Page 111 Guide to Pain Management in Low-Resource Settings

Psychological Evaluation of the Patient with Chronic Pain 99

a year. She knows that her back is “unstable and endan- quency of his headaches can interfere with everyday life,
gered,” but she can deal with that; only the abdominal which puts a lot of strain on him. His wife cares about
pain is a burden to her as it also impairs her sexual re- him very much and tries her best not to stress him, and
lationship with her husband. Since about a year ago she has taken over doing more housework. He worries that
has tried to avoid sex, because of increasing abdominal this may cause problems in the relationship. Usually, he
pain afterwards. In a subsequent interview, Mrs. Ag- has looked after everything; but now his self-esteem is
bori reports that she has a pronounced fear of becoming starting to be aff ected. Additionally, he has become very
pregnant. She could not talk to anyone about this fear irritable because of the headaches. He has begun to lash
because everyone in the family wanted her to have chil- out at small things, which he would regret afterwards.
dren. She is afraid that she will not be able to go through Further psychological analysis reveals that the
the pregnancy and look after her child properly. In other patient has suff ered from headaches since early child-
words, she would not make a good mother. She also fears hood. His single mother had been very ill, and he had
that hear back might “break apart” and she would be to take over the responsibility for the family since a very
confi ned to a wheelchair. young age. Since her pregnancy, his wife has stopped
working. Th is has confl icted with his wishes to off er his
What does this case report show us? child a better childhood that he has had himself. Finan-

Th is case report illustrates how an innate psychological cially supporting the family on his own would be very
confl ict can contribute to the chronicity of pain. Th e pa- stressful; it creates feelings of being overwhelmed, and he
tient has a pronounced fear of pregnancy, although she, often feels that he is not up to his tasks. During the fur-
as well as her family, had a strong desire for her to have ther course of counseling, issues such as sharing responsi-
a child. At the same time she harbors guilty feelings be- bilities and feelings of guilt were discussed.
cause she could not fulfi l this desire. Th e pain in this con-
text is probably made more intense by a feeling of guilt. What confl icts may prevent healing?
In the framework of a family-based therapeu- A signifi cant confl ict of goals that may impede the treat-
tic approach, the family is considered as a system of ment of chronic pain is the desire for retirement. Often,
relationships in which the well-being of each member continuing disability leads to long periods of absen-
depends on that of the others. Th is system strives for teeism at work. If the individual is forced to return to
homoeostasis. A sick member of the family can, for work, there are further periods of increased absentee-
example, have a stabilizing eff ect when the illness is ism. Th is can cause a change in attitude toward work
a distraction from other problems, such as marital or and the workplace, including colleagues. Restoration of
pregnancy problems. Th e confl ict of goals, here, could an amiable attitude to work now seems impossible. Pa-
be that it is not easy for the sick person to “give up the tients very often start to think that continuing work will
disease” without risking the stability of the family. In aff ect their health, and retirement is the only possibility
behavioral theory, operant, respondent, and model- for a sane existence. Sometimes, employers and insurers
learning mechanisms can play a role in the chronicity of demand a solution diff erent from ongoing further treat-
pain. An increase in illness behavior may, for example, ment, which is expensive for them.
happen when a partner gives too much emotional sup-
port. Th e illness behavior thus ensures also the attention How do we implement
psychological treatment?
and emotional support of third parties, which might not
happen without the disease. It is more useful if the part- According to current knowledge, multimodal treatment
ner helps to cope with pain, for example, by supporting concepts should be considered as soon as possible when
daily activities. risks of chronifi cation become evident. A precondition
for psychological pain therapy is the results of the so-
matic examination and the psychological diagnosis. Th e
Case report 4
aim is to reach an adequate description of the chronic
A 38-year-old man reports increasing headaches since pain syndrome and an analysis of the sustained condi-
his wife has become pregnant. He cannot understand it, tions of the illness process, so that an individual care
he says, because the expectation of becoming a father has plan can be plotted and discussed with the patient,
made him very happy. Th e increasing intensity and fre- along with a relative if possible.