Implications for primary care
In our estimation, an evaluation of pain must be based on awareness of the signs and symptoms of all 3 mechanisms of pain perception: nociceptive tissue pathology, nerve injury that alters nervous system processing of sensory stimuli, and/or psychological injury that alters nervous system sensory processing. This approach opens up a whole new menu of treatment options and helps to demystify patients whom we previously regarded as difficult to understand and treat. No longer should we be stumped when we cannot find a traditional cause for pain (ie, tissue injury).
When screening in the primary care clinic reveals signs and symptoms of the third type of pain, the next step should be to look for the presence of psychologically traumatic experiences. Assessments of anxiety, depression, and developmental trauma13 should be added to the patient assessment. If pain due to psychological factors is identified, consider:
- cognitive behavioral therapy
- therapies such as eye movement desensitization reprocessing and somatic experiencing, both of which are already used to alleviate the stress associated with posttraumatic stress disorder
- pharmacotherapy with a serotonin-norepinephrine reuptake inhibitor (SNRI), such as duloxetine or venlafaxine
Reassurance goes a long way. Above all, when you are caring for someone who has pain without clear tissue pathology or who has recognized intensified emotional pain processing, reassure the person that the pain experience is not in his or her head, but rather in his or her nervous system. (See "Case study: Were psychological factors driving these symptoms?")
You can explain that research suggests that emotional, cognitive, or developmental factors may have affected the way his or her nervous system processes sensory information. Such discussions go a long way toward helping patients understand their experience, as well as feel validated. And that can lead to improved compliance with therapy going forward.
Bennet Davis, MD, 2455 E. Miraval Primero, Tucson, AZ 85718; firstname.lastname@example.org.