Page 32 Guide to Pain Management in Low-Resource Settings

20 Harald C. Traue et al.

however, avoiding activities and social contact aff ects associated with them. Conversely, patients with clear
the patient by leading to even less activity, social with- somatic symptoms often do not receive adequate psy-
drawal, and an almost complete focus of attention on chological care: pain-related anxiety and depressive
the pain. Th is tendency leads to a vicious circle of pain, moods, unfavorable illness-related behavior, and psy-
lack of activity, fear, depression, and more pain. chopathological comorbidities may be neglected.
From a psychological perspective, it is assumed
Patients often have that chronic pain disorders are caused by somatic pro-
a somatic pain model cesses (physical pathology) or by signifi cant stress levels.
Th ere could be a physical illness, but also a functional
In Western medicine, pain is often seen as a neurophys- process such a physiological reaction to stress in the
iological reaction to the stimulation of nociceptors, the form of muscle tension, vegetative hyperactivity, and an
intensity of which—similar to heat or cold—depends on increase in the sensitivity of the pain receptors. Only as
the degree of stimulation. Th e stronger the heat from the disorder progresses do the original trigger factors
the stove, the worse the pain is usually perceived to be. become less important, as the psychological chronifi -
Such a simple, neuronal process, however, only applies cation mechanisms gain prevalence. Th e eff ects of the
to acute or experimental pain under highly controlled pain symptom then may themselves become a cause for
laboratory conditions that only last for a brief period of sustaining the symptoms.
time. Due to the manner in which pain is portrayed in Modern brain-imaging techniques have con-
popular science, patients also tend to adhere to this na- fi rmed psychological assumptions on pain and provide
ive lay theory. Th is leads to unfavorable patient assump- the basis for an improved understanding of how psy-
tions, such as (1) pain always has somatic causes and chological and somatic factors act together. As Chen
you just have to keep looking for them, (2) pain without summarized, there is not just one pain center associated
any pathological causes must be psychogenic, and (3) with the pain, but a neuronal matrix made up of all ar-
psychogenic means psychopathological. eas that are activated by sensory, aff ective, and cognitive
Physicians only start considering psychogenic data processing, particularly the primary sensory cortex,
factors as a contributing factor if the causes of the pain the insula, the cingulate gyrus, the periaqueductal gray,
cannot be suffi ciently explained by somatic causes. In and the frontal cortical area: “Th e neurophysiological
these cases, they would say, for example, that the pain and neuro-hemodynamic brain measures of experimen-
is “psychologically superimposed.” Consequently, pa- tal pain can now largely satisfy the psychophysiologist’s
tients worry that they will not be taken seriously and dream, unimaginable only a few years ago, of modeling
will insist even more that the physician look for somatic the body-brain, brain-mind, mind-matter duality in an
causes. Th is situation leads to a useless dichotomy of interlinking 3-P triad: physics (stimulus energy); physi-
somatogenic vs. psychogenic pain. But pain always con- ology (brain activity); and the psyche (perception). We
sists of both factors—the somatic and the psychological. may envision that the modular identifi cation and delin-
Th is obsolete dichotomization must be addressed with- eation of the arousal-attention, emotion-motivation and
in the context of holistic pain therapy. perception-cognition neuronal network of pain process-
ing in the brain will also lead to deeper understanding
Th e interaction of biological, of the human mind.”
psychological, and social factors One of the important results of this research
is that in studies using fMRI (functional nuclear mag-
A complete pain concept for chronic pain is complex netic resonance imaging of the brain), negative feelings
and attempts to take as many factors as possible into such as rejection and loss that are generally referred to
consideration. Psychologically oriented pain therapists as painful experiences also create neuronal stimulation
cannot have a naive attitude toward the pain and ne- patterns similar to those created by noxious stimulation.
glect somatic causes, because otherwise, patients with Th is fi nding is of great clinical signifi cance, because so-
mental disorders (e.g., depression or anxiety) will not cially outcast and traumatized persons not only may
receive the somatic care they require; just because have post-traumatic stress disorder (PTSD), but also
someone has a mental disorder does not mean he or show high levels of pain that can persist even after the
she is immune from physical disorders and the pain body had healed.