Posted by: faithful | August 2, 2007

why is chronic pain so difficult to treat

Why is chronic pain so difficult to treat?

Psychological considerations from simple to complex care

Mark B. Weisberg, PhD; Alfred L. Clavel Jr, MD, VOL 106 / NO 6 / NOVEMBER 1999 / POSTGRADUATE MEDICINE

 

CME learning objectives

  • To appreciate the importance of psychological, social, cultural, and biologic factors in treating chronic pain
  • To recognize the numerous factors that play a role in initiating, maintaining, and exacerbating chronic pain
  • To be aware of the special demands of caring for patients with complex chronic pain


Preview: Traditional conceptualization and treatment of chronic pain based solely on biologic factors have proved inadequate for patients with complex pain conditions. Drs Weisberg and Clavel explain why and describe a more effective approach that also includes psychological, social, and cultural factors. A case report illustrates this multidisciplinary approach to diagnosis and treatment of complex chronic pain.
Weisberg MB, Clavel AL Jr. Why is chronic pain so difficult to treat?: psychological considerations from simple to complex care. Postgrad Med 1999;106(6):141-64


Every clinician who treats patients with chronic musculoskeletal or nerve injuries, headache, or other chronic pain frequently faces difficult dilemmas. Treatment approaches are often unclear. Patient encounters may be time-consuming, frustrating, and emotionally draining. After repeated referrals for diagnostic tests, physical therapy, or specialty care, patients often return more depressed, hopeless, and demoralized than before. Yet, it may be difficult for the clinician to bring up the psychological aspects of a problem. Patients may react defensively, believing that the clinician thinks the distress is “all in their head.”

As time passes, patients become more somatically focused, report multiple vague symptoms, and become increasingly inactive. Often, their expectations and concerns increase while their compliance with self-care regimens declines. For persistent pain sufferers, the search for results is met with an increasing sense of failure, dissatisfaction, and frustration. This typical chain of events leads many patients, clinicians, and insurance companies to believe that chronic pain is untreatable.

What can be done about the enigma of chronic pain? This article addresses some significant variables that can aid in more effective treatment. First, since efforts to control and treat pain stem directly from basic assumptions regarding the cause and management of disease, it is important to review differences between the biomedical and biopsychosocial paradigms and their implications for treatment. Second, psychological variables are considered, because an understanding of how they affect the etiology and maintenance of chronic pain can assist in more effective conceptualization and treatment. Finally, criteria for distinguishing simple from complex chronic pain are presented. Interdisciplinary management is stressed here, because outcomes are improved when multiple aspects of a patient’s problem are addressed simultaneously, especially in complex cases.

Biomedical paradigm

The biomedical paradigm, evolving simultaneously with developments in the fields of genetics, anatomy, and physiology, views biologic factors as being primary in the causation and maintenance of disease. In this model, a patient’s complaint is assumed to result from a specific disease state manifested by a biologic disorder. Objective tests should target diseased systems, leading to a correction of the organic pathologic condition. Psychological factors are viewed as either irrelevant or secondary, as if the mind were reactive to, but otherwise disconnected from, disease in the body (1).

Two categories of patients are thus implied: patients with clearly definable organic disease, who are considered to have “real” disease, and those viewed as having “psychogenic” disease (which might mean “not real,” “untreatable,” or “all in the patient’s head”). Primary treatment options in this model would emphasize somatic interventions, such as medication, physical therapy, and surgery.

Traditional biomedicine has made tremendous contributions to health, especially in the treatment of acute disease. However, attention to biologic factors, while necessary, is insufficient for conceptualization and treatment of chronic pain. For example, highly diverse responses to identical objective physical symptoms and treatments have been noted clinically and have been documented in many empirical investigations. Deyo (2) found no identifiable organic basis for back pain in about 80% of patients studied. Many patients suffer from persistent pain that is refractory to standard biomedical treatments, and functional disability is often greater than would be predicted on the basis of physical findings alone. In many chronic pain conditions, current and persistent pain is not necessarily associated with corresponding fluctuations or progression of specific physical disease (3). As a result, the need for a different type of model has been recently acknowledged (4-9). The biopsychosocial paradigm has evolved in response to this need.

Biopsychosocial paradigm

The biopsychosocial paradigm represents an attempt to incorporate, but also expand, what is best from biomedicine. This model reflects a combination of biologic, psychological, social, and cultural influences that are viewed as essential in causing, maintaining, and exacerbating disease (6). From this perspective, the organic versus psychogenic dichotomy is outdated. The diversity in presentation of chronic pain symptoms (eg, severity, duration, degree of functional disability) can be explained by the interrelationships among pathophysiologic changes, psychological functioning, and the social and cultural factors that affect a patient’s perception of and response to distress.

Is chronic pain a “psychosomatic disorder”?

One term that reflects the confusion between biomedical and biopsychosocial models is “psychosomatic,” a label often used in discussing patients with chronic pain. “Psychosomatic Disorders” was listed in the original 1952 edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association. A disease was classified as psychosomatic if a clear biologic origin could not be delineated. (For this reason, migraine and essential hypertension were considered psychosomatic.) Only when this “diagnosis by exclusion” occurred was psychological intervention involved, since the problem was then deemed psychogenic.

Psychological-physiologic interactions
With increasing recognition that psychological factors are operative in precipitating or exacerbating most organic disorders (1,5,6,9-12), it became apparent that the term “psychosomatic” perpetuated an unclear understanding of what transpires in chronic illness, including chronic pain. Pain clinicians recognize that psychological and social factors are not only reactive to biologic changes (eg, depression and social withdrawal in response to a pain disorder), but that these factors may alter biologic function as well.

Burgeoning research in psychoneuroimmunology (13) (the study of effects of emotion, cognition, and behavior on the endocrine, neuroimmune, and autonomic nervous systems (1,12,14)) suggests some of the neurohormonal and neuroimmune pathways by which psychological factors impact on pathophysiology in pain. For example, it is now understood that certain factors, such as negative emotional states, sleep disruption, and environmental triggers, can alter brain-stem processing in certain genetically susceptible individuals. This starts a cascade of events leading to the release of neuropeptides in the dura mater. These neuropeptides cause vasodilation and plasma extravasation in a process called neurogenic inflammation, which is critical to an understanding of migraine headache (15).

Elliot (16) points out that depression and anxiety in patients with chronic pain can alter levels of neurohormonal substances such as cortisol, corticotropin (ACTH), epinephrine, and norepinephrine. Alterations in blood levels of these substances may contribute to the encoding of state-dependent physiologic and affective responses. In other words, initial or reactive negative emotional states can have a direct impact on physiologic processes that affect the progression of chronic pain. Some investigators (17,18) believe that negative emotion manifests physiologically through altered stress hormone production and neuropeptide cascades that affect all organ systems. For example, in a recent randomized trial, Smyth and associates (19) found that patients with rheumatoid arthritis who wrote about stressful experiences and associated negative emotions experienced significant decreases in chronic joint pain.

As pain researchers from the fields of psychology and psychiatry have incorporated these findings, new diagnostic categories have been developed, such as “Psychological Factors Affecting Physical Condition” in DSM-III and “Pain Disorder Associated With Both Psychological Factors and a General Medical Condition” in DSM-IV. These changes have helped pain clinicians adopt a much more useful approach to diagnosis and intervention in the psychological dimensions of chronic pain.

Thus, the role of psychological factors in chronic pain is more complex than originally understood. In the early 1950s, intractable chronic pain might often have been considered a psychosomatic disorder. Today we realize that chronic pain constitutes a complex mixture of pathophysiologic factors interacting with numerous psychological, social, and cultural factors, including:

  • Depression, anxiety, and personality disorders (5,7,9)
  • Defective coping styles (20,21)
  • Autonomic stress reactions (1,10,12,14)
  • Lifestyle factors (22,23)
  • Noncompliance with treatment program (5,7,11)
  • Somatization (8,16,24)
  • Disturbances of interpersonal relationships (7,25)
  • Appraisal of stressful events (23)
  • Beliefs about control of pain (26)
  • Self-efficacy and cognitive distortions (21)
  • Involvement with disability or workers compensation programs (11,20)

Comprehensive chronic pain treatment model
In a comprehensive chronic pain treatment model, the clinical health psychologist consults with the patient, family, and treatment team. The target of intervention is the interaction of psychological and physiologic factors that cause and perpetuate chronic pain. This is in contrast to the earlier, traditional notion of “treating the patient’s neurosis and then the real physical problem.” (6,11) By involving the clinical health psychologist in the patient’s assessment and treatment, outcomes are improved (7,9). Table 1 lists goals for psychological assessment and treatment of patients with chronic pain.

Table 1. Psychological assessment and treatment interventions in complex chronic pain

Assessment of
Initial pain complaints

Previous attempts at treatment

Medical resource utilization and comorbid conditions

Factors that exacerbate or decrease pain

Family history and review of concurrent functioning of familial, vocational, social, and legal systems

Parafunctional postural, muscular, and behavioral habits (eg, slumping, muscle clenching, bruxism)

Patient-specific psychophysiologic reactivity (eg, unique autonomic or muscular reaction occurring in response to stress or pain)

Psychopathologic condition that may affect or prevent appropriate pain treatment if not addressed

Treatment interventions
Cognitive-behavioral treatment of parafunctional muscular, postural, and behavioral habits (eg, slumping, muscle clenching, bruxism)

Hypnosis and biofeedback for relaxation training, pain reduction, development of emotional mastery and behavioral skills, and enhancement of ego-strengthening and coping resilience

Brief, structured psychotherapy to address depression, anxiety, somatization, and other emotional, cognitive, and behavioral variables that affect pain maintenance

Systems intervention with patient’s family and work environment or legal system (as in workers compensation cases)

Education of patient and family about factors that promote future health and a reduction in relapse episodes

Coordination of meeting between patient, family, and treatment team to ensure optimal benefit (particularly when there are concerns about compliance, motivation, secondary gain, adverse litigation-related incentives, or poor comprehension of treatment plan)


 

Application of biopsychosocial model to chronic pain

Advances continue to be made in our understanding of the basic mechanisms of pain and its transmission, modulation, and perception. The importance of mind-body interactions has been demonstrated. New therapies, high-technology interventions, and pharmacologic options have developed rapidly. All of these advances place great demands on clinicians, who must offer a rational approach to their patients. This is particularly true in chronic pain, where traditional approaches to treatment have proved less than satisfactory. Each clinician needs to have a system of conceptualization and treatment to help guide appropriate therapy. As discussed earlier, the biopsychosocial model is useful here, especially in complex cases. Symptoms are viewed as the product of multiple dynamic factors that develop synergistically in combination with certain genetic, psychological, and environmental vulnerabilities.

It is helpful for the clinician to think of these dynamic factors as predisposing, initiating, or perpetuating. They can be divided into contributing factors (table 2), which are managed as part of overall pain treatment, and barriers to treatment (table 3), which are addressed before pain treatment begins.

Table 2. Contributing factors in complex chronic pain

Predisposing factors (primarily systemic conditions)
A. Pathophysiologic conditions
  1. Degenerative, rheumatologic changes
  2. Neurologic conditions
  3. Hormonal, nutritional, and metabolic conditions
  4. Vascular problems

B. Psychological and psychophysiologic conditions
  1. Increased levels of muscle activity
    a. Increased muscle tone
    b. Deficits in muscle discrimination
    c. Poor posture
    d. Reduced flexibility
    e. Poor body mechanics
    f. Deconditioning
  2. Premorbid psychopathology
    a. Depression, anxiety, somatization tendencies
    b. Unresolved psychological trauma
    c. Personality disorders

C. Structural conditions
  1. Skeletal malformations
  2. Degenerative spine disease
  3. Disk herniation or bulge

Initiating factors
A. Trauma
  1. Accidents (motor vehicle, work- or home-related)
  2. Physical abuse
  3. Medical procedures

B. Adverse loading on joint or musculature
  1. Parafunctional habits
    a. Poor body mechanics
    b. Prolonged sitting
    c. Poor lumbar stability
    d. Weak abdominal muscles
    e. Chronic muscle tension
  2. Repetitive heavy lifting or bending

Perpetuating factors
A. Permanent tissue damage

B. Behavioral factors
  1. Bracing, guarding
  2. Work-related behaviors, ergonomic variables
  3. Inactivity or excessive bed rest
  4. Pain cycle

C. Emotional factors
  1. Reactive depression or anxiety
  2. Reactive somatization
  3. Emotional significance of disorder to patient

D. Cognitive factors
  1. Catastrophizing
  2. Unrealistic expectations

E. Social factors
  1. Litigation
  2. Secondary gain
    a. Concern from others, family systemic changes
    b. Relief from responsibility

F. Persistent predisposing and initiating factors


Adapted from Glaros A, Glass E. Temporomandibular disorders. In: Gatchel RJ, Blanchard EB, eds. Psycho-physiological disorders: research and clinical applications. Washington, DC: American Psychological Association Press, 1993.


 

Table 3. Barriers to treatment of complex chronic pain

Primary chemical dependency

Primary psychological disorder

Ongoing litigation

Overwhelming other life stressors

Lack of motivation to change


 

Management of simple versus complex chronic pain

Effective assessment and treatment of chronic pain begin by establishing a medical diagnosis, defining the extent of disease, identifying psychophysiologic and social contributing factors, and clarifying the overriding goals of treatment. The patient’s condition is categorized as simple or complex, since treatment differs. Table 4 lists some of the factors that distinguish complex from simple cases, while figure 1 (not shown) illustrates the decision tree for involving patients in simple or complex care (27).

Table 4. Distinguishing features of complex chronic pain

Multiple pain problems

Multiple medical problems

Pain duration longer than 6 months

Significant psychopathology

Frequent visits to healthcare providers

Frequent use of medications

Significant physical deconditioning

Difficulty achieving muscular relaxation

Significant lifestyle disturbance (eg, marital, familial, vocational)

Language or cultural barriers

History of multiple treatment failures


 

Simple chronic pain
Patients with simple chronic pain resulting from a clearly defined condition can initially be managed by one clinician alone. This group of patients has good potential for rapid adjustment and recovery. Generally, they are able to achieve muscular relaxation, institute time management strategies, and maintain exercise and other daily activities. Compared with patients with complex pain, they are more likely to come from stable marriages and families and to have supportive friends, good interpersonal skills, and a good work record.

During treatment, patients with simple chronic pain are monitored for response to therapy, compliance with treatment, and development of reactive emotional distress and disability. Owing to all the foregoing factors, any treatment used in chronic pain, such as drug therapies, hypnosis, or physical therapy exercises, is likely to work relatively well and quickly in this group.

In simple chronic pain, psychological interventions are relatively brief because of the patient’s active participation in care and lack of significant premorbid psychopathology. The patient and family should be made aware that occasional setbacks are normal and should be taught the management skills necessary to deal effectively with the attendant stress and anxiety. Measures may include institution of hypnosis or other techniques to help the patient learn effective physiologic self-regulation of anxious states. The psychologist also teaches the patient to improve proprioceptive awareness of parafunctional postural and muscular patterns.

Complex chronic pain
Patients with complex chronic pain present with multiple risk factors for poor outcome and are significantly more difficult for one clinician alone to treat (table 4). For example, patients may present with a combination of physical diagnoses, such as fibromyalgia, cluster headaches, and temporomandibular disorder. They may be involved with workers compensation or other litigation. They may exhibit possible analgesic rebound pain due to long-term opioid use.

Psychological factors are usually significant and numerous in patients with complex chronic pain. Like patients with simple pain, they need help with relaxation training and reduction of parafunctional muscular habits. However, they may also exhibit depression, anxiety, or personality disorders that can interfere with treatment if not addressed. Many of them may have been given various combinations of antidepressant or anxiolytic medications without obtaining significant relief of physical pain or emotional distress. Some may also exhibit somatization disorder. In other words, their underlying pathophysiologic state may be exacerbated by emotional distress, which presents as intensified pain symptoms (8). An example of this would be a patient whose symptoms of chronic low back pain heighten at times of anxiety about her impending marriage, yet she has no awareness of this connection. Some patients with a history of untreated physical or sexual abuse exhibit paradoxically increased anxiety after relaxation exercises. Their increased autonomic hyperreactivity may continually exacerbate pain flare-ups. Patients with dysfunctional marriages are at increased risk for assuming a sick role (25), with unintentional spousal reinforcement of dysfunctional pain behaviors.

It is unrealistic and unwise to expect only one clinician to address the multitude of contributing factors that may be present in complex chronic pain. In such cases, referral to an interdisciplinary team of specialists who can address the condition from different but complementary perspectives is indicated (3,7,28).

Interdisciplinary pain team

The interdisciplinary pain management team can be part of a primary care practice or a specialty pain clinic. It usually consists of a physician specializing in pain management (eg, neurologist, anesthesiologist, family physician, internist, physical medicine and rehabilitation specialist), a clinical health psychologist, and a physical therapist. Other specialists (eg, dentist, allergist, otolaryngologist, psychiatrist) may be involved as needed. Simultaneous treatment of multiple risk factors is more synergistically effective than treatment of each factor individually. Team members often share ongoing assessment and treatment data to ensure the needed continuity of approach, particularly in complex cases. All team members provide a supportive relationship in a positive environment that promotes gradual change and compliance with treatment, self-efficacy, self-responsibility, and self-care.

Treatment of structural pathologic conditions is based on accepted medical care. The pharmaceutical management of sleep disruption, mood disturbance, muscle tension, and pain greatly facilitates overall progress (29). Analgesics are prescribed on a time-contingent rather than a pain-contingent basis to facilitate monitoring and self-awareness. The goal of medication is to provide baseline pain relief so that the patient can more actively participate in self-care and rehabilitation. If opiates are prescribed for patients with chronic pain, they should be part of a reasonable, rational, biopsychosocial treatment approach (30) and should be discontinued if psychosocial components are neglected.

The clinical health psychologist monitors for critical risk factors, such as psychopathology, poor motivation, secondary gain, somatization, or noncompliance. Any of these factors could interfere with treatment and lead to relapse. Hypnosis may be used not only for relaxation and pain reduction, but also for enhancing coping resilience and addressing underlying fears that may interfere with full participation in treatment. Ongoing management of contributing factors is accomplished through education, behavioral and psychological techniques, and progressive rehabilitation.

For patients with complex chronic pain, this type of approach typically involves a series of weekly to monthly visits, gradually tapering over 6 to 12 months. Since most pain clinics practice evidence-based care, team members often review treatment results and outcome data to ensure empirical support for ongoing clinical practices.

A hypothetical case history involving multidisciplinary diagnosis and treatment of complex chronic pain is presented in the box below. This case report illustrates the practical value of a biopsychosocial approach. Note the effect on the patient of receiving varying diagnoses from different clinicians in multiple settings. Notice also how reactive depression and anxiety led to increased interference with normal work functioning and how multimodal intervention was utilized to simultaneously reduce symptoms and decrease multiple risk factors.

Ramifications for primary care physicians treating chronic pain

As is evident from the foregoing discussion, management of the patient with chronic pain can be aided by increased attention to the interaction of physical and psychological factors. Careful observation of the patient’s behavior, affect, and social interaction during history taking and physical examination provides clues to the level of complexity of the case. Observations regarding the patient’s present emotional status may indicate the need for referral to a psychologist who specializes in pain management. Indicators of such a need include excessively depressed, angry, or anxious affect; an unconcerned or hypervigilant attitude; and overly supportive, enabling, or co-dependent behavior by the patient’s spouse or significant other.

The care of patients with complex chronic pain places special demands on the clinician, and these must be considered when working with this population. Factors such as providing sufficient time for the patient to be heard and sensitively handling painful emotions and delicate situations (such as discussion of patient motivation and secondary gain issues) are critical. Taking time to educate patients about their problem and about the interaction of physical and psychological factors from a biopsychosocial perspective can greatly enhance patient self-responsibility, self-efficacy, and compliance while improving patient satisfaction and reducing defensiveness. Patients with complex chronic pain often require more time per visit, initially need to be seen on a more regular basis, and may call frequently for reassurance.

Summary

The treatment of patients with chronic pain can be difficult and challenging. Recent advances in our understanding of the pathophysiologic mechanisms involved have led to viewing this condition as a multifactorial problem with interrelated structural, functional, and psychophysiologic factors. Treatment of simple chronic pain is fundamentally different from that of complex chronic pain. The former can be managed by one clinician alone, whereas the latter requires the integration of a multidisciplinary team of specialists with a biopsychosocial treatment philosophy.

References

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  8. Rosen G, Kleinman A, Katon W. Somatization in family practice: a biopsychosocial approach. J Fam Prac 1982;14(3):493-502
  9. Gatchel R. Psychophysiological disorders: past and present perspectives. In: Gatchel R, Blanchard E, eds. Psychophysiological disorders: research and clinical applications. Washington, DC: American Psychological Association Press, 1993:1-22
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Hypothetical case: Complex chronic headache responds to a biopsychosocial approach

A 43-year-old married man employed as a midlevel bank manager had headaches dating back to childhood. In recent years, the headaches had become a constant, bilateral, dull pain encompassing the neck and temporal area and occasionally becoming throbbing and severe. They were progressively affecting his mood, job, and relationships as he became increasingly angry, sullen, and withdrawn. His family physician found no organic basis for the condition and made the diagnosis of tension headaches, prescribed diazepam, and recommended that the patient reduce stress. The patient was not exactly sure how to accomplish this.

Individual referrals and therapies
The headaches gradually increased over the next 4 months, and the patient’s family physician referred him to a neurologist. Neurologic examination, a computed tomographic scan, an electroencephalogram, and blood studies indicated no significant abnormalities. Ergotamine was prescribed for mixed tension and vascular headaches and was initially effective for severe headache. Its effectiveness decreased, however, and the patient became increasingly fearful about his condition. The neurologist increased the dosage of ergotamine, then switched to muscle relaxants and barbiturates.

As the headaches continued unrelieved, the patient felt increasingly irritable and started reporting initial and middle insomnia. As his sleep became less rejuvenative, he began to miss work more often. Subsequently, symptoms included clicking and pain in the jaw, tinnitus, dizziness, blurred vision, and generalized fatigue and malaise.

His family physician then referred him to an allergist, an otolaryngologist, and a dentist. The otolaryngologist and allergist both diagnosed sinusitis and prescribed, respectively, an antibiotic and allergy injections. The dentist adjusted the patient’s bite and performed endodontic therapy, which gave transient relief.

When the pain returned more intensely than before, the patient became increasingly depressed and hopeless. As he relied on larger doses of ergotamine with caffeine and aspirin, stomach irritation developed. He became more socially withdrawn and increasingly absent from his job, finally taking a temporary medical leave.

Multidisciplinary management
He was then referred to a multidisciplinary chronic pain clinic staffed by a neurologist (board-certified in pain management), a clinical health psychologist (board-certified in clinical health psychology), a physical therapist, and a dentist who specialized in temporomandibular and craniofacial disorders. Their team assessment is described in the following paragraphs.

At the time of evaluation, the patient described daily bilateral temporal headache, jaw pain, and weekly unilateral throbbing headaches. He exhibited significant frontal and occipital muscle tightening and guarding, with numerous trigger points in these areas. His posture was poor, and he tended to slope his shoulders and thrust his chin forward, causing strain on the neck and shoulders. Both clenching and nocturnal bruxism were occurring, and a high degree of generalized muscle tension was present.

When aided in achieving a relaxation response, the patient had difficulty maintaining it and also had difficulty differentiating between tension and relaxation. This state was exacerbated by his consumption of about 10 cups of coffee daily.

The patient had a long history of intermittent depression and somatic anxiety, and he worried often about possible catastrophic illnesses. His sleep was disrupted, and when he awoke, he would lie in bed for 30 to 60 minutes, trying to get back to sleep.

The Minnesota Multiphasic Personality Inventory (MMPI) suggested depression, somatic anxiety, poor coping resilience, and a tendency to heighten pathophysiologic distress by internalization of emotional concerns (somatization). He was a poor evaluator of his somatic sensations, having difficulty noticing normal daily fluctuations in pain and therefore fearing that the pain was constant, severe, and unchangeable. These worries were temporally related to an increase in headache and jaw pain. He did not engage in any regular physical exercise.

The team’s diagnoses consisted of myofascial (masticatory and cervical) pain syndrome, migraine without aura, pain disorder due to psychological factors as well as to a general medical condition, and reactive depression.

On the basis of the comprehensive assessment and diagnoses, the team instituted the following: Sumatriptan was prescribed for management of migraine, and a tricyclic antidepressant was given to help alleviate symptoms of both depression and pain. The patient was slowly weaned off caffeine and started eating three meals daily. The dentist fitted him with an acrylic occlusal mouthguard to prevent further damage from nocturnal clenching and bruxing.

Meanwhile, a behavior modification program was initiated to enable the patient to notice and reduce these parafunctional muscular habits. The psychologist instituted brief structured psychotherapy to reduce reactive depression and somatic anxiety. He also instituted hypnosis for relaxation and reduction of pain, anxiety, and catastrophic worry related to the symptoms. A self-hypnosis tape was made, and the patient was instructed to listen to this twice daily. He learned how worrying about the symptoms actually increased their intensity and was shown strategies for appraising his symptoms with less anxiety and concern (cognitive restructuring).

Physical therapy consisting of daily stretching and strengthening exercises was instituted. The patient also learned proper sleep hygiene, such as avoiding daytime naps, staying out of bed until time to sleep, and getting out of bed if awake for more than 10 minutes rather than struggling to sleep. He was started on a program of mild aerobic exercise 4 days per week. Within 2 weeks after starting the behavior modification program, he returned to work, armed with improved tools for self-care, time management, and conflict resolution.

At 6-month follow-up, the patient reported significant, sustained reduction in the frequency and intensity of headaches and jaw pain. When he did have headache pain, he was much less anxious about it and felt more hopeful. In collaboration with the pain clinic, he was able to phase out all pain medication. Having learned the importance of relapse prevention, he remained compliant with his self-care program. A brief course of psychotherapy to address anxiety and marital conflict proved helpful in reducing the underlying emotional distress that previously tended to heighten pain symptoms.

What this case shows
This case report illustrates the interaction of various contributing factors in complex chronic headache pain. Some of these factors, such as poor posture, have multiple causes, including deconditioning, habit, underlying structural problems, and heightened autonomic reactions due to depression and anxiety. The interactive, synergistic effects of psychological and pathophysiologic factors should be noted. For example, pain and anxiety can lead to increased muscle tension and poor body mechanics, which can lead to more pain with activity. In a patient with a premorbid history of moderate anxiety or depression, this can lead to increased frustration, catastrophizing, and feelings of hopelessness. These emotions perpetuate this unfortunate psychophysiologic cycle.


Dr Weisberg is a board-certified clinical health psychologist and a consultant at Fairview-University Medical Center, Methodist Hospital, and the Minnesota Head and Neck Pain Clinic, Minneapolis. Dr Clavel is a neurologist specializing in pain management. He is director of the pain clinic at Hennepin County Medical Center, assistant professor of neurology at the University of Minnesota Medical School-Minneapolis, and a consultant at the Minnesota Head and Neck Pain Clinic. Correspondence: Mark B. Weisberg, PhD, ABPP, Minnesota Head and Neck Pain Clinic, 701 25th Ave S, Suite 304, Minneapolis, MN 55454. E-mail: weispsymus@worldnet.att.net.

For a helpful list of references on pain management for physicians and patients, see Resource Guide on Pain Management


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