McLean Researchers Urge Increased Pain Training for Psychiatrists

January 25, 2011

Psychiatric residencies should include training in pain medicine, since pain problems are extremely common in mental health patients, according to a paper by researchers at Harvard-affiliated McLean Hospital who point out that chronic pain is a disease of the brain that affects sensory, cognitive and emotional systems.

“Many psychiatrists treat pain patients but until they get formal training in pain they will not be able to realize their full potential in this important clinical domain,” said Dr. David Borsook, senior author of the paper published in the January issue of the Archives of General Psychiatry (PMID: 21199962).

Borsook is a neurologist and director of the Center for Pain and the Brain at the Departments of Psychiatry at McLean and Massachusetts General Hospital.

He said: “It is the maladaptation of the brain’s emotional systems that is manifested in chronic pain.”

The paper, a review and perspective article looking at major aspects of pain and their relevance to psychiatric training, points out that chronic pain afflicts more than 70 million Americans and is the most common problem for which patients seek medical attention.

“Nevertheless, remarkably few pain-related themes are currently included in psychiatric residency training,” says the paper, co-authored by two psychiatrists, Dr. Igor Elman, Director of the Clinical Psychopathology Laboratory at McLean, and Dr. Jon-Kar Zubieta, of the Departments of Psychiatry and Radiology and Molecular and Behavioral Neuroscience Institute at the University of Michigan.

“It is a big problem,” said Elman. “The population is aging and a greater proportion of psychiatric patients is going to be older and there is a greater chance they will suffer from pain, so psychiatrists will see more pain patients.”

Epidemiological and clinical data suggests that psychiatric patients have a predilection for the development of various pain conditions, while at the same time, neuropsychiatric characteristics form a key component of chronic pain disorders, the paper concludes.

“While pain is clearly associated with depression, it is not as obvious that depression may also be causing pain. Significant numbers of depressed patients are also suffering from comorbid pain conditions,” Borsook said.

Elman added: “These are flip sides of the same coin. Pain has psychiatric as well as neurological aspects.”

“There is evidence that abnormalities in the emotional brain circuitry arise in mentally healthy people who are exposed to persistent pain, the paper notes. At the same time, almost the entire spectrum of psychiatric disorders is commonly associated with alterations in pain processing, it says. To illustrate this point, the paper describes the role of pain in the course of such syndromes as major depressive disorder, borderline personality disorder, addictions and post-traumatic stress disorder (PTSD).”

In this paper, the authors seek to raise the awareness and sensitivity to the critical need in improving psychiatry residents’ training in pain and in pain management as a public health matter.

“Psychiatrists appear to be inadequately trained in pain medicine and to consequently perceive their work with patients who have chronic pain as ungratifying, so the current psychiatric training requirements may be suboptimal for the physicians who are uniquely poised to evaluate and treat patients experiencing pain while sharing responsibility with their medical colleagues for the treatment of mental health issues,” the paper says.

The authors note: “Psychiatrists can become strong advocates for the use of cognitive and behavioral techniques in the field of pain as they routinely apply them to the care of psychiatric patients.”

They add: “If psychiatric residents received training in pain, they would be more adept and less fearful of handling these patients. Psychiatry is well positioned to potentially provide a huge contribution to the treatment of pain, a condition that current treatments for the most part are not highly effective.”

According to Zubieta: “The idea is that oftentimes physical and psychiatric illnesses are not separate from each other. Depression and anxiety are often precipitated by chronic stress and life events and persistent pain is a condition that affects function and leads to a high level of comorbidity in terms of depression and anxiety.”

“From the perspective of treatment, it requires not just attention to pain, but also to how that pain is interfering with the life of the individual,” he added. “This is one place where physical medicine and mental health treatments come together.”

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