Like a voice in the wilderness, we have begged psychiatrists to stop talking about placebo and to begin treating the very serious anxiety which severe pain causes.
In a model of nociceptive pain (not nerve injury), Ji et al in Mol Pain. 2007 Jun 5;3(1):13 have shown that while external administration of corticotrophin releasing factor-1 (CRF-1) into the amygdala attenuated the anxiety normally shown by rats in pain. This result did not obtain when corticosteroids were administered systemmically, or as a vehicle. CRF is the pituitary key which turns on release of cortisol in the adrenal cortex. Cortisol and related chemicals are the well known stress steroids of the body. They all derive from cholesterol.
In a recent article we reviewed Gould’s work on anticipation of reward in the hippocampus. The emotional or limbic system is a loop that runs through the brain which carries emotion. Perhaps you would wish to refer to one of the many brain atlases at Google Pictures to view the limbic tracts. The hippocampus is one part. Near it is the amygdala.
All we are doing here is emphasizing that pain is not an isolated phenomena, but for the most part can cause very potent emotional distress, and that CRF-1 is linked to pain. So many clinicians seem to forget that. For example, have you EVER had a pain doctor ask about your anxiety. Has any nurse come in to comfort or reassure you as you waited for the doctor?
The limbic system is also known as the Papez circuit. Blocking yet another link in this circuit helps relieve the anxiety associatated with pain.
Now if the psychiatrists would only acknowledge that pain causes anxiety. Have they never spoken with someone in severe pain? This author was fortunate enough to have such a psychiatrist, but also many who placed the highly terrifying stress of central pain somewhere beneath post traumatic stress. Why is this. Central pain is PRESENT traumatic stress, which, just for the record is worse than the enchoes of trauma which reverberate LATER. Chronicity is a factor in both. Stress does NOT conveniently move out of the way during the experience of continual severe pain. It jumps on the identity destroying bandwagon and can scramble the thoughts.
Incidentally, in this study, the rats whose anxiety was relieved also showed less pain, ie less nocifensive (pain avoidance) behavior. This may indicate why antidepressants and anticonvulsants have a little benefit for central pain. They make pain patients less anxious. Stress being additive to other stress, this seems to make the pain more bearable. Lest you be in a hurry to self medicate with alcohol to achieve the same result, alcohol is a depressant and has NOT been shown elsewhere to alleviate pain as effectively as antidepressants. It also adds one more problem to your long list.
June 14th, 2007 at 11:36 pm #Caroline
I have been referring to my C.P. as “OTSD” (Ongoing Traumatic Stress Disorder” for well over a year now. Indeed, it appears to live in the past, present and - unfortunately - my future. And the future of legions. Simply outrageous. A couple “unenlightened” neurologists attempted to apply some wildly inappropriate DSM labels to my pain behaviors. (The DSM being the diagnostic “bible” of the psych. community. I know it well. When I was ABLE to work, I conducted mental health triage in a hospital E.R. I am a licensed clinical social worker and have not been able to work since May ‘04 and, oh, how I miss working.)
BEWARE the psychiatric “labels” that might be applied to you, dear friends. I recommend getting a copy of EVERY office visit notation written after you have visited a physician. The laughter/giggling of nervousness or embarrassment or shame could be labeled as “hypo-manic” “manic”, “inappropriate”, or lead the physician to suspect a bipolar disorder.
In my case, I sometimes simply cannot speak - the pain is so “unspeakable”. So, if I am lucky, some “premedicating” with an opioid MIGHT blunt the pain enough for me to communicate with a physician and *try* to describe my current state. And, when I CAN speak, I speak with an urgency that a physician might deem to be “pressured” speech, which is a HALLMARK of bipolar disorder. See where I am going with this?
Luckily (I suppose), a more enlightened psychiatrist brushed aside the idiocy of the “bipolar” tags and came up with ….. ICD-9 diagnostic code 309.24. “Adjustment Disorder w/ Anxiety”. That particular diagnosis is “code” in the psych. world for “typical person going through a very, very rough time”. That diagnosis doesn’t carry the “stigma” of some of the other psych. disorders but INSURANCE WILL USUALLY PAY for services for individuals w/ adjustment disorders.
Finally, if you are well enough (& blessed enough)to be able to RESEARCH your condition and advocate for yourself, be CAREFUL that physicians do not label you as “obsessive-compulsive”. SURVIVAL behavior can appear to be obsessive-compulsive to the untrained eye. As mentioned above, DO get copies of every single office note written and don’t allow any idiotic psych. labels to follow you to any other practices.
I won’t go into the story of the neurologist who yelled at me for using the word, “allodynia”. Evidently, the gent doesn’t like his patients to possess a modicum of intelligence.
Wishing you some peace,
Caroline