Psychosomatic pain: new insights and management strategies.

At least 40 to 60 percent of women and at least 20 percent of men with chronic pain disorders report a history of being abused during childhood and/or adulthood. This incidence of abuse is two to four times higher than in the general population. Patients with more severe or frequent abuse, usually during childhood and worse if sexual in nature. often develop specific syndromes or combinations of syndromes. These syndromes include posttraumatic stress disorder, fibromyalgia, and other conditions characterized by repression, somatization, and increased utilization of medical care. Psychosomatic symptoms and dysfunctional behaviors may emerge as these patients seek attention and validation of their suffering, while paradoxically repressing painful memories of trauma. Behavioral observations and key features of the physical examination may greatly help the clinician identify both the presence and severity of psychosomatic disease. In addition, it is very interesting that various studies document physiologic changes in the brains of patients with a history of abuse and in patients with a diagnosis of fibromyalgia. These studies suggest that abuse may physiologically and developmentally increase a person's susceptibility to pain and that some organic changes may be associated with psychogenic disease. Diagnosis and treatment of even the most challenging patients with chronic pain is much more effective if it includes (a) careful inquiry about any history of past or present abuse or other severe trauma, (b) empathy and constructive validation of disease and suffering, (c) recognition of dysfunctional pain behaviors and personality traits, (d) documentation of nonanatomic as well as anatomic features on examination, (e) multidisciplinary treatments including psychotherapy whenever indicated, and (f) noninvasive procedures and alternatives to potentially habit-forming medications whenever possible and appropriate. Furthermore, it has been shown that helping patients gain insight about the relationship between abuse and their current symptoms leads to decreased health care utilization. Practical guidelines are provided for identifying psychopathology, communicating effectively, and achieving better treatment outcomes for these unfortunate patients.