Douleur en psychiatrie

Abstract

Pain is a personal and subjective experience. The consequences are important for the individuals. In the case of psychiatric patients, pain is difficult to perceive and insensitivity is often suggested. Because the expression of pain is significantly altered, our understanding of pain in mental health becomes even more complex. Too often, painful complaint is interpreted as a clinical sign of the psychiatric symptom in these patients such as if a somatic painful condition was not possible. Many studies on pain, in particular in schizophrenia, are reporting atypical behavior that lead to interpret it as a kind of hypoalgesia. This conclusion derived from clinical observations in psychiatry of pain insensitivity in schizophrenic patients. To objectify the reported insensitivity number of experimental studies were developped. There is a big difference, in these studies in both the variability and interpretation of results. Current clinical research concluded that schizophrenic patients experience pain but do not have the pain awareness signal, which is an adaptive phenomenon to avoid injury due to persistent stimulation. The perception and communication of pain in psychiatric patients have important clinical implications and can be related to physical risk or even be life-threatening. Often, it is not allowed for the patient to speak about his pain, in his own language, about his suffering, his disease, if his speech does not fit in our organic and anatomical references. Pain is subjective and it is an individual experience. The consequences are important for the patient. In the case of psychiatric patients, pain is difficult to perceive and hypoalgesia has been always suggested. But the fundamental principles of pain assessement are constant regardless of patient. Pain does not represent just discomfort in a specific body part but a person with a unique phenotype, prior learning history and adaptive ressources. There is no objective method for assessing pain. The way to know about someone pain is by what they say or show by their behavior. Self-report provides the gold standard in assessments of pain and its characteristics. In psychiaric patient we recommand: (1) self-report measure of pain, ask the patient to quantify their pain by providing a single, general rating of pain. Use verbal rating scales: VRS. The Faces Pain Scale-Revised: FPS-R. The faces show how much something can hurt. Do not use words like “happy and sad”; (2) in the case of non-communicant patients, multidimensional pain scale is actually on validation stage like EDAAP. However pain exists in this population and specific language or behavioral changes should suggest pain. Mental illness produces particular attitudes and expressions of pain, in every case, the patient feels pain. Treating each patient's pain is an important part of quality care. Psychiatric patients have their own characteristics, the evaluation and the treatment of their pain are not that simple, their is no contraindication to prescribe usual therapies for them. Some specific iatrogenic interactions have to be known to make the best choice. Pharmacological Approaches: we used WHO ladder for the drugs: paracetamol, NSAIDs, tramadol, opiods, analgesic anticonvulsants. Non pharmacological Approaches: psychological approach emerges as the shared component of a therapeutic project, which is both multidimensional and pluridisciplinary. Cognitive-behavioral approaches are distinct due to the active role played by the therapist in relation to the patient, in the process of learning new behaviors. Physical treatment has to be proposed such as electrophysical and thermal agents, manual therapy, exercise. The relationship between psychiatric patient and pain is often overlooked and did not attract too much attention until recently. In addition, pain and mental health are complex phenomena that are interacting. Pain associates psychic and somatic dimensions. The interaction between pain and mental health is important to have a good comprehension, since the evolution of one or the other will influence the second. How can we help our patients when they suffer and with which words?