Pain in psychiatric disorders

Understanding pain in psychiatric presentations is crucial due to the profound and multifaceted impact pain can have on mental health. Pain, whether acute or chronic, often serves as both a cause and a significant contributor to psychiatric disorders.

Acute pain, stemming from sudden injuries or medical conditions, triggers biological responses that can exacerbate anxiety, stress, and emotional distress. This heightened state can lead to psychological symptoms such as irritability, cognitive impairment, and mood disturbances.

Chronic pain, on the other hand, involves persistent activation of pain pathways and can lead to conditions like depression and anxiety, creating a cyclical relationship where pain and mental health issues perpetuate each other. By thoroughly assessing and addressing pain, healthcare providers can uncover underlying issues that might be driving psychiatric symptoms, ensuring more accurate diagnoses and effective treatment plans. This article should be read together with that on The Biopsychosocial Assessment.

Moreover, pain is often a confounding factor in psychiatric disorders, complicating both diagnosis and treatment. Patients with cognitive impairments, learning disabilities, or conditions like dementia may struggle to communicate their pain effectively, leading to behavioural disturbances that can be misinterpreted as primary psychiatric symptoms. This misinterpretation can result in inappropriate or incomplete treatment if the underlying pain is not identified and managed. Recognising and treating pain within psychiatric contexts requires a comprehensive, multidisciplinary approach that considers the biological, psychological, and social dimensions of pain.

In addition to physical pain, psychological pain—stemming from emotional suffering, trauma, grief, and existential distress—is equally significant in psychiatric presentations. This form of pain, though intangible and often harder to articulate, can profoundly affect mental health, leading to or worsening conditions such as depression, anxiety, and post-traumatic stress disorder. Psychological pain can disrupt an individual’s cognitive functions, emotional stability, and social relationships. Understanding and addressing psychological pain is essential for providing comprehensive treatment, as it can deeply influence a patient’s overall well-being and their response to both physical and psychiatric interventions.

This holistic perspective ensures that patients receive well-rounded care, addressing not only their mental health needs but also the pain that may be exacerbating or even causing their psychiatric conditions. By integrating pain management into psychiatric care, we can improve overall patient outcomes, enhance quality of life, and provide more compassionate and effective healthcare.

This article will not venture into pain management. It is an area of expert management that is not normally within psychiatry. However, psychiatrists and psychiatric teams should work closely with pain management experts.

Mental state assessment

Mental state should be meticulous and through for people suffering with pain. Suicidality needs gentle and expert exploration after gaining the confidence of the patient. Exploring suicidality in patients suffering from chronic or severe pain requires sensitivity and open-ended prompts that encourage discussion without leading the patient to a specific answer. ‘Quizzing’ the patient is novice behaviour. An expert may spend a good 15 to 30 mins developing rapport with the patient. This essential for any sound assessment, that should never be rushed. Common sense must prevail – assessment durations have to take into account the patient’s pain levels and mental condition. It may be the case that assessments have to be spread out over several days at times that suit the patient. Flexibility builds confidence and close working.

Here are some prompts to facilitate this exploration:

1. “Tell me – how you’ve been feeling about the levels of pain you are in lately” – This encourages the patient to talk about their recent experiences and emotions related to their pain.
2. “How has your pain been affecting your mood and overall outlook on life?” – This helps assess the broader impact of pain on their emotional state and mental health.
3. “What thoughts have been on your mind when you think about your pain and how it is affecting you?” – This allows the patient to share their inner thoughts and feelings, including any distressing or suicidal thoughts.
4. “Describe any moments when you felt particularly overwhelmed by your pain” – This prompt can lead to discussions about specific times when the patient felt their pain was unbearable, possibly revealing suicidal ideation.
5. “How do you cope on days when the pain feels most intense?” -This explores coping mechanisms and can indicate if the patient is struggling to find ways to manage their pain, which may lead to feelings of hopelessness.
6. “What kind of support or help do you feel you need right now?” – This question opens up a conversation about the patient’s needs and can highlight feelings of helplessness or despair.
7. “Some people feel that they can’t go on because of their pain” – This direct yet open-ended question allows the patient to talk about suicidal thoughts without feeling pressured to respond in a specific way.
8. “When you’re in pain, what kinds of thoughts or feelings come up for you?” -This prompt invites the patient to explore the emotional and cognitive impact of their pain.
9. “What do you think about when you imagine the future with this pain?” – This helps gauge the patient’s outlook and any potential feelings of hopelessness or despair regarding their chronic pain.
10. “How do you feel your pain is understood by those around you?” – This can lead to discussions about isolation, support, and whether the patient feels their suffering is recognised by others.

These open-ended prompts should not be memorised and recited, as they will appear artificial. Questions or prompts can be worded along the lines above. Experts may add their own prompts or sub-prompts for exploration. They can help healthcare professionals gather comprehensive information about a patient’s emotional and psychological state, particularly concerning suicidality, while maintaining a supportive and non-judgmental approach.

Category	Areas to Explore	Description
Appearance	General appearance and grooming	Look for signs of pain, neglect, weight loss, or fatigue that might indicate ongoing pain.
	Facial expressions	Observe for signs of distress, grimacing, or flat affect.
Behaviour	Activity level	Note restlessness, agitation, or psychomotor retardation.
	Interaction with the examiner	Assess for withdrawal, irritability, or lack of eye contact.
Speech	Rate, volume, and tone	Evaluate for slow, hesitant speech, or pressured speech indicative of anxiety or distress.
	Content of speech	Listen for expressions of pain, hopelessness, or themes related to suffering.
Mood and Affect	Self-reported mood	Ask the patient to describe their mood in their own words. Suicidal ideas/intent. Hopelessness.
	Observed affect	Assess congruence with reported mood, noting any signs of depression, anxiety, or irritability.
Thought Processes	Coherence and organisation	Look for disorganised thinking, rumination, or preoccupation with pain.
	Content of thought	Identify themes of hopelessness, worthlessness, or excessive focus on pain and its impact.
Perception	Hallucinations and delusions	Assess for pain-related perceptual disturbances, such as somatic hallucinations.
Cognition	Attention and concentration	Evaluate for difficulties in sustaining attention or concentration, which can be affected by pain.
	Memory	Assess for short-term memory problems that might be related to pain or pain medications.
	Executive function	Test for difficulties in planning, organising, or decision-making.
Insight and Judgement	Insight into pain and its impact	Gauge the patient’s understanding of their pain and its effects on their mental health.
	Judgement related to pain management	Assess the patient’s decision-making abilities regarding their treatment and coping strategies.
Risk Assessment	Suicidal ideation and/or plans	Explore any thoughts of self-harm or suicide, especially if the patient expresses feelings of hopelessness.
	Risk to others	Evaluate any potential for aggression or irritability towards others due to pain.

Functional assessment

Cognitively impaired patients may struggle with questions of the above kind. It is important not to slip into closed questions because responses then tend to be of the ‘yes’ or ‘no’ type which could be meaningless if the questions were not understood, or if the patient is struggling with their thoughts.

In that sort of scenario it is important to carry out the fullest functional assessment and integrate that into the mental state assessment.

Physical pain

Psychological pain

Psychological pain, also known as emotional or mental pain, is a complex and deeply personal experience that is often not well connected to physical pain. This type of pain arises from a variety of emotional states and experiences, such as grief, loss, trauma, loneliness, and existential distress. Unlike physical pain, which typically has a clear and identifiable source, psychological pain is more abstract and subjective, making it difficult for many patients to articulate and communicate.

One of the primary challenges in addressing psychological pain is its intangible nature. Patients may struggle to find the right words to describe their feelings, often using metaphors or vague terms like “heartache,” “suffering,” or “feeling broken” to convey their experiences. This lack of precise language can hinder effective communication with healthcare providers, making it harder to diagnose and treat the underlying issues. Additionally, societal stigma around mental health can lead individuals to downplay or hide their psychological pain, further complicating the process of seeking and receiving help.

Psychological pain can manifest in various ways, including persistent sadness, anxiety, irritability, and a sense of emptiness or hopelessness. It can affect an individual’s ability to function in daily life, impacting relationships, work performance, and overall well-being. Unlike physical pain, psychological pain often lacks clear external signs, making it less visible to others and sometimes leading to misunderstandings or dismissals of the individual’s suffering.

Addressing psychological pain requires a compassionate and holistic approach. Mental health professionals must create a safe and supportive environment where patients feel comfortable expressing their emotions without judgment. Therapeutic techniques such as cognitive-behavioural therapy (CBT), psychotherapy, and mindfulness-based practices can help individuals explore and process their pain, developing healthier coping mechanisms and emotional resilience. Additionally, fostering open communication and raising awareness about the validity and importance of psychological pain can help reduce stigma and encourage more individuals to seek the support they need.

Aspect	Physical Pain	Psychological Pain	Mood Disorders
Definition	Sensory and emotional experience related to actual or potential tissue damage.	Emotional suffering arising from psychological factors such as trauma, grief, or existential distress.	A category of mental health disorders primarily characterised by disturbances in mood, such as depression and bipolar disorder.
Common Symptoms	Acute or chronic discomfort, muscle tension, fatigue, sleep disturbances.	Persistent sadness, grief, feelings of worthlessness, emotional numbness.	Prolonged sadness, irritability, feelings of hopelessness, changes in appetite and sleep, loss of interest in activities.
Biological Impact	Involves activation of pain pathways, potential changes in brain chemistry and function, immune response.	Can lead to stress responses, changes in brain function similar to those seen in physical pain.	Involves neurotransmitter imbalances, changes in brain structure and function, hormonal changes.
Psychological Impact	Increased anxiety, depression, cognitive impairment, emotional distress.	Directly contributes to mental health conditions like depression and anxiety.	Includes a wide range of emotional and cognitive symptoms such as negative thought patterns, suicidal ideation, impaired concentration.
Social Impact	Reduced social engagement, potential strain on relationships, social withdrawal.	Can lead to social isolation, relationship difficulties, reduced social functioning.	Social withdrawal, impaired relationships, occupational and educational challenges.
Overlap with Mood Disorders	Chronic pain often co-occurs with mood disorders; mood disorders can exacerbate the perception of pain.	Psychological pain is a core component of mood disorders; emotional distress can directly trigger mood disorder symptoms.	Mood disorders frequently involve both physical pain (e.g., somatic symptoms) and psychological pain.
Assessment Tools	Pain scales (e.g., Visual Analog Scale), physical exams, patient self-reports.	Psychological assessments, interviews, mental health questionnaires.	Clinical interviews, standardised diagnostic tools (e.g., DSM-5 criteria), mood rating scales (e.g., PHQ-9).
Management Strategies	Pharmacological treatments (analgesics, anti-inflammatories), physical therapy, lifestyle modifications.	Psychotherapy (CBT, EMDR), counseling, stress management techniques, support groups.	Antidepressants, mood stabilisers, psychotherapy (CBT, DBT), lifestyle changes, social support interventions.

Missing pain as a factor

Healthcare professionals can miss pain as a cause of psychiatric ill-health for several reasons, despite its significant impact on mental health. Understanding these reasons can help in improving assessment and management practices to ensure comprehensive patient care.

1. Communication barriers: Patients, particularly those with cognitive impairments, learning disabilities, or dementia, may have difficulty expressing their pain. Their inability to articulate pain clearly can lead healthcare professionals to overlook or misinterpret their symptoms. Additionally, patients might use vague or non-specific language to describe their pain, making it harder for professionals to identify the underlying issue.
2. Diagnostic overshadowing: In individuals with known psychiatric conditions, healthcare professionals might attribute new symptoms or behavioural changes solely to the existing mental health disorder, rather than considering pain as a contributing factor. This phenomenon, known as diagnostic overshadowing, can result in missed diagnoses of physical conditions that are causing or exacerbating psychiatric symptoms.
3. Focus on psychiatric symptoms: Mental health professionals often concentrate on psychiatric symptoms and their management, sometimes at the expense of thoroughly investigating potential physical health issues. The primary focus on mental health can inadvertently lead to the under-recognition of physical pain as a significant factor affecting the patient’s psychological state.
4. Lack of training and awareness: Some healthcare professionals may lack specific training in recognising and assessing pain, particularly in populations that have difficulty communicating their pain, such as those with cognitive impairments or learning disabilities. Without adequate training, professionals might not be equipped to identify the subtle signs and symptoms of pain.
5. Misinterpretation of behaviour: Behavioural changes resulting from pain, such as aggression, agitation, or withdrawal, can be misinterpreted as purely psychiatric issues. Professionals might view these behaviours as symptoms of a mental health disorder rather than potential indicators of underlying pain, leading to inappropriate or incomplete treatment plans.
6. Time constraints and workload pressures: High patient loads and time constraints in clinical settings can lead to rushed assessments and incomplete evaluations. Healthcare professionals might not have sufficient time to conduct thorough pain assessments, particularly if the patient has complex needs or communication difficulties.
7. Reliance on self-report: Pain assessment often relies heavily on self-report, which can be problematic for patients who cannot effectively communicate their pain. Healthcare professionals may not always use alternative assessment tools or methods to evaluate pain in these patients, leading to under-diagnosis or misdiagnosis.
8. Cultural and systemic factors: Cultural factors, such as varying expressions of pain and discomfort, and systemic issues, such as inadequate pain assessment protocols, can also contribute to the under-recognition of pain. Healthcare systems may not always prioritise pain assessment and management, particularly in mental health settings.

Steps to improve pain recognition among professionals

To address these challenges, healthcare professionals can:

1. Enhance training: Provide comprehensive training on pain assessment, particularly for populations with communication difficulties.
2. Use appropriate tools: Implement validated pain assessment tools tailored for non-verbal or cognitively impaired patients.
3. Promote multidisciplinary collaboration: Encourage collaboration between physical health and mental health professionals to ensure holistic patient care.
4. Improve communication: Foster open and empathetic communication with patients and caregivers to better understand the patient’s pain experience.
5. Integrate pain assessments: Regularly incorporate pain assessments into routine mental health evaluations to identify and address pain promptly.

By addressing these factors, healthcare professionals can improve their ability to recognise and manage pain, ultimately enhancing the overall care and well-being of their patients.

Liaison with pain management services

Psychiatric multidisciplinary teams (MDTs) can effectively liaise with pain management services through structured collaboration, communication, and coordinated care strategies. The following are some key approaches:

Regular interdisciplinary meetings: Hold regular interdisciplinary meetings that include members of both the psychiatric MDT and pain management services. These meetings can be used to discuss complex cases, share insights, and develop integrated care plans. Ensuring all relevant parties are present helps maintain a unified approach to patient care.

Shared care plans: Develop shared care plans that outline the roles and responsibilities of both teams in managing a patient’s treatment. These plans should include specific interventions, timelines, and follow-up schedules. Having a documented care plan ensures that both teams are aligned and working towards common goals.

Joint assessments: Conduct joint assessments of patients who present with both psychiatric and pain management needs. This collaborative approach allows for a comprehensive evaluation of the patient’s condition from both perspectives, leading to more accurate diagnoses and effective treatment plans.

Integrated communication systems: Implement integrated communication systems such as shared electronic health records (EHRs) to facilitate real-time information sharing between psychiatric and pain management teams. This ensures that all team members have access to up-to-date patient information, reducing the risk of miscommunication and improving continuity of care.

Cross-training and education: Provide cross-training opportunities for staff from both teams to enhance their understanding of each other’s fields. For instance, psychiatric professionals can receive training on pain assessment and management, while pain specialists can be educated on recognising and addressing psychiatric symptoms. This mutual education fosters a more holistic approach to patient care.

Referral Pathways: Establish clear referral pathways to streamline the process of referring patients between psychiatric and pain management services. Clear guidelines on when and how to refer patients can help ensure timely and appropriate interventions.

Patient-centred Care Conferences: Organise patient-centred care conferences where both psychiatric and pain management teams, along with the patient and their family, discuss treatment options and care strategies. This inclusive approach ensures that the patient’s preferences and needs are central to the care planning process.

Collaborative treatment interventions: Design and implement collaborative treatment interventions that address both pain and psychiatric symptoms. For example, combining cognitive-behavioural therapy (CBT) for pain management with pharmacological treatments for psychiatric conditions can provide comprehensive care.

Continuous monitoring and feedback: Establish a system for continuous monitoring and feedback to evaluate the effectiveness of the integrated care approach. Regularly review patient outcomes and make necessary adjustments to treatment plans based on feedback from both teams and the patient.

Supportive services: Coordinate supportive services such as occupational therapy, physical therapy, and social work to address the broader needs of patients with chronic pain and psychiatric conditions. These services can provide additional layers of support, enhancing the overall effectiveness of the care plan.

Summary and take away points

This exploration into pain as a factor in psychiatric disorders has underscored the intricate interplay between physical, psychological, and social dimensions of health, as outlined in the biopsychosocial model. Pain, whether acute or chronic, significantly impacts mental health, influencing mood, cognitive function, and social interactions. Acute physical pain, arising from sudden injuries or medical conditions, can trigger immediate physiological responses that exacerbate anxiety, stress, and emotional distress. This biological impact extends into the psychological domain, affecting cognitive functions and mood, and often disrupting social relationships and daily activities.

Chronic pain, which persists over an extended period, presents even more profound challenges. It not only involves continuous activation of pain pathways and potential changes in brain chemistry but also is closely linked with mental health conditions such as depression and anxiety. This persistent pain creates a cycle where psychological distress and pain reinforce each other, leading to significant emotional suffering and cognitive impairments. The social implications are equally severe, as individuals may withdraw from relationships and activities, experiencing isolation and economic hardship, further exacerbating their mental health issues.

Psychological pain, distinct yet deeply interwoven with physical pain, emerges from emotional suffering, trauma, and existential distress. It shares many symptoms with mood disorders like depression and anxiety, complicating diagnosis and treatment. Psychological pain can profoundly affect an individual’s mental health, leading to persistent sadness, hopelessness, and cognitive challenges. Addressing this type of pain requires empathetic communication and therapeutic interventions tailored to the individual’s emotional experiences, ensuring that their psychological suffering is recognised and managed alongside any physical symptoms.

The mental state assessment is an essential component in evaluating patients with psychiatric disorders, particularly those experiencing pain. It provides a comprehensive overview of the patient’s current cognitive, emotional, and behavioural functioning, helping to identify symptoms that might be linked to both physical and psychological pain. Emphasising suicidality within this assessment is vital, as chronic or severe pain often correlates with increased risk of suicidal thoughts and behaviours. Open-ended, empathetic inquiries about the patient’s mood, coping mechanisms, and thoughts about their pain can reveal underlying distress that might otherwise go unnoticed. Early identification and intervention for suicidality can prevent tragic outcomes, ensuring that patients receive the necessary support and care to manage their pain and associated mental health challenges effectively.

Effective management of pain in psychiatric contexts necessitates a collaborative, multidisciplinary approach. Psychiatric multidisciplinary teams must work closely with pain management services to ensure comprehensive care. This involves regular interdisciplinary meetings, shared care plans, joint assessments, and integrated communication systems. Such collaboration enables healthcare providers to develop holistic treatment strategies that address both the physical and psychological aspects of pain, improving patient outcomes and quality of life. By recognising and addressing pain as a core component of psychiatric care, healthcare professionals can offer more compassionate, effective, and comprehensive treatment to those suffering from both physical and psychological pain.