I Feel Your Pain

The relationship between physical and emotional illnesses is a really complex one. There's nothing easy about this, and there are psychiatrists who specialize (like Roy) in consultation-liason psychiatry: the interface where psychiatrists deal with psychiatric issues in patients who are hospitalized on med/surg units. There are psychiatrists and neurologists who specialize in pain management.

It's probably no surprise that people with known psychiatric disorders are more easily dismissed by their primary care docs-- their chest pain is assumed to be 'anxiety' and their GI symptoms are due to "stress." It drives me nuts.

This shrink's rule of thumb for medical workups [I hope Dinah doesn't mind me sticking in my 2 cents :-Roy] :

• All symptoms which may be indicative of medical illness should be assumed to be so until proven otherwise. I don't want to see a patient for "panic attacks" until after a thorough work up to rule out cardiovascular or pulmonary disease. What's the work up? Well, it's one thing for an 18 year old girl with no risk factors and a primary complaint of "I feel panicky" and another work-up for a 55 year old smoker with hypertension and a father who died at 54 of an MI who presents with chest pain and shortness of breath on exertion. Don't send the 55 year old smoker with chest pain to see a psychiatrist until after he has a cardiac catheterization! [It's not uncommon to get a consult request to "rule out" conversion disorder when they cannot find a cause for symptoms. Sometimes it is appropriate; others I tell to keep looking.]
  
  
• Elusive symptoms are elusive symptoms and should be worked up completely, even if the patient has a psych history.
  
  
• Bizarre, non-biologically founded symptoms may require less of a work up--- the classic being "My hair hurts when I pee" or "the machine the aliens inplanted in me is squeezing my thighs." [Though this last example reminds me that people with psychosis get sick, and sometimes interpret their symptoms in a psychotic manner. Don't blow off the alien machine guy's complaint until you've ruled out a blood clot, fracture, or compartment syndrome.]
  
  
• Pain syndromes often respond to psychiatric treatments: it doesn't mean the pain wasn't real. Unfortunately, people take this to mean "it was all in your head," and who ever came up with that phrase is not my friend. You can have back pain. It can be real pain and it can really be in your back. Psychiatric treatments may make your pain go away. It was still real pain and it was still in your back. [e.g., tricyclic antidepressants reduce sensitivity to visceral pain]
  
  
• Some people have known medical/anatomical reasons for their symptoms and adding psychiatric treatment to the medical regimen helps.
  
  
• Some people have extensive workups for an assortment of symptoms: pain, weight loss, diarrhea, migraines, you name it. These can be really extensive work ups running tens of thousands of dollars (or more) with many invasive procedures and nothing is revealed that explains the symptoms. These patients become depressed (this is a very frustrating scenario), and sometimes when the depression is treated, the rest of the symptoms go away. Yes, this really happens, it's profound and it's remarkable. How do you explain this, given that the physical symptoms preceded the depression? I'm left to say that in some people, their stress gets funneled into their body, it's just how they're wired. It doesn't mean their symptoms weren't real, it doesn't mean they are crazy, it doesn't mean it was all in their head, it just means that for them, Depression starts with physical symptoms. Some of these patients do amazingly well, get off their narcotics, and resume normal lives that are no longer controlled by pain/medication regimens/doctor's appointments and tests. If you can't figure out the physical causes for an illness, there should be no shame to looking for a psychological cause. It's sad that there is.
  

Shrink Rap: Grand Rounds is up at Emergiblog

Check out this week's Grand Rounds on Emergiblog.

Notables:

• Doctor Anonymous' BlogTalkRadio interview of NeoNurseChic about her chronic headache pain.
• Dr Deb Serani blogs about the Mental Health Parity law.
• InsureBlog discusses the Personal Genome Project.
• Colorado Health Insurance Insider writes about autism and insurance.
• The Anesthesioboist takes on Descarte's mind-body dualism.

Guest Blogger Eric Kuhn from CBS News on Easing the Pain

Hey, so we got an email from Eric at CBS. He wanted to tell us about a series CBS is doing on pain-- too late to watch, but I'll put up his synopsis and links. Cool stuff. And Eric, remember us when the Shrink Rappers get the book together!

Eric writes:

I have been reading your blog and think it is great. I thought you might be interested in a story that we are doing this week about pain.

EASING THE PAIN
February 19 – 21

Tuesday: NERVE STIMULATORS
Dr. Jon LaPook reported on a new kind of nerve stimulator in the final stage of FDA trials to treat pain. It's a headset that pulses electric currents to the back of the head and users say it works miracles to stop the throbbing. We follow a man with excruciating knee pain for a week of treatment to see firsthand what a difference it makes. It works because electrical currents somehow change the brain's perception of pain. Check it out the story that aired here - http://www.cbsnews.com/stories/2008/02/19/eveningnews/main3849876.shtml

Wednesday: ABUSE PROOF DRUGS
Dr. Jon LaPook examined the newest aspect of pain management, which are drugs that are called "Abuse Deterrent Opiates". These drugs can help prevent people from getting physically dependent on opiates, because they don't work if they're crushed and taken improperly. Doctors face a huge dilemma when trying to balance treatment and risk of addiction at the bedside. We'll meet people you'd never expect to become addicts, but who wound up getting hooked. We'll meet others for whom this new drug relieves the pain without risking addiction. Check it out here - http://www.cbsnews.com/stories/2008/02/20/eveningnews/main3854165.shtml

Thursday: BABIES' PAIN
CNN's Dr. Sanja Gupta reports on how there is no gold standard for measuring pain and discomfort in babies, especially newborns…however there is a clinical trial of a facial recognition technology to identify pain in infants. The initial research used photographs of infant faces but now there is research using video images. Catch this TONIGHT on the CBS Evening News with Katie Couric at 6:30 PM EST.

My Assorted Thoughts on Tara Parker-Pope's Wellness Blog Today

I feel this funny kinship with The New York Times Wellness blogger, Tara Parker-Pope. I don't know her, probably never will, and I'm jealous that her blog is so much more widely read than mine. Why hasn't The New York Times hired me?? Maybe it's because she's a blogger, I think she's a mom, and "Tara" is the name of my college roommate who has journeyed around the country collecting advanced degrees and remains a beach-ball of energy (there's something 'round' about my Tara, I don't know why, she's petite, slim and runs miles a day, but she's energetic and hard to grab on to, nonetheless). More simply, though, Tara Parker-Pope often writes about things we like to address on Shrink Rap, and for the second time recently, we've "known" in some sideline way, the same people. Not long ago she wrote about headaches and referenced my neighbor, the Johns Hopkins migraine king-- a man with beautiful gardens, a lovely wife, who run circles around our neighborhood for exercise, but my conversation with him has been limited to mutual nods.

So the Wellness Blog of 2/8 came to my attention this morning because it's on When Doctors Become Patients. That was ClinkShrink's post!! There Tara Parker-Pope goes, stealing from Shrink Rap again. We got to do something about this!

So I click over and there's a photo of Bob. Who's Bob? you say. Well Robert Klitzman certainly wouldn't remember me, but he pops up in the media now and then so I remember him. When I was a third year medical student doing my much-anticipated psychiatry rotation (for Bob's sake, I won't say where), Bob was one of the four PGY-2 residents on the fourth floor unit I was assigned to. Only I wasn't assigned to work with him, I worked with Beth. Beth was great, the thing I remember most about Beth was she told me she didn't like to go to the movies on a first date; she wanted a chance to meet a guy, get to know him a little, so she could dump him right away (she eventually married a musician, don't know what happened to the marriage, but my feeling towards Beth remain fond).

Bob wrote a book about his residency training experience: In a House of Glass and Dreams. I stumbled upon it in a bookstore. I knew the author so I bought it, and while he never named the program, I knew all the details. I remembered the lock that stuck outside the hallway to my supervisors office. He talks about his first day going to therapy, and I remembered being in a conference and a bunch of the residents saying "Where's Bob?" and someone replied "Bob went to therapy!" "Bob went to therapy???" I didn't really know Bob but I assumed that wasn't expected. This was in an institution where the chief resident posted on a black board what times he'd be psychoanalysis, don't beep me then. At some point, many years ago, I chatted with Bob briefly when I accidentally ended up at the wrong reception at APA, and I told him how much I liked his book. I think he was flattered. The book, which I read well after completing my own residency at an institution where one certainly didn't announce that they were going to psychoanalysis, resonated with me and and left me feeling understood-- it was during a time in my life where I was having a hard time feeling like anyone understood. I'd had enough wine to be at the wrong reception, so who really knows what we talked about, maybe 15 years ago.

At some point, and I'm not sure why, I learned that Bob's sister had died in the September 11th attacks. My heart went out to a man I hadn't ever really known, and the Wellness blog is about Bob's experience of being a psychiatrist with depression in the aftermath of his sister's death, and how his own journey has made him a better, more considerate doc. I don't doubt it.

I guess the other thing I wanted to comment on, since this NYTimes post hit on so much for me, is that Bob initially experienced his depression as physical symptoms and didn't recognize them as a mental illness. This is not uncommon. I've had patients lose tremendous amounts of weight (50 pounds anyone?), have severe pain (usually GI) and have extensive cancer workups. One tells me frequently "No one ever told me this could be depression." Another is only now getting to be a little better after his zillion-dollar work up. When I heard of the case, as he was being referred, I said to the internist, "Hmmm, sounds like cancer." He agreed, said they were continuing to look for the elusive tumor. One look at the patient and I rethought, "Looks like depression." Patients, unfortunately hear this as "Your Pain Is All in Your Head." I' rephrase this as "Sometimes depression is expressed as pain. It doesn't mean the pain isn't real." I want it to not be insulting, but the reality is that the prognosis for pain as a symptom of depression is a whole lot better than the prognosis of pain as a symptom of lots of other things that people are wishing will be found.

From The NYTimes: When is a Pain Doctor a Drug Pusher

Oh, no, I did it again, I posted over Roy! I swear, I didn't know. Scroll down for his post.


We like to talk about subjects where the lines get blurry. Who should get care? When is it an illness? Xanax? Seroquel? Which side of the fence and how far over might one lean?

So here's an interesting cover story in the Sunday New York Times Magazine: When is A Pain Doctor A Drug Pusher?

It's the story of a pain doctor who has been sentenced to 30 years in prison for his sloppy and questionable prescribing practices. The article's author, Tina Rosenberg, comes at it with the tone that it's outrageous that he was sent to jail, deemed a criminal, for his lax practice. Bad doctoring, she contends, is cause for civil malpractice litigation, not criminal prosecution. The docs who prescribe in exchange for sex or drugs, they are the criminals. The doctor in the story did none of those things. She makes the point that the standards for prescribing narcotics, especially to a chronic and drug-tolerant population of pain patients (who may be peppered with occasional abusers) are purposely not stated, and leave the doctor open to both scrutiny and criminal charges.

There are red flags that indicate possible abuse or diversion: patients
who drive long distances to see the doctor, or ask for specific drugs by name,
or claim to need more and more of them. But people with real pain also
occasionally do these things. The doctor’s dilemma is how to stop the diverters
without condemning other patients to suffer unnecessarily, since a drug diverter
and a legitimate patient can look very much alike. The dishonest prescriber and
the honest one can also look alike. Society has a parallel dilemma: how to stop
drug-dealing doctors without discouraging real ones and worsening America’s
undertreatment of pain.
* * *
But such guidelines are futile while there is one pain specialist for,
at the very least, every several thousand chronic-pain sufferers nationwide. And
even though pain is an exciting new specialty, doctors are not flocking to it.
The Federation of State Medical Boards calls “fear among physicians that they
will be investigated, or even arrested, for prescribing controlled substances
for pain” one of the two most important barriers to pain treatment, alongside
lack of understanding. Various surveys of physicians have shown that this fear
is widespread. “The bottom line is, doctors say they don’t need this,” said
Heit. “They’re in a health care system that wants them to see a patient every 10
to 15 minutes. They don’t have time to take a complete history about whether the
patient has been addicted. The fear is very real and palpable that if they
prescribe Schedule II opioids they will come under the scrutiny of the D.E.A.,
and they don’t need this aggravation.”

By the time I finished this article, I was glad I'm not a pain doc. I was even more glad I'm not a pain patient.

Serotonin Knockouts are a Pain in the SSRI

[PWT=pain withdrawal threshold... a lower number means greater sensitivity to mechanical pain. Carrageenan was used as the source of mechanical pain here. In A, you see that duloxetine (Cymbalta) restored PWT to normal in both normal mice (WT) and mice without serotonin brain cells (Lmx1b), thus indicating a pain-relieving effect. However, in B at the bottom, fluoxetine (Prozac) did NOT improve the PWT after injection of carrageenan (focus on the black bars), indicating that Prozac does not help this kind of pain in mice without serotonin, meaning that serotonin is an important part of pain regulation, but norepinephrine may be even more important.]

---

Okay, Dinah, here's something (though it doesn't really "shake things up").

Check out this article in the Journal of Neuroscience by ZQ Zhao et al., showing pretty good evidence (like we needed more) that the brain neurotransmitter, serotonin (or 5HT), is involved in pain regulation.

What they did was use knockout mice -- mice which have been genetically altered to remove or disable the gene which codes for a given protein -- which have had the codes for serotonin neurons in the brain removed. So, these mice do not have serotonin-producing brain cells. This permits the researchers to see the effect that selective serotonin reuptake inhibitors (SSRIs) and other antidepressants have (or don't have) on the mice.

They were interested in the anti-pain (also called nociceptive) effects of these antidepressants, and the role that serotonin plays. For example, we know that antidepressants which have BOTH serotonin and norepinephrine (NE) effects (SNRIs, like Cymbalta and Effexor) are better at reducing pain than those with solely serotonin effects (SSRIs, like Prozac and Paxil).

So, these particular mice have normal pain responses to hot things, reduced pain responses to mechanical pain (eg, pinch, squeeze, crush... in this study, they simply poked them with different sizes of fishing line), and elevated pain responses to inflammation (eg, an infection, arthritis, etc). The acute analgesic properties of antidepressants were simply nonexistent in these mice. Their acute pain responses were unaffected by antidepressants. However, SNRIs did reduce their responses to chronic pain, while SSRIs did not.

Although the noradrenergic system in Lmx1b^f/f/p mice appears to be normal, the analgesic effect of the TCA amitriptyline on acute thermal pain behavior was strongly attenuated in Lmx1b^f/f/p mice. Because a total absence of analgesic effect was observed in Lmx1b^f/f/p mice treated with fluoxetine and duloxetine, the residual analgesic effect observed in Lmx1b^f/f/p mice treated with amitriptyline is likely caused by mechanisms other than blockade of 5-HT and NE reuptake, such as channel modulation and NMDA receptor antagonism (Lawson, 2002; Wang et al., 2004). Together, our data indicate that although the NE component seems to be critical in the analgesic effect of antidepressants, endogenous 5-HT is also of fundamental importance for the analgesic effect of these drugs, especially in reducing thermal sensitivity.

They conclude that "Together, our data indicate that although the NE component seems to be critical in the analgesic effect of antidepressants, endogenous 5-HT is also of fundamental importance for the analgesic effect of these drugs, especially in reducing thermal sensitivity."

The main reason I posted this is just to demonstrate the cool things one can do with genetics. You can knock out a gene; in this case, the one responsible for turning a developing neuron into a serotonin-producing neuron. You can then figure out what the consequences of that absent gene are. Finally, this also emphasizes how we can learn how to fine-tune our knowledge about pain control, so that more effective -- and less addictive -- treatments can be developed.

Are You In Pain?

Or:

I Can't Think for Myself

Or:

One Great Way to Kill Trees

At the institution where I work, there is a requirement by JCAHO that all patients be assessed for pain. What this means, in practical terms, is that every patient at every visit in every department of the hospital is given a form and asked to mark off on a numerical scale how severe their pain is. For patients who can't negotiate that, there are smiley-to-frowny faces drawn and one can circle the face that best approximates one's degree of pain. Unlike the photo depicted above, my institution does not have the scale in color, and our smiley faces do not wear bow ties. You must sign the form at the bottom. I don't know what happens if you refuse, and the form is placed in your chart. We won't discuss what this does to the size of the charts, but hey, they pay me to be here.

I'm a psychiatrist, everyone who walks in the door, at least for the first time, is in pain. No No No No! Not that kind of pain, it has to be physical pain or it doesn't count! Does your body hurt? Now if the pain is more than a 3 out of 10, the patient is to be asked if they want to see a doctor. Oh, I am a doctor. 8 out of 9, maybe 9, It's that arthritis or maybe the chronic migraine. Yup, they have medicine for it. Okay, so now it's checked, they've seen the doctor, the sheet is signed, and it gets filed in the chart. Three cheers for us, we're JHACO compliant. Damn the trees, that's what Oregon's for.

So a patient comes to see me. The patient, John YoungGuy, is 27 years old. He has no significant medical or surgical history, he's here at the psychiatric clinic to get his mental illness treated. He's not in any physical pain (--He signed so it's a fact). The next week, Mr. YoungGuy returns to see me. I should ask him if he hurts? Why would he hurt? Wasn't I listening last week when he said he was healthy and had no pain. Really, he circled the zero and signed. Do I think he wouldn't tell me if he'd broken an arm on Saturday? By the fifth visit, by the fifth request to look at the demeaning smiley faces and sign off of that really, truly, he's not in any physical pain, might Mr. YoungGuy wonder if I'm not listening? If I'm not anything other than some idiot RobotShrink who sits there with a checklist (yup, I do, but at least a few of those questions are relevant, but trust me, the state-mandated 90 med check doesn't count if it isn't written up on the yellow sheet of paper).

I believe the intent of the mandate was good. Attention to pain, treatment of pain-- they are important things in medicine. The kneejerk phenomenon of signing off on a condescending smiley-face form, however, creates a culture where the goal is Compliance with regulatory agencies, not one of caring, attentiveness, creative solutions, or even of compassion. We shouldn't neglect pain, we (meaning all of us form-filler-outers from the orthopedist to the psychiatrist to the dermatologist) should enable relationships of trust and openness where the patient tells us they are in pain, and we address it as best we know how.

By the way: I lied. I never fill the forms out, they go straight into the trash, unchecked, unsigned. I feel way too foolish to even ask. Please don't tell anyone. You can, I hope, feel my pain.

--And by the way, has anyone seen Roy?