Psychological Factors that Influence Elective Surgical Outcome for Chronic Pain Patients
Pain relief is the primary reason why patients undergo elective surgery in the United States. This article will attempt to point out a number of psychological factors that should be considered before elective surgery is considered with patients experiencing persistent or chronic pain. The accepted benchmark for pain to be considered chronic is six months. Recently, many in the pain medicine field have opted to shorten the time frame to three months. Personally, I evaluate each patient individually, taking into consideration the extensiveness of the procedure and the patient's degree of motivation in their rehabilitation.
Initially, we need to consider some historical influences that will assist us in understanding how the field of pain medicine evolved and the conundrum that persists today. The problem began in the 17th century with Rene Descartes and his dualistic approach to pain. Based on the science available in the mid-1600s Descartes proposed that pain was primarily an old brain, or limbic response, that was linear and stimulus-response in nature. His classic drawing of the young boy placing his hand in the fire was the beginning of pain theory that has continued to influence pain medicine to the present day. Dualism, or what I refer to as the either/or school of thinking, greatly influenced Freud in the 20th century when he proposed his conversion theory. Is it psychogenic or is it "real" physical pain? The evolution of the Diagnostic and Statistical Manual (DSM) from volume I, when it was referred to as Conversion Disorder, to volume IV, where it is called Somatoform Pain Disorder, still implies conversion. This formulation of either/or thinking is the basis of the dualistic conundrum in present day medicine.
Either/or thinking directly impacts the surgical patient selection process for elective surgery, especially when objective evidence is lacking or equivocal. It is relevant to point out that the DSM is published and endorsed by the American Psychiatric Association. Unfortunately, there is no empirical evidence to support the diagnosis of conversion or the either/or school of thinking. In my opinion, this is why dualism is not well received within the mainstream of either the International Association for the Study of Pain or the American Pain Society. This may also be one of the defining differences between psychological and psychiatric approaches to evaluating and treating chronic pain. I would strongly recommend the thinking and writing of Antonio Damasio, MD, PhD. Dr. Damasio is currently the chairman of the Department of Neurology at the University of Iowa School of Medicine. I was greatly influenced by a talk he gave in Portland a number of years ago and have read and re-read his book, Descartes Error, many times.