| FEATURE |
EXAMPLE |
COMMENT |
|
Vague, bizarre or unusual description of pain
|
“It
feels like my brain is festering and decaying.” |
Most
patients use words such as “throbbing,”
“sharp,” or “burning” to describe
physical pain. Patients who are describing emotional
pain are more likely to use words such as “terrifying,”
“scary,” or “agonizing.” Statements
must be interpreted in the context of family,
ethnic and cultural influences. |
| Unvarying
pain intensity |
“My
headache is so bad that even banging my head on
the wall doesn’t make it worse. And the 6
mg of morphine I got in the emergency department
didn’t touch it.” |
It
is uncommon for pain of physiologic origin to
be without response of any kind to maneuvers such
as distraction or the use of strong analgesics.
Even severe pain can generally be made worse,
for example. Must distinguish from exaggeration
in order to obtain needed medical attention. |
| Poor,
inconsistent or paradoxical response to treatments
|
Gentle
neck range of motion exercises produce severe
aggravation of headache requiring bedrest and
absence from work. |
Must
be separated from a placebo effect or natural
waxing and waning of the underlying disorder.
However, if repeated and occurring with many different
kinds of treatments, should prompt consideration
of a psychiatric explanation for symptoms. |
| Unusual,
dramatic or unexplainable treatment side effects |
One
dose of 10 mg amitriptyline causes profound agitation,
chest pain and insomnia lasting 8 days. |
Even
ordinarily innocuous medications can occasionally
provoke dramatic side effects. Repeated such reactions
in a single patient involving different classes
of drugs, though, should prompt consideration
of a psychiatric cause for the symptoms. |
| Affectual
indifference to headache |
A
well-groomed, smiling patient reports that his
headache is “18” on a scale of 0 –
10. |
Must
be distinguished from exaggeration that is intended
to obtain needed medical attention to problem. |
| Lack
of insight into psychological influences on headache
|
A
lawyer who has failed to make partner at her firm
because of headache-related absences from work
denies that she is upset about this. |
Most
patients with headache acknowledge that emotional
stress may aggravate or result from headache. |
| Discrepancy
between pain report and appearance or function
|
A
teenager with daily, severe headache that prevents
school attendance is able to participate in social
and competitive sports activities. He does not
miss time from his part-time weekend job. |
Physical
symptoms such as headache may provide a socially
acceptable solution to personal or family problems
such as fear of leaving home or continuing in
an unsatisfactory job. |
| Headache
onset in association with psychologically significant
life event or stage |
Constant,
featureless, treatment-refractory headache in
an 18 year old girl prevents her from accomplishing
normal developmental and separation tasks such
as leaving home to attend college. |
As
above. In addition, psychological tensions that
cannot be acknowledged are sometimes expressed
as physical symptoms. |
