The relationship of pathogenetic mechanisms to treatment in patients with pain.

Pain is the somatic symptom par excellence, legitimizing more than any other the sick role and illness behavior. The functions and implications of pain are clearest in situations of acute illness or injury or in chronic, organically based conditions in which actual or threatened tissue damage is signaled by its report. Much greater complexity is found in a variety of clinical presentations (conversion hysteria, hypochondriasis, chronic pain syndromes, Briquet's syndrome, Munchausen's syndrome) in which pain may form part or all of the clinical picture. In such conditions the relationship of the patient's report of pain to other phenomena (tissue damage, physiopathology, perceptual and cognitive styles, personality type, individual and family psychodynamics, anxiety, depression, behavioral patterns, social and economic factors, cultural influences) is important in elucidating pathogenetic mechanisms of which several may be operating in any one case. Awareness of the existence and interaction of these mechanisms facilitates the development and integration of treatment approaches.

A protocol for the medico-psychosocial evaluation of patients with chronic pain.

A protocol is presented for the full medico-psychosocial evaluation of patients with chronic benign pain. Complete history taking is often difficult with these patients. However, this can be accomplished with a combined approach by an anaesthetist and a psychiatrist following a structured interview pattern which respects the patient's attitude towards psychological factors. The specific format of this interview is described.

The measure of symbolic function in alexithymic pain patients.

The archetypal test with 9 elements (AT9), a tracer of symbolic function, was completed by 30 pain patients in whom alexithymia had been measured by two means: the Beth Israel psychosomatic questionnaire (BIQ) and the Minnesota multiphasic personality inventory (MMPI) alexithymia scale. Results show a correlation of adequate statistical significance (p less than 0.05) between the AT9 and the BIQ but not with the MMPI alexithymia scale. The scored AT9 (SAT9) allows one to discriminate between forms and degrees of disorganization in symbolic activity within an alexithymic population. The AT9 measures something central to the construct of alexithymia and its advantages and possibilities over other tools to assess alexithymia are discussed.

Epidemiology of psychosomatic disorders in schizophrenic patients: methodological issues.

The value of an epidemiological study investigating the prevalence of certain somatoform diseases in schizophrenic patients can be strengthened by attention to the following methodological principles: (1) sufficient size of sample; (2) representativeness of sample, controlling if possible such variables as age range, inpatient or outpatient status, ward population or milieu and cultural aspects; (3) study of control groups in same milieu with other psychiatric diagnoses; (4) clear specification of diagnostic criteria employed; (5) establishment of interrater reliability concerning psychiatric diagnosis, patient historical data or medical record information.

International comparison of the prevalence of psychosomatic disorders in schizophrenic patients.

An epidemiological survey was carried out in Montreal (Canada). Plattsburgh (USA) and Lodz (Poland) to test the hypothesis that certain psychosomatic disorders show a low lifetime prevalence in schizophrenic patients (total n = 665). The same method for collection and evaluation of demographic and clinical data was used in order to establish the lifetime prevalence of peptic ulcer (PU), bronchial asthma (BA), neurodermatitis (ND) and rheumatoid arthritis (RA) in the patients as well as in their nuclear families. Low values of lifetime prevalence were found in schizophrenic patients in chronic hospitals as compared with those in general-university hospitals. Similarities were found in age- and sex-related patterns of these psychosomatic disorders in both samples. However, PU showed higher prevalence, and BA, ND and RA showed lower prevalence in the Polish sample.

Schizophrenia and psychosomatic illness.

In order to explore the possibility of a mutually exclusive relationship between schizophrenia and certain psychosomatic disorders, 354 adult schizophrenic patients, both acute and chronic, were studied with regard to lifetime prevalence of peptic ulcer, bronchial asthma, neurodermatitis and rheumatoid arthritis. Significant evidence to support the hypothesis of mutual exclusivity was found only in the case of peptic ulcer in the overall sample. Prevalence was higher in younger, more acute patients than in older, chronic patients, but this finding was difficult to interpret. Parallel enquiry into the prevalence of schizophrenia and the same disorders among close family members of the patients yielded inconclusive results.

Definition, practice, and teaching of psychosomatics. A global survey.

Two sets of overlapping questionnaires were distributed world-wide via college members to 200 psychiatrists and 200 physicians. 50% of psychiatrists (n = 101) and 30% of physicians (n = 63), replied, representing 25 countries. Areas surveyed include definitions of 'psychosomatics', physician-psychiatrist attitudes, liaison activities, teaching patterns and methods, and professional affiliation of respondents. Comparative statistical analysis of the two groups reveals significant response differences in certain conceptualizations of 'psychosomatics' and in the diagnostic distribution of referred patients. Cross-continental comparisons revealed greater acceptance of the term 'psychosomatics' by respondents from Asia, differences between North American and European conceptualizations, and a stronger attachment of the field in the Far East to academic departments of medicine as compared with the West.

The understanding and teaching of reaction to pain.

Pain is both the commonest and one of the most enigmatic symptoms in medicine. Its subjective nature renders management difficult and its conceptualization is complex. Reaction to pain cannot be easily generalized; group differences are postulated, based on sex, age, culture, psychiatric diagnosis and personality variables. Early developmental aspects of pain and discussed in animal studies and case reports but little systematic data exist. Experimental findings show the influence on pain response of cognitive and emotional factors. Clinically, the variables determining perception, reporting and reaction to pain are numerous and harder to study scientifically. Acute and chronic pain should be distinguished: the latter is more complicated, leading of ten to diagnostic problems and management stalemates. Discovering the relationship of pain to emotional phenomena, as cause or effect, is difficult, though essential to effective treatment. Various frames of reference apply: e.g., individual medical, familial, and "workmen's compensation" models. Reaction by family, lawyer, or work commission involves potential secondary gain and may reinforce or discourage pathological responses by the patient. The potential of pain for symbolic meaning and its acceptance as a "legitimate" medical symptom renders it ideal for both expression and masquerading of intrapsychic and interpersonal conflicts involving anger, punishment, control and dependency. Teaching about pain and its significance is best done in clinical settings such as obstetrical units and multidisciplinary pain clinics. Videotaped modular presentations with discussion provide a satisfactory though less desirable alternative.

Nicotinic acid as adjuvant therapy in newly admitted schizophrenic patients.

A placebo-controlled, comparative clinical study was conducted to test the hypothesis that nicotinic acid as an adjuvant medication has a beneficial therapeutic effect over and above the effect which can be achieved by the administration of phenothiazine drugs alone, over a six-month period, in newly (recently) admitted schizophrenic patients.The most important single finding was that no statistically significant therapeutic difference was seen between the active treatment and the placebo groups; i.e., the addition of nicotinic acid or nicotinamide to the regular phenothiazine treatment regimen did not have any measurable therapeutic effect in this sample of patients. It was shown that patients in the placebo group received a lower total daily amount of phenothiazine drugs than those on either of the active substances. Furthermore, it was noted that the addition of the active substances did not reduce the number of days of hospitalization.