One Day "Medical Approach in Holistic

Management to Relieve Pain" 13 Des

2015 at The Sunan Hotel, SOLO

Pain Is the 5th Vital Sign

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

Temperature Respiration Pulse Blood pressure

Pain

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

Time to resolution

Acute pain Chronic pain

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.). Bonica’s Management of Pain. 3rd ed. Lippincott Williams & Wilkins; Hagerstown, MD: 2001.

Insult

Normal, time-limited response

to „noxious‟ experience

(less than 3 months)

Pain that has persisted beyond

normal tissue healing time

(usually more than 3 months)

• Usually obvious tissue damage

• Serves a protective function

• Pain resolves upon healing

• Usually has no protective function

• Degrades health and function

Acute pain may become chronic

Pain Categories

1. Somatogenic pain is pain with cause (usually known) localised in the body tissue

a/ nociceptive pain b/ neuropatic pain 2. Psychogenic pain is pain for which there is no known physical cause but processing of sensitive information 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

• 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 hasn’t 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 30’s.

• 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): 167–176)

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

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

PAIN in Psychosomatic Patient

Multimodal Treatment of Pain Based on Biopsychosocial Approach

Pharmacotherapy

Stress management

Interventional pain

management

Biofeedback Complementary therapies

Physical

therapy

Education

Lifestyle management

Sleep hygiene

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.

Occupational therapy

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

Twitter : @mbahndi

IG : andripsikosomatik

Curriculum Vitae • Nama : Dr.Andri,SpKJ,FAPM

• Usia : 37 tahun

• Pendidikan : – Dokter : Fakultas Kedokteran Universitas Indonesia (Lulus 2003)

– Psikiater : Fakultas Kedokteran Universitas Indonesia (Lulus 2008)

– Pendidikan tambahan di bidang psikosomatik medis dari American Psychosomatic Society di Portland, Oregon, USA tahun 2010 dan Academy of Psychosomatic Medicine di Atlanta, USA 2012, di Tucson 2013 dan di Fort- LeDaurdale 2014

– Pengakuan sebagai Fellow of The Academy of Psychosomatic Medicine (FAPM) November 2013

• Organisasi :

– IDI

– PDSKJI

– American Psychosomatic Society

– Academy of Psychosomatic Medicine

• Jabatan :

– Dosen Psikiatri di FK UKRIDA, Jakarta

– Kepala Klinik Psikosomatik Omni Hospital, Alam Sutera

– Ketua Sub Kredensial Komite Medik RS OMNI Alam Sutera