This presentation was presented in "Medical Approach in Holistic Management to Relieve Pain" 13 Des 2015 at The Sunan Hotel, SOLO. Since Pain is always subjective, Psychogenic pain is very related to psychiatric problems and very often it does not recognized by physicians in their practice.

1. One Day "Medical Approach in Holistic
Management to Relieve Pain" 13 Des
2015 at The Sunan Hotel, SOLO

2. Pain Is the 5th Vital Sign
Phillips DM. JAMA 2000; 284(4):428-9.
TemperatureRespiration Pulse Blood pressure
Pain

3. Pain. What is it?
“An unpleasant sensory and emotional
experience associated with actual or
potential tissue damage, or
described in terms of such damage.”
International Association for the
Study of Pain

4. The Pain Continuum
Time to resolution
Acute pain Chronic pain
Chapman CR, Stillman M. In: Kruger L (ed). Pain and Touch. Academic Press; New York, NY: 1996; Cole BE. Hosp Physician 2002; 38(6):23-30;
International Association for the Study of Pain. Unrelieved Pain Is a Major Global Healthcare Problem.
Available at: http://www.iasp-pain.org/AM/Template.cfm?Section=Press_Release&Template=/CM/ContentDisplay.cfm&ContentID=2908. Accessed:
July 24: 2013;
National Pain Summit Initiative. National Pain Strategy: Pain Management for All Australians.
Available at: http://www.iasp-pain.org/PainSummit/Australia_2010PainStrategy.pdf. Accessed: July 24, 2013;
Turk DC, Okifuji A. In: Loeser D et al (eds.). Bonica’s Management of Pain. 3rd ed. Lippincott Williams & Wilkins; Hagerstown, MD: 2001.
Insult
Normal, time-limited response
to „noxious‟ experience
(less than 3 months)
Pain that has persisted beyond
normal tissue healing time
(usually more than 3 months)
• Usually obvious tissue damage
• Serves a protective function
• Pain resolves upon healing
• Usually has no protective function
• Degrades health and function
Acute pain may become chronic

5. Pain Categories
1. Somatogenic pain is pain with cause (usually known)
localised in the body tissue
a/ nociceptive pain
b/ neuropatic pain
2. Psychogenic pain is pain for which there is no known
physical cause but processing of sensitive information
in CNS is disturbed

6. Psychological Pain = Psychogenic Pain
• Psychological pain
– “Pain specifically attributable to the thought
process, emotional state, or personality of the
patient in the absence of an organic or
delusional cause or tension mechanism.”
International Association for the Study of Pain

7. Case from Clinic (1)
• A 52 yrs old woman complained headache since
3 years ago. She had already checked to a
neurologist, a TNT-Specialist and internist and
did some examinations.
• The previous physician did not find any
problems and the examinations ruled out any
underlying disease, except “the pain” still existed
• She could not described the pain specifically,
“come and go” but very annoying. She realized
that the pain intensity was related to stress

8. Psychiatry and Pain
Diagnosis of Pain in Psychiatry (DSM)
• DSM I (1952)
– Psychophysiological disorders“
– “Psychoneurotic Disorders”
• DSM II (1968)
– Hysterical neurosis
• III (1980)
– Psychogenic Pain
• Etiologically related
• III-R (1987)
– Somatoform pain
– Dropped etiology part

9. Psychiatry and Pain
• DSM IV
– Pain Disorder
• Pain=predominant focus
• Substantial distress/impairment
• Psych factors “have role”
– Onset or expression
• Not malingering/factitious disorder
• DSM 5 : Somatic Symptoms Disorder and
Its Related Disorder.
– Somatic Symptoms Disorder with
predominant pain

10. PPDGJ and Pain
• Dalam diagnosis gangguan jiwa menurut PPDGJ 3 terdapat
diagnosis gangguan nyeri sebagai bagian dari gangguan
somatoform yaitu F. 45.4 . GANGGUAN NYERI YANG
MENETAP.
– Nyeri pada satu atau lebih tempat anatomis
– Nyeri menyebabkan penderitaan yang bermakna secara klinis atau
gangguan dalam fungsi sosial, pekerjaan, atau fungsi penting lain.
– Faktor psikologis dianggap memiliki peranan penting dalam onset,
kemarahan, eksaserbasi atau bertahannya nyeri.
– Gejala atau defisit tidak ditimbulkan secara sengaja atau dibuat-buat
(seperti pada gangguan buatan atau berpura-pura).
– Nyeri tidak dapat diterangkan lebih baik oleh gangguan mood,
kecemasan, atau gangguan psikotik dan tidak memenuhi kriteria
dispareunia.

11. Assessment of Pain
• Immediate Pain
• Physical Functioning
• Psychological Factors
• Pain Behaviors
• Objective Correlates

12. The Cause of Psychogenic Pain
• Theory 1:
Underlying psychological factors cause
psychogenic pain
• anxiety disorder
• depression
• Theory 2:
Psychogenic pain results from some previous injury
that hasn’t yet fully healed.
• Theory 3:
Psychogenic pain causes existing pain to feel
worse than the situation actually warrants.

13. Symptoms of Psychogenic Pain
• Constant discomfort despite taking
medication
• Difficulty describing the location, quality
and depth of pain
• Non localized pains that encompass larger
parts of the body
• Worsening pain independent of any
underlying medical condition.
All above symptoms exist in absence of any chronic
disorder with physical cause

14. Case from Clinic (2)
• A 45 yrs old man with history of major
depressive disorder in his 30’s.
• He complained that the symptoms of depression
were coming back recently
• He also complained aches all over his body
• The man was diagnosed with MDD with somatic
as a predominat symptoms
Notes : Approximately two thirds of patients with depression in
primary care present with somatic symptoms
(Tylee, et al, J Clin Psychiatry. 2005; 7(4): 167–176)

15. Psychiatric Disorder and Pain
DEPRESSION
• Approximately 60% of patients with depression present pain at the
moment of the diagnosis
• The presence of depressive disorder may increase the risk of
developing a musculoskeletal pain, headache and chest pain 3
years later on.
• Elderly patients with depression are at increased risk for cervical,
lumbar and hip pain.
• Depression prevalence was 12 times in individuals with three or
more pain-related symptoms, as compared with patients without
pain.
• Patients with chronic pain suffered from major depression between
8% and 50%
Pain and psychiatry: a critical analysis and pharmacological review. Marazziti, et al,
Clinical Practice and Epidemiology in Mental Health 2006, 2:31

16. Psychiatric Disorder and Pain
ANXIETY
• Patients with different painful syndromes showed an increased risk
of anxiety syndromes or disorders (50% have anxiety symptoms and
19% have a panic disorder or generalized anxiety disorder)
• A prospective study involving 1007 young adults found that a
history of headache was associated with a higher of panic
disorder
• Anxiety disorders are associated with high somatic
preoccupation levels and physical symptoms.
• In a study of panic disorder, at least 40% patients described chronic
pain symptoms and more than 7% took pain relievers daily

17. Unpublished survey. Conducted by
Dr Andri for educational and promoting
mental health purpose only. Data were
collected using ww.surveymonkey.com.
Bias of the result is one of the weakness
of this survey
PAIN in Psychosomatic Patient

18. Multimodal Treatment of Pain Based on
Biopsychosocial Approach
Pharmacotherapy
Stress management
Interventional pain
management
BiofeedbackComplementary therapies
Physical
therapy
Education
Lifestyle management
Sleep hygiene
Gatchel RJ et al. Psychol Bull 2007; 133(4):581-624; Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research.;
National Academies Press; Washington, DC: 2011; Mayo Foundation for Medical Education and Research. Comprehensive Pain Rehabilitation Center Program Guide. Mayo
Clinic; Rochester, MN: 2006.
Occupational therapy

19. Barrier to Psychiatric Approach
A referral to psychiatrist may mean to the
patient:
- The pain is not real
- Physicians are giving up on them
- Physicians have failed to diagnose the
underlying disease
- Physicians refer only when they think no
organic pathology could be detected

20. Psychiatric Treatment Approach
• Interdisciplinary approach with other specialists
• Acknowledge the symptoms : “the pain is real “
• Supportive therapy and cognitive therapy: “How
can I live with this pain? ; “How can I adapt
with it?”
• If commorbid with mental disorder, Treat it Well
• Drugs that psychiatrist usually use :
– SNRI (duloxetine), Amytriptiline, Pregabalin

22. Twitter : @mbahndi
IG : andripsikosomatik

23. Curriculum Vitae
• Nama : Dr.Andri,SpKJ,FAPM
• Usia : 37 tahun
• Pendidikan :
– Dokter : Fakultas Kedokteran Universitas Indonesia (Lulus 2003)
– Psikiater : Fakultas Kedokteran Universitas Indonesia (Lulus 2008)
– Pendidikan tambahan di bidang psikosomatik medis dari American
Psychosomatic Society di Portland, Oregon, USA tahun 2010 dan Academy
of Psychosomatic Medicine di Atlanta, USA 2012, di Tucson 2013 dan di
Fort- LeDaurdale 2014
– Pengakuan sebagai Fellow of The Academy of Psychosomatic Medicine
(FAPM) November 2013
• Organisasi :
– IDI
– PDSKJI
– American Psychosomatic Society
– Academy of Psychosomatic Medicine
• Jabatan :
– Dosen Psikiatri di FK UKRIDA, Jakarta
– Kepala Klinik Psikosomatik Omni Hospital, Alam Sutera
– Ketua Sub Kredensial Komite Medik RS OMNI Alam Sutera