were studied to investigate the relationships between stress, depression and psychogenic pain. Three groups (the coronary heart disease (CHD) group; the left-sided psychogenic chest pain (LPCP) group; and the control group) comprising 30 patients per group, each completed the Social Readjustment Rating Scale (SRRS), as a measure of stress; the Schedule of Recent Experience, to document the recency of actual life events experienced as listed in the SRRS; and the Beck Depression Inventory, as a measure of the severity of depression. Separate analyses of the variables stress and depression failed to yield significant stress differences in the 3 groups, but the LPCP group was significantly more depressed than the CHD and control groups. Factor analysis, however, indicated that the stress profiles were significantly different in each of the 3 groups. This study indicates that the condition of LPCP shares a similar depressive profile to other psychogenic pain conditions and further lends support to the hypothesis linking psychogenic pain to depressive disorders.

Idiopathic pelvic pain. The relationship to depression

Episodic and chronic idiopathic pelvic pain is enigmatic for both physician and patient. Antidepressant drug therapy combined with behavior modification techniques is beneficial in improving the functional status of some patients. Whether the decrease in frequency, intensity, and duration of pelvic pain complaints results from treatment of underlying depression or analgesic effects of the antidepressant drugs is difficult to determine. Addressing the psychological component of idiopathic pelvic pain through education and counseling is essential to long-term resolution of symptoms.