Bridging the Gap Between Psychiatry and Physical Medicine

Edward Michael Philips, MD

Dr. Philips is Director of Outpatient Medical Service, Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitatioin Hospital

“When your patient complains about pain it is imperative to fully evaluate and treat as appropriate” states Edward M. Phillips, M.D. Though he consults at a psychiatric hospital he is not a psychiatrist but a physiatrist, a specialist in Physical Medicine and Rehabilitation (PM&R). The interface between psychiatry and PM&R has been neglected for too long, according to Dr. Phillips who is director of outpatient medical services at Spaulding Rehabilitation Hospital Network and a 10-year veteran consultant at McLean Hospital in Massachusetts. The presence of a physiatrist in a psychiatric hospital is unusual, but it offers up a wealth of lessons to the office- or hospital-based psychiatrist dealing with patients co-presenting with psychiatric disorders and pain.

Pain is heavily linked with psychiatric disorders (Table 1), particularly addiction and depression, and the interplay between the different elements can be quite complex. In Dr. Phillips’ experience, patients addicted to narcotics frequently report that their substance-abuse is a form of self-medication for their chronic pain. Further, their chronic pain, substance use, and any physical disability often contribute to their depression. Depression in turn tends to amplify their complaints of pain. However, narcotics may lead not only to addiction and depression but there’s solid evidence to support the hyperalgesia theory, which posits that prolonged exposure to pain-regulatory narcotics can often hypersensitize a patient to pain rather than alleviate her suffering.

A knotty problem such as pain and depression takes a team approach to unravel. However, all too often patients with both physical and psychiatric disabilities are shuttled back and forth between physiatrists and psychiatrists. As Dr. Phillips explains, “you’ll have a patient who’s too depressed to function in the physical rehab unit, so you send him to the psychiatric ward where the psychiatrists attempt to treat the depression but often lack the tools and resources to address the pain.”

Dr. Phillips offers a number of suggestions for psychiatrists and primary care physicians dealing with patients presenting with pain:

Refer them to a pain doctor. “Psychiatrists tend to be rightfully wary that patients complaining of pain are merely shopping for a doctor willing to feed their addiction to narcotics,” Dr. Phillips points out. “However, often the pain is generated by a problem that warrants intervention. But pain is by definition subjective. Even if no clear pathology is found the mere fact that the complaint of pain is taken seriously can have a tremendous beneficial effect on the patient.” Further, discussing pain can be an easy inroad to gaining patient trust.

Fully examine the patient. Often, an underlying physical problem will go unnoticed for years merely due to lack of simple physical examination. This is especially true in patients who are labeled as somatic.

If narcotics are indicated, then carefully monitor the patient’s response to the medications. Dr. Phillips stresses function over subjective reports of pain: “If the patient is taking a narcotic, but her function, either physical or psychological, isn’t improving, it’s time to try another option.” There are a number of quite successful alternative ways to treat pain (Table 2).

Offer the patient a way out. In Dr. Phillips’ experience, it’s easier for a patient with a substance-abuse disorder to rehabilitate if she has an excuse—both for the substance-abuse and for quitting. “Someone who’s been taking narcotics and claiming it’s due to extreme physical pain is going to have an easier time quitting if a specialist has addressed and attempted to treat his or her pain.” The focus shifts from making excuses to treating an actual, tangible problem.

Get conversant, or consult with someone who is, in pain psychology. “Often,” Dr. Phillips attests, “providing the patient with a psychological coping mechanism, such as a comforting metaphor, can be very useful.”

“Most importantly,” Dr. Phillips says, “assess and treat the person’s pain. Take it seriously. Get to the bottom of it.” When dealing with complex problems, of the sort commonly encountered in psychiatry and physical rehabilitation, a team approach is often the best bet.

– For more information on pain, go to http://www.painconnection.org