Pain: What Psychiatrists Need to Know

This is a magnificent book. It is timely, readable, and authoritative. Over recent decades, psychiatry has become peripheral to pain management. That is bad, because psychiatry has an enormous amount to offer this field, at least as much as any another single discipline. Freud opened the batting at the turn of the twentieth century and made an important contribution with psychodynamic theory and hysteria as an explanation for chronic pain for which a physical basis could not be located. Other important contributions from psychiatry include the conceptualization of pain as a variant of depression (1). Recently anesthesiology has moved onto center stage with ever more sophisticated interventions, including radiofrequency neurolysis, implanted medication pumps, and spinal cord stimulators.

One of the great contributions to humanity of the twentieth century was the liaison psychiatrist George Engel’s biopsychosocial medical model (2). This model is particularly well suited to the management of chronic pain. Other advances include moving away from the concept of the nervous system as a fixed stimulus-response mechanism and the coining of the definition of pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in such terms” (3).

Why are psychiatrists so well placed to assist in the field of pain management? First, they know the biopsychosocial model. Second, they understand the nervous system and have some familiarity with the new area of plasticity. Third, they already use many of the most important drugs in the field (antidepressants and membrane stabilizers). Fourth, they are skilled in treating the comorbidity of depression (at least 30% of cases) and adjustment problems. Fifth, they are conversant with addictive behavior. Finally, they can tolerate ambiguity and uncertainty.

Pain: What Psychiatrists Need to Know, written by 11 prominent clinicians, is a wake-up call. It alerts psychiatrists to the size of the problem and informs them that they have the skills to make a contribution. It begins with a chapter on definitions and assessment, which describes the biopsychosocial model and gently introduces the necessary terminology such as nociception and neuropathic pain. A major chapter concerns pharmacological and nonpharmacological treatments. Aimed at psychiatrists, most of this chapter is given over to pharmacological matters. It is straightforward and practical and of great value to the psychiatrist looking for a sensible reintroduction. There is not a lot in this chapter that is totally unfamiliar to the general psychiatrist.

Randy S. Roth, Ph.D., writes an excellent chapter titled “Psychogenic Models of Chronic Pain.” He draws attention to the wide range of opinion on the prevalence of psychogenic pain and gently suggests that neuroplasticity and sensitization may explain some of the pain that appears to exist independent of tissue damage. He finds that the psychodynamic of pain as a variant of depression models, while useful in individual cases, is insufficient as a general model of chronic pain. He attacks the operant model, stating that this focus on pain behavior rather than pain experience has not served patients well. He ends by encouraging the multivariate (biopsychosocial) perspective.

This is an excellent book. I hope it will encourage psychiatrists back into a field, recently abandoned, in which they have much to offer.