Chronic Pain
I can still recall our attempts at the then Institute of Rehabilitation Medicine, New York University Medical Center, to establish a program for the treatment of chronic pain many years ago. Since I was beginning to realize that most back pain was psychologically induced and the medical literature was suggesting that chronic pain was the result of psychological factors, establishing a program to treat chronic pain seemed like a good thing to pursue. Accordingly, we followed the guidelines recommended by the experts, set up a multidisciplinary team consisting of physical therapist, occupational therapist, nurse, psychologist, social worker and doctor, and proceeded to admit patients to the program. The patients we treated suffered from various painful structural conditions, including arthritis of the spine, a herniated disc, and fibrositis (now called fibromyalgia). Their pain had continued for more than six months despite treatment and was so severe it dominated their lives. It prevented work and normal social intercourse and led to a host of personal problems. In most cases the patients were taking a variety of drugs in high dosages.
The postulated psychological factor central to the therapeutic program was that patients were deriving secondary gain from the pain, meaning that unconsciously they needed the pain to continue so they could be cared for, avoid responsibility or work or perhaps get money. Most patients were anxious and depressed, had trouble sleeping, ate poorly and looked ill. They were clearly not malingering; the secondary gain was said to be unconscious. Chronic pain was proclaimed to be a disease entity unto itself.
Based on these observations the program developed as follows:
1. Psychological testing on admission
2. Evaluation by each member of the team to determine what his or her contribution to the recovery process would be 3. No discussion of pain or reward for pain behavior
4. Stimulation of physical, vocational and social activities
5. Identification and treatment of psychological and social problems
6. Creation of a “cocktail” of drugs the patient had been taking, and the gradual reduction of the component amounts without the patient’s knowledge
We all participated in the program with great enthusiasm. It was perfect for rehabilitation medicine because we routinely worked as a team to treat many disabling conditions. Before long we began to suspect that the postulated psychological basis for the condition was flawed. Our psychological evaluations suggested that there were, indeed, powerful psychological factors at work to perpetuate the pain, but they did not precipitate secondary gain. A good example was a woman who had suffered childhood sexual and emotional abuse so severe that we marveled she had survived it. She was almost totally disabled by pain, so great was the rage she carried in her unconscious.
Increasingly, we discussed the pain with the patient, where it came from and why it would go away once the psychological poison was revealed. We found it wasn’t necessary to surreptitiously reduce drugs; the patients stopped taking them spontaneously. And, of course, the physiologic explanation for the pain had emerged. Chronic pain was TMS in one of its most severe forms. There was no need to formulate a separate disease entity called chronic pain.
That was about twenty years ago and time has only reinforced our conclusions.
