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CHRONIC PAIN
HUASHAN HOSPITAL
FUDAN UNIVERSITY
SHENXUN SHI
2014/03/17
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Do you have experience of pain
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WHAT IS PAIN
Pain is an unsatisfied feeling and emotion
experience
This experience is associated with actual
or potential impairment
Pain is one of describing symptom by
patient with the role being impaired
International association for the study of pain, IASP
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Representation of pain
One of symptoms
Disorder
Disease

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Characteristic of pain
A complex sensory and consciousness, and
combined often with other somatic sensations
A complex mental state, often associated with
emotion response strongly
A complex physiological and psychological
response,
Painful feeling or responsive severity is closely
related with pains quality, strength, range,
lasting time, body environment of in/outside
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Characteristic of pain
Various pain: bearing down
Pain perception and pain reaction
Subjective experience
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Significance of pain
Is a signal of body impairment
Is a good warning
Is an information exchange
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Testing of pain
1. Subjective evaluation:
Perception character
Feeling quality
Subjective intensity
2. Medication test indirectly
3. Pain threshold
4. Pain tolerance
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Psychological factors of pain
Experiences
Meaning of situation
Attention and divert
Suggestion and hypnotize
Emotion
Personality
Social culture
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Chronic pain characteristic
Disorder/disease entity
Difficult diagnosis, outcome poor
Difficult treatment
Comorbidity mental disorder
Psychosomatic disease
Abnormal action of sympathetic nerve
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Chronic pain name
Cancer pain-malignant pain
primary cancer pain
transfer cancer pain
secondary pain from chemical and radial
treatment
Non-cancer chronic pain
trigeminal neuralgia
herpes zoster neurolgia
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Non-cancer chronic pain
Obstinate pain-
Chronic pain syndrome, CPS
Is a body syndrome with consistent,
obstinate pain associated with mind and
somatic disorder
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Characteristic of CPS
Many time, multiple hospital
Many consultation
Many diagnosis
Many treatment
Many care from family and relatives
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Classified of Pain
Quality
Physical function
Position
Time and level
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Quality of pain
Tingling
Burning
Rheumatic
Radiating
Referred
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Physical function

Physical pain
Pathologic pain
Neural disease pain
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Position
Somatic
Visceral
psychogenic
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Time and level

Transient
Acute
Chronic
tiny
Mild
Severe

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Psychological and environment
Psychophysical mechanism
Self response mechanism
Psychological mechanism
Psychiatric mechanism
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Limbic System

Prefrontal
Cortex

Locus
Coeruleus
(NE source)
Raphe Nuclei
(5-HT source)

5-HT and NE pathways
Amygdala

Hippocampus

Cooper JR, et al. The Biochemical Basis of Neuropharmacology. 8th ed. New York: Oxford University Press; 2003.
Descending 5-HT
pathways

Descending
NE pathways
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BDNF

Duric V, McCarson KE. Neuroscience 2005;133(4):999-1006.
0
2
4
6
8
P
g

B
D
N
F

m
R
N
A
/
n
g

-
a
c
t
i
n

m
R
N
A


*
*


0
2
4
6
8
P
g

B
D
N
F

m
R
N
A
/
n
g

-
a
c
t
i
n

m
R
N
A

2:45h 24h
*
*
6h
*
10-Day
CFA
*

brain-derived neurotrophic factor (BDNF)
CFA=complete Freunds adjuvant.
*P<.05 compared to control *P<.05 compared to control
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Psychosocial factors
Cognition
Emotion
Childhood experience
Attention
Culture
Personality
Suggestion

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Meaning of pain
Warming
Response of affect
Sign for help
Somatilization

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Related mental disorders
of chronic pain
Depressive pain
Anxiety pain
Somaticform pain
Psychotic pain
Chronic pain syndrome
Psychogenic pain
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0
5
10
15
20
25
30
35
40
45
50
Normal Mood Depressive Mood MDD
F
r
e
q
u
e
n
c
y

Limb pain
Backaches
Joint/Articular
Gastro-intestinal
Headaches
Any pain
Ohayon MM, Schatzberg AF. Arch Gen Psychiatry, 60(1), 39-41, 2003.
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Pain disorder
Prevalence
Pain disorder appears to be relatively
common. For example, it is estimated that,
in any given year, 10%-15% of adults in
the United States have some form of work
disability due to back pain alone.
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Pain disorder
Course
Most acute pain resolves in relatively short periods of
time. There is a wide range of variability in the onset of
chronic pain. In most cases, the symptom has persisted
for many years by the time the individual comes to the
attention of the mental health profession.
Important factors that appear to influence recovery from
Pain Disorder are the individuals participation in
regularly scheduled activities (e.g. work) despite the pain
and resistance to allowing the pain to become the
determining factor in his or her lifestyle.
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Pain disorder
Familial pattern
Depressive disorder, alcohol dependence,
and chronic pain may be more common in
the first-degree biological relatives of
individuals with chronic Pain Disorder.
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Specific culture, age, and gender
features
There may be differences in how various ethnic
and cultural groups respond to painful stimuli
and how they express their reactions to pain.
However, because there is so much individual
variation, these factors are of limited usefulness
in the evaluation and management of individuals
with Pain Disorder
Pain Disorder may occur at any age. Females
appear to experience certain chronic pain
conditions, most notably headaches and
musculoskeletal pain, more often than do males
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Major etiologic theories
Pain is heterogeneous disorder. no single
etiologic factor is likely to apply to all
patients.
Psychodynamic formulations: pain
represents an unconsciously determined
punishment to expiate guilt or for
aggressive feelings or an effort to maintain
a relationship with a lost object.
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Major etiologic theories
Another etiologic theory proposes that pain
represents learned behavior. It is hypothesized
that the patients previous experiences of
personal pain have led to changes in other
persons behavior, thereby reinforcing the
experience of pain and pain behaviors.
Consistent with this theory are observations that
some pain patients have experienced medical
illness or injuries associated with pain or lived in
childhood homes where disease, illness, and
pain were present.
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Clinical findings
Sign & findings
Pain syndromes include atypical facial
pain, chronic pelvic pain, chronic low back
pain, recurrent or persistent headaches,
and so on.
These patients descriptions of pain are
often dramatic and include vivid
descriptions such as stabbing back pain
or a fire in my belly
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Diagnostic criteria for pain disorder
A. Pain in one or more anatomical sites is the
predominant focus of the clinical presentation
and is of sufficient severity to warrant clinical
attention.
B. The pain causes clinically significant distress or
impairment in social, occupational, or other
important areas of functioning
C. Psychological factors are judged to have an
important role in the onset, severity, exacebation,
or maintenance of the pain.
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Diagnostic criteria for pain disorder
D. The symptom of deficit is not intentionally
produced or feigned ( as in Facticious
Disorder or Malingering)
E. The pain is not better accounted for by a
Mood, Anxiety, or Psychotic Disorder and
does not meet criteria for Dyspareunia
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Diagnostic criteria for pain disorder
Code as follows:
Acute : duration of less than 6 months
Chronic: duration of 6 months or longer
307.80 pain disorder associated with psychological
factors
307.89 pain disorder associated with psychological
factors and a general medical condition
pain disorder associated with a general medical
condition
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Differential diagnosis
Somatization disorder
Dyspareunia
Conversion disorder
Other mental disorder
Factitious disorder malingering
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Basic contents of evaluation
Psychological testing: e.g.
MMPI are often used to evaluate pain
patients.
McGill Pain Questionnaire, a patient self-
report test

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Basic contents of evaluation
Laboratory Findings & Imaging:
pain disorder patients often have a lower
threshold for pain than do normal subjects.
It is difficult to determine if this greater
sensitivity is the result of physiological or
psychological differences
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Treatment
Psychotherapy:
cognitive
behavioral
family therapy

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Treatment
Medicines:
antidepressants: duloxetine
psychotropic medications

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SSRIs
(Lynch J Psych Neurosci 2001)
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*
*
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*
Poster: Raskin J, et al. 25th American Pain Society (APS) Annual Scientific Meeting; San Antonio, TX; May 36, 2006.
Duloxetine Reduces 24-Hour Average
Pain Severity in DPNP
-3.5
-3.0
-2.5
-2.0
-1.5
-1.0
-0.5
0.0
0 1 2 3 4 5 6 7 8
9
10 11 12
Placebo
(n=330)
Duloxetine
20 mg QD
(n=111)
Duloxetine
60 mg QD
(n=334)
Duloxetine
60 mg BID
(n=333)
*
* P .05
vs placebo
MMRM
Weeks
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A reduction of approximately 2 points or 30% represents a clinically
important difference (mean baseline score was 5.83)
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Pooled data from 3 studies