Pain management poses many problems for the doctor. The American psychiatrist, Thomas Szasz, who has written extensively on pain and what it means to pain sufferers, studied what he termed ‘pain-prone’ patients suffering repeated physical disability with, or without, detectable injury or illness. He described many of them as having excessive guilt feelings, their pain often serving as an unconscious punishment. Some of them even feel at their healthiest when life is at its worst! Szasz proposed that pain results from a threat to the body, either real or imagined.
Thus, the doctor assessing the patient with chronic pain should be aware of both the psychological as well as the physical threat. With the exclusion of a physical cause of pain, both a psychiatric and social history should be taken as well as an appropriate psychological assessment. In addition, a full medical examination should be made and the appropriate investigations undertaken.
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