Psychopharmacologic and psychotherapeutic approaches to pain management

Introduction In the past, pain had been conceptualized by clinicians as a purely sensory phenomenon emanating from a pathophysiologic state, e.g., tissue injury generating pain transduction through the activity of peripheral or visceral nociceptors. The treating physician would then be proactive in undertaking pharmacologic and other interventions to treat the underlying disease state or relieve pain. In ambiguous cases for which the source of pain was unclear, there would often be an exhaustive search for biomedical causes and treatment. Taken from this perspective, there was an implicit mind-body dualism of pain, distinguishing it as either somatic (physical in origin) or psychogenic (psychological in origin). Consequently, there was a tendency to attribute to psychic factors any pain process in which the physical causes could not be fully delineated, when pain complaints seem disproportionate to the underlying disease, or when the pain failed to respond to treatment as expected. Patients deemed to have psychogenic pain were dismissed from medical care and instead relegated to the province of psychiatry and psychology. Concurrently, in an attempt to delineate diagnostic criteria to assist in the classification of patients for whom psychological disturbances “masquerade” as somatic preoccupations such as pain, early versions of the Diagnostic and Statistical Manual of Psychiatric Disorders (DSM) required that clinicians infer whether psychological underpinnings or conflicts precipitated pain complaints.