Management of chronic pain: Psychotherapeutic perspective

There are several types of pain, due to different sources. In patients with chronic pain, the original nociceptive source of the pain is no longer sufficient to explain the pain that the patient is currently experiencing. So psychiatric referral is needed but must be done with catuion.Physicians sometimes doubt the veracity of the pain complaints. Psychiatric consultation in such patients may complicate the problem by suggesting to the patient that his or her treating physician thinks his or her underlying problem is mental, rather than physical, in nature. This problem can be avoided by a careful explanation that consultation is being requested to help the patient deal with his or her pain problem, and not because the physician doubts its underlying veracity. In addition to medication usage for pain, there are general principals of pain therapy, according to psychotherapeutic perspective that should be regarded; These principals include: 1) Pain Is not psychological by default; 2) Care does not only involve symptom management; 3) Caveats in using placebos; 4) Deafferentation surgery is usually not the answer; and 5) Necessitating talking and listening. Considering theses principals may enhance medication compliance and response to it and relieving symptoms. Talking and listening, effectively, empathically and professionally, in general, has its difficulties, because we must be attempting to verify patients’ suffering despite trying to cope with it.After that psychiatrists must consider comorbidities like depression and anxiety, so common in chronic pain disorder. Pharmacotherapy may benefit these comorbidities.Today we know that formal, but modified, psychotherapies with different approaches, are the main methods that may benefit these patients. First of all, Cognitive-behavioral therapy (CBT) has been shown to be effective in patients who suffer from either continuous or chronic pain. Techniques those usually we use in CBT will be helpful in treating these patients, such as Homework assignments, Relaxation, Physical activity, Positive affirmation, Relapse prevention techniques, Operant-behavioral therapy, Biofeedback, Hypnosis and Meditation, but We will review some especial practical points that help in dealing with them.On the other hand, psychodynamic psychotherapies may be of value for treating patients with chronic pain, but there is relatively less evidence for effectiveness of it, because of the specific nature of them. Systematic reviews have shown that a modification of the psychotherapeutic technique, involving an approach that is more structured and is also rather supportive at least at the beginning, is necessary for enhancing effectiveness of them.Understanding the dynamics underlying patients’ symptoms, however, will help both patients and physicians do better in treatment and coping with pain. Some psychodynamic aspects of coping involve conflicts over autonomy and care. Old conflicts about nurturance can manifest themselves as mixed feelings, negative and positive, about recovery. Thus, shame may develop and then mimic depression, cause conservation avoidance, and produce pseudo-dependent behaviors. Non-compliance and help-rejecting behavior may occur due to excessiveregression, some of which is normal. Tracing these situations will help both physicians and psychiatrists to manage their patients’ and also their own conflicts.