Chronic Pain Syndrome

            When I first see patients in my office, I believe that it is very important to determine whether or not they have the Chronic Pain Syndrome.  The Chronic Pain Syndrome is somewhat controversial and many physicians consider the use of this somewhat negative and derogatory towards the patients.  I do not consider it any such thing, and believe that it is important to understand what you are approaching when you are attempting to help someone to get better.  The following is the American Medical Association diagnostic characteristics of the Chronic Pain Syndrome. 

The presence of two or more of the following characteristics should be considered to establish a presumptive diagnosis of Chronic Pain Syndrome:

1.   Duration:  In the past, the term "chronic pain" has been applied to pain of greater than 6 months duration; however, current opinion is that the Chronic Pain Syndrome can be diagnosed as early as 2-4 weeks after its onset.  Prompt evaluation and treatment are essential.

2.   Dramatization:  Patients with chronic pain display unusual verbal and nonverbal pain behavior.  Words used to describe the pain are emotionally charged, effective and exaggerated.  Patients may exhibit maladaptive theatrical behavior, such as moaning, groaning, gasping, grimacing, posturing, or pantomiming. 

3.   Diagnostic dilemma:  Patients tend to have extensive histories of evaluation by multiple physicians.  The patient has undergone repeated diagnostic studies, despite which the clinical impressions tend to be vague, inconsistent, and inaccurate. 

4.   Drugs:  Substance dependence and abuse involving drugs and alcohol is a frequent concomitant.  Patients are willing recipients of multiple drugs, which may interact adversely.  Often they consume excessive amounts of prescribed drugs.  These patients become dependent on their physicians and demand excessive medical care.  They expect passive types of physical therapy over long periods of time, but these provide no lasting benefit.  They become dependent on their spouses and families, and relinquish all domestic and social responsibilities. 

5.    Depression: The condition is characterized by emotional upheaval.  Patients tend to have psychological test results that suggest depression, hypochondriasis, and hysteria.  Cognitive aberrations give way to unhappiness, depression, despair, apprehension, irritability, and hostility.  Coping mechanisms are severely impaired.  Low self-esteem results in impaired self-reliance and increased dependence on others. 

6.   Disuse:  Prolonged, excessive immobilization results in secondary pain of musculoskeletal.  Self-imposing splinting may be validated by misguided medical directives to be "cautious", and this can result in  1l        progressive muscular dysfunction and generalized deconditioning.  The secondary pain further perpetuates the reverberating pain cycle. 

7.   Dysfunction:  Having lost adequate coping skills, patients with chronic pain begin to withdraw from the social milieu.  They disengage from work, drop recreational endeavors, tend to alienate friends and family and become increasingly isolated, and eventually restricting their activities to the bare essentials of life.  Bereft of social contacts, rebuffed by the medical system, and deprived of adequate financial means, the patient becomes an invalid in the broadest sense; physical, emotional, social, and economic. 

8.   Dependence:  These patients become dependent on their physicians and demand excessive medical care.  They expect passive types of physical therapy over long periods, but these provide no lasting benefits.  They become dependent on their spouse and families, and relinquish all domestic and social responsibilities.   There is no doubt that the chronic pain that these patients suffer from is very real.  As I have noted before, it is not something that can oftentimes be seen on x-ray or seen on MRI, or even on physical examination.  Not uncommonly, patients with chronic pain have a negative evaluation.  It is my considered opinion that up to 70% of the patients that I see will have an undiagnosed reason that definitely explains their pain.  Their pain defies detection by conventional means.  Sometimes its effects can be measured by the reactions to it that the body manifests; sometimes not, but the pain is there nonetheless, and as the patients attest to it can be relentless whether or not it is constant or intermittent.  In the beginning the pain may be intermittent, but eventually it becomes constant.  Fortunately, we could diagnose the Chronic Pain Syndrome and once it is diagnosed we can start to treat this.  I firmly believe that a diagnosis of Chronic Pain Syndrome needs to be made and then we can move forward in treating this.  I have seen in many patients that have made significant improvement in their Chronic Pain Syndrome.  You may be asking how I diagnose Chronic Pain Syndrome and I have been very fortunate to have found early on in my training and management of chronic pain, the excellent book The Pain Cure: The Proven Medical Program That Helps End Your Chronic Pain by Dharma Singh Khalsa, MD, with Cameron Stauth.  In his book he talks about the Chronic Pain Syndrome.  Starting on page 10 he has a subsection entitled:

“CHRONIC PAIN SYNDROME:  YOUR WORST NIGHTMARE!”

He states, “Chronic Pain Syndrome is a terrible force that turns chronic pain into constant suffering.  It is the biggest threat that pain-patients face. 

Chronic Pain Syndrome is a group of physical and mental characteristics that often accompany chronic pain.  It consists of negative behaviors and attitudes that gradually pull pain-patients away from their lives, into a ceaseless whirlpool of pain. 

Chronic Pain Syndrome is highly destructive in and of itself.  It also greatly magnifies the physical sensation of pain. 

To find out if you have Chronic Pain Syndrome, complete the following questionnaire: 

Dr. Khalsa goes on to state, “For those who have taken the above test, if you answered ‘true’ to only questions 1, 2, and 3, you are suffering from chronic pain but not from Chronic Pain Syndrome.  If that is the case, you are a person of unusual courage and wisdom.  If you answered ‘true’ to at least 10 of the 20 questions, you have moderate Chronic Pain Syndrome.  If you answered ‘true’ to 15 questions, you have advanced Chronic Pain Syndrome.  If you answered ‘true’ to 18 or more questions, you have severe Chronic Pain Syndrome.  If you have any degree of Chronic Pain Syndrome, you almost certainly need help to overcome it.  I could provide much of that help with this book. 

You probably developed Chronic Pain Syndrome gradually.  When you first began to suffer from chronic pain, you may have consciously chosen to adopt some of the Chronic Pain Syndrome behaviors, thinking that they would spare you further pain.  For example, you might have decided to limit your involvement with your work or hobbies, to save your energies, and to save yourself from extra pain. 

Most of the syndrome’s characteristics probably abated your life against your will.  You didn’t chose to become depressed, irritable, or tired.  It just happened because of your pain’s biological and psychological impact.

One of the awful things about Chronic Pain Syndrome is that it makes the physical feeling of pain much more intense.  It increases the brain’s perception
“of pain”.  Just one example; arthritis patient’s who suffer from depression are approximately twice as sensitive to painful stimuli as nondepressed arthritis. 

Thus, Chronic Pain Syndrome – which is “caused” by pain – also causes “further pain”.  It contributes to physical phenomenon called the “cycle of pain” which haunts the lives of many pain-patients. 

To break this insidious cycle, you will need to follow a careful, constructive program, such as the one I describe in this book.  It is up to you to actively implement this program into your own life, and to defeat Chronic Pain Syndrome, which is also called, “Pain disorder with medical and psychological features.”

There are many elements in my pain program that intervene in the cycle of pain, and you can start the program by engaging in almost any of them. 

My pain program consists of 4 fundamental treatment modalities or levels.  Each of them helps break the cycle of pain and eliminate Chronic Pain Syndrome.  I highly recommend Dr. Khalsa’s excellent book, The Pain Cure and have recommended this to several hundred chronic pain-patients that I have treated.

Dr. Khalsa points out that one needs to approach the chronic pain in a completely different way, than just relying upon medications to control the symptoms.  He notes that one must approach it from numerous angles and elicit the help of numerous different disciplines to help to control the Chronic Pain Syndrome.  It is very common for patient’s with chronic pain to have undergone a variety of procedures such as epidural steroid injections, trigger point injections, and other forms of invasive treatment.  Oftentimes, these procedures work for a very short period of time, but eventually the pain returns.  Each time that this occurs, the patient struggles to summon the strength to continue.  Each time, the pain-patient feels defeated and begins to blame those that should have found the answers.  Faith becomes shaken over time.  The ability to “rise to the occasion” begins to weaken.  Failure becomes a word too often spoken.  You might even begin to wonder if you are going “crazy” or if maybe it isn’t all in your head.  You wonder if that is what others area thinking, especially your loved ones. 

“The world breaks everyone … and then some become strong at the broken places”   -Ernest Hemmingway.

While investigating Chronic Pain Syndrome on the Internet, I found the AMA definition of the “Chronic Pain Syndrome” in a website for the Tri-Life Center pain program.  Here they had many excellent quotes, including the one regarding the use of a variety of procedures.  They point out the following:   “The keyword is management.  For some of us, this means learning to eliminate pain entirely.  For others it means reducing pain to a level that allows us to live a full life.  It means a reduction or elimination of dependence on a medication to control pain.  It means restoring the quality of life.  In essence, our philosophy at Tri-Life is our goal:  The following is a part of that philosophy.

To restore and renew you;

To reduce your pain;

To teach you to connect with yourself as a whole;

To help you to regain the quality of your life for the rest of your life.

“Each and every one of us is one of a kind; unique in all creation”.

You have the tools within you to overcome adversity;

To turn negative to positive;

To be the best you can be.

We, at Tri-Life, offer you a team of dedicated people who can help you use these tools to their ultimate advantage; to empower you to take command of the rest of your life.

Ask your physician about us.  We want to help.

- Sometimes what seems like an end ... is only a beginning –

For those of us with chronic pain there can be no healing or cure.

The word “chronic” means constant and habitual; something that continues for a long time, recurring frequently; having long preparing for danger.

It suggests that we are, essentially, "Stuck with it."

We are told that we must somehow "Learn to live with it." 

Many of us find ourselves in an endless cycle riding the waves of hope, only to fall into the depths of bitter disappointment.  

Chronic pain makes us feel helpless.  It makes us angry, confused, and frustrated.  

It alienates us from those we love and the things we love to do.  

It saps us of strength and deprives us of the quality of life we once knew.

We often feel alone and that no one really understands that our pain is real.

  

 - The difficulties of life are intended to make us better, not bitter -

Our mission at Tri-Life Center is to restore.  By definition, restoration means to renew, revive, to re-establish.  It means bring back to a state of health, soundness or vigor.  This is very different from curing or healing, which implies eradication of disease or sickness, the making whole of wounds, et cetera.  Curing suggests a successful remedial treatment. Healing, to bring to an end or a conclusion.  In essence, to effect a cure.

-A cure of the part should not be attempted
without treatment of the whole -
~Plato

Tri-Life Center embraces a holistic approach to chronic pain.  Holism is a theory which states that whole entities, as fundamental components, have an existence other than as the mere sum of their parts.  At Tri-Life Center, we believe this to be fundamental to the successful rehabilitation of our clients.  It is true that we are "stuck with it."  It is also true that we must "learn to live with it."  But to us, being stuck with it means an opportunity to rise above.  And learning to live with it means learning to live.

Our mission is helping you to regain your dignity.  Our mission is to restore you.  Some of us have been where you now stand.  We have risen above it.  We have learned to live. We want to share what we have learned.

Our mission is being centered ... on you.  Your mind, body, and spirit must be treated together.  Once restored, you can be better that you were before.

The Mind and Body Connection
“Mind and body are one.  How we think about pain greatly affects our perception.  When we fear pain as a threat it causes our sympathetic nervous system to become hyper-vigilant and react to pain and stress abnormally.  It is preparing for danger by increasing muscle tension, increasing heart rate, increasing breathing rate, and approximately 200 chemicals are released, which, in turn increase pain.”

When we teach our nervous system to decrease intensity and to think differently about our pain, the hyper-vigilant process is eliminated, and pain levels decrease.  Learning to live with chronic pain is learning skills to bring pain to comfortable levels rather than finding an end to the pain.

Mind and body - perception one

Identification of Chronic Pain

·          Pain persists after initial healing has occurred.

·          Negative response to medical treatment.

·          Pain intensifies and may spread over total body.

·          Disruptions of sleep patterns.

·          Increased use of pain medication.

·          Stopping of all pleasurable activities.

·          Chronic pain behaviors are observed.

o       It is preparing for danger by, increasing for there muscle intensions

o       Guarding.   

o       Bracing.

o       Moaning.

o       Groaning.

o       Rubbing,

o       Holding,

o       Limping,

o       Pain talk.

·          Display feelings of anger and depression.

Myth Versus Fact

            I have recently in my practice started to ask patients if they have a chronic pain syndrome.  Many patients state that they feel that they have this but when questioned about it, do not know what it entails.  Other patients question exactly what this is and when they are shown the 20 questions, and that they answered positive to all 20 of these when I first started seeing them, oftentimes will remark that they are much better at this point in time.  I have tested many of these patients and indeed, have found that their testing to have dropped remarkably down to a level of 2 or 3 being positive rather than 20.  These patients have changed their orientation to their chronic pain.  They continue to take pain medications but they generally do not have problems with excessive use of pain medications.  These patients have learned a multitude of pain reduction techniques.  They have also expanded their lives to become stronger emotionally, mentally, socially, and spiritually.  These patients have a different orientation to their chronic pain and instead of being a victim of their chronic pain, now have chronic pain as a medical challenge that they are managing, much as they manage high blood pressure or diabetes.  I am very happy to administer the chronic pain inventory test again to these patients and note that I have been a partner with them in lowering their chronic pain inventory score significantly.  I know, however, that the patient themselves have done the vast majority of the work and I have merely been a guide and someone who helps point out the way that they should go.  They make the decision to put forth the effort to get better and manifest that in a life that is much more enjoyable.  Our goals of pain treatment at Intractable Pain Centers, where I work, is reduction of the patient’s pain to a tolerable level most of the time with minimal or no side effects from the medication or treatment.  We also want to markedly increase the functional capacity of the patients.  We desire for them to be able to function at a much higher level.  It is my desire that the disabled would become enabled and that the retired and disabled may return to work if they so desire.  It is also my desire for the patients to be generally happy and to have a marked increase in the quality of their life.  It has been my experience that if the patient’s quality of life increases and if they are happy, then their quality of life is markedly improved. 

            Many people may question as to why the chronic pain syndrome can develop.  Part of the answer to this comes from our growing understanding of what chronic pain is.  Scientists once viewed it as merely a symptom of injury.  This was an intuitive idea that resonated with laymen.  “The public understanding of pain has been that it is a stubbed toe or a broken bone” says Will Rowe, executive director of the American Pain Foundation.” But that is just one aspect of it.  Now there is a growing awareness that pain is a disease of its own. 

Now there is a growing awareness that pain is a disease of its own.

This statement from Dr. Rowe is more than just a semantic change, Dr. Rowe adds, “It is tectonic”.  Doctors now know that the brain and spinal cord rewire themselves in response to injuries, forming “pain pathways” that can become pathologically overactive years later.  They are trying to sever this maladaptive mind-body connection with a host of new drugs and approaches.  Some focus on recently discovered chemical receptors in the brain and muscles.  Others pack all the punch of narcotics with less of the specter of addiction (patients can still become dependent on a new form of the morphine derivative called Kadian, for instance, but if they crush one of the pills for snorting, its center explodes, releasing a substance that blocks the euphoric high).  New types of electric stimulators targeting the brain, the spine, and the muscles, hit the market almost every year.  Fentanyl skin patches, first introduced in 1990, have evolved into a patient-controlled, push-button device called IONSYS, available by the end of this year, a complementary and alternative medicine offering a parallel universe of treatment; herbs, yoga, acupuncture, chiropractic, massage, and prolotherapy (which injects various solutions including cod liver oil into ligaments and tendons near the area of pain).  This article points out that in regard to increasing functionality of people that “What we are now starting to recognize that if you control people’s pain, they are not liabilities, they are assets.  That is not to say pain is all bad.  It is unpleasant, of course, but in an evolutionary sense, it has its uses.  Acute pain begins in the peripheries of the body, where sensory neurons are constantly on patrol for signs of damage.  They are the mechanisms that alert us to one injury so that we can avoid a second one.  Touch a hot stove for the first time and you won’t be happy, but you will ultimately be better off, because you’ll certainly never want to do it again. 

            By the time it has become a chronic condition, however, pain is no longer useful.  It is, as Rowe says, “A disease – specifically, an over-activity of the nervous system”.  The brain keeps a diary of the injuries that the body receives; writes each entry by reconfiguring certain neurons into new interconnected patterns.  In healthy people, these neurons stop firing once the initial damage is fixed.  But in chronic pain, they keep going longer after the injury has healed.  “The circuits get turned up and they stay up.  They get stuck”, says Gallagher.   “Most diseases are physiology gone wrong.  Pain is one of them”.  Also in the article it points out that scientists don’t know why some people develop chronic problems after injuries while others continue on with no pain.  It is nearly impossible to answer the question on a wide scale; pain simply has too many causes.  Some patients fully recover from massive trauma.  Others like most of the boomers with aching backs and knees, find themselves debilitated by nothing more than the accumulated mundane strains put on joints, bones, and muscles every day.  “Even soldiers can fall into this second category – if the bullets don’t get them, the back pain brought on by months of jumping out of trucks, burdened with heavy equipment, well may”. 

            Complicating the issue even further is pain’s inherently subjective nature.  We may say, “we feel each others pain” but really, we can’t.  Doctors do not have any good way of measuring pain from one person to the next.  The best they can do is to ask patients to rate it for themselves on a scale of zero to 10, with 10 being the greatest agony of their lives.  This is absurd but precise.  Patients are usually honest (and fakery is fairly easy to spot), but they can exaggerate.  A patient feeling a 4, may claim a 7 to get aggressive treatment, and a patient feeling a 7 may downplay it as a 4 in hopes of looking tough.  Robin Walker, a psychologist at the Tampa (Florida) VA, says she has seen the latter dynamic in her clinic (these patients know what a 10 feels like), she says.  (But they are active, - __40:09__ soldiers, and they minimize their problems.  In less you really ask them about their pain, they can be very hesitant to tell you.)  Doctors are trying to develop new methods of measuring pain, but their most advanced ideas so far is to study facial expressions; which aren’t much more standardized than the 10-point scale.  “On top of that, one patient’s “7” may be another’s “4”.  Our bodies are not “one-size-fits-all”, notes Rowe, and doctors are finding that this is far more true with pain than they ever imagined.  Genes may vastly influence how intensely people feel pain, and how much they can withstand, although genetic testing for pain susceptibility is probably decades away.  Gender matters too.  Women have up to twice as many nerve fibers in the skin as men do, so they feel some types of pain more intensely.  This does not mean they are weaker, it means that, all other factors being equal, their 10 is off a mans chart.  Even traits that seem unrelated to pain, like vitamin D deficiency, may increase it for reasons no one fully understands.  Trying to untangle all these factors is a scientific nightmare.  The article goes on to point out part of the reason that patients who deal with chronic pain oftentimes do develop a chronic pain syndrome, even though this is not an article about chronic pain syndrome, it talks quite a bit about what is going on in patients that develop chronic pain syndrome.  It states, regardless of their injuries, their genes, their gender, or their background, though, nearly all chronic-pain patients agree on one thing:  “The hyperactive neurons can make life near unbearable.”    

“The hyperactive neurons can make life near unbearable.”

            “The cascade of changes in the nervous system can lead to an equally painful cascade of events in the patient’s life:  Memory loss, job loss, marital strife, depression, suicide.   And through it all, the body hurts like hell.”  “Imagine somebody holding a knife in your back and twisting against your nerves continually, never stopping.  That is what chronic pain is” says Dan O’Neal, a contractor who herniated two vertebrae in 2003, while cleaning up a job site.  “At first you just shut off totally.  It is terrible living like that.”  This article goes on to point out that, “among chronic pain, patients, O’Neal is actually one of the lucky ones.  He, at least, knows why his pain started; some patients are denied even that knowledge.  Chronic regional pain syndrome, for instance, is a rare disorder that can begin with something as trivial as a skinned knee.  The scrapped heels, but the nervous system does not.  Within a few years, the knee that was skinned feels like it is on fire, even though nothing is outwardly wrong.  Similarly, fibromyalgia __44:38__ the bones, muscles, and joints, but has no obvious bodily causes and does not show up on x-rays.  Growing evidence now suggests that it is, in part, a brain disorder that sets the pain pathways afire, responding to imaginary wounds – as if the brain’s diary of injuries has suddenly filled up with wild, untrue stories.  The pain itself is not imaginary, but because it is hard to pinpoint, and even harder to treat, for years many doctors used to write it off as such.  Andrea Cooper says that all doctors did when she first developed fibromyalgia, which afflicts six million Americans, was to say, “We cannot figure out what is wrong with you, therefore, there is nothing wrong with you.”  People do not like to hear about symptoms that they cannot do anything about.  The article goes on to point out that “some fibromyalgia patients may be helped by standard pain treatments, others are not.  In that, at least fibromyalgia patients are just like all other pain patients; relief can come for them, but it is often hard-won.  Cooper, who is now on Fentanyl and Kadian, compares her current pain to “the roar of the far away interstate, as opposed to being in traffic.”  But to get to her current regimen, she had to go through nearly everything else:  Antidepressants, anticonvulsants, muscle relaxers, acupuncture in six operations that probably made the pain worse. 

            “Some of the most promising pain treatments in the past decade have turned out to be disappointments.  Study of some radiofrequency therapies shows that they work no better than placebos.  Spinal fusion surgery, a recent review found has “no acceptable evidence” to support it.  And, if a treatment does work, said Edward Covington, a pain specialist at the Cleveland Clinic, “for most people, the effect is temporary.”  There is no cure for chronic pain. 

            So as you can see, the chronic pain syndrome is fairly easy to diagnose.  The chronic pain syndrome can be diagnosed easily by taking a 20-question true-false inventory.  In my opinion, if you answer yes to 10 or more, you indeed have developed a chronic pain syndrome.  This is not something to get terribly excited or bent out of shape over, it is something to understand and realize that you suffer from and it will take quite a bit of effort to overcome this challenge.  Once you understand that you are facing a challenge, and I believe that you are better able to deal with that challenge.  I have taken care of hundreds of patients that have overcome chronic pain syndrome and although they are afflicted with a chronic painful condition, it no longer controls their life and colors everything that they do, but is instead just a background to their lives which they lead in a happy and productive fashion.  I believe that it is impossible to say exactly how you will be able to bring your chronic pain syndrome under control.  I believe that it most likely will be done by utilizing a combination of medications and then adding to this a multitude of pain reduction techniques.  I believe that these can all be learned easily by the patient and that you, as a chronic pain patient, can start to apply and learn techniques that have an excellent chance of improving the quality of life and making your life much happier.  I have oftentimes been surprised to find on retesting patients that they no longer have the chronic pain syndrome, and that for many months I have been checking the chronic pain syndrome box as a yes on their patient assessment sheet.  I have done this out of habit, and although I am acutely aware that the patients are living much fuller and happier lives with much less pain, I do not take the time to retest them for a chronic pain syndrome.  I believe that it is very important to do this at the beginning of treatment.  This is done to understand what challenges you are facing.  But after this, it loses its major importance.  In the past I used to quantify patients chronic pain syndrome by having them take a neuropsychological test entitled, “The Millen Behavioral and Medical Diagnostic Test.  Patients that scored high on the Chronic Pain Inventory had a very standard response to the questions, which consist of 165 true/false questions.  These patients that scored high on the Chronic Pain Inventory seemed to be afflicted with similar deficiencies.  They had high incidence of emotional challenges, including depression and anxiety.  They had limited abilities to deal with the stressor that were present in their life.  Their coping abilities to adjust to the stress of their daily life, including their work and family life was markedly impaired.  Their sleeping was generally impaired.  Their self-care techniques, such as exercise, diet, and maintaining a positive self image were all impaired.  But as the patients had a standard profile, they also had a somewhat standard recovery to the challenge to their chronic pain syndrome.  As their pain came under control to a tolerable degree and they started to apply the principles that I teach, including moderate exercise, practical dietary moderation, stress reduction, meditation, improvement in depression, strengthening of their spiritual life, and the other factors that you will learn about in this book, they overcame the chronic pain syndrome and became just patients afflicted with chronic pain.  It is my considered medical opinion that their lives were much fuller and happier, and that they much preferred not having the difficult baggage of the chronic pain syndrome.  Although they have not all recovered and returned to normal, they are profoundly more functional and definitely much happier.  So, in summary, chronic pain syndrome very commonly afflicts patients with chronic pain.  Not all patients with chronic pain develop chronic pain syndrome, but a significant number unfortunately do.  The chronic pain syndrome can be easily diagnosed.  Patients with a chronic pain syndrome should avoid surgery or any invasive procedures unless they have definite indications that the surgery is required on an emergency basis.  Elective surgery should be strictly avoided in my opinion.  The chronic pain syndrome psychological features can be easily quantified with an inexpensive computer-generated response through a test available at Intractable Pain Centers.  This test will help somewhat in categorizing the difficulties that you are facing and that you will need to overcome in order to bring the chronic pain syndrome under control.  A chronic pain syndrome can develop very quickly after an injury, and I believe this is caused by a predisposition that the patient’s bring to the injury that quickly become manifest after the injury has occurred.  So on many of these chronic pain patients that quickly develop the chronic pain syndrome; it is my considered medical opinion that they have a preexisting and predisposing personality and life profile that predisposes them to rapid development of the chronic pain syndrome.  Oftentimes these patients have a very severe and florid chronic pain syndrome.  I base my diagnosis of chronic pain syndrome on three features.  I base it on the Chronic Pain Inventory testing score, the direct observation of the patient’s pain behavior, and by the historical features that I notice during the taking of the patients’ history.  I examine all of the patient’s that I care for and directly take their history, as I believe that it allows me to observe them very carefully and to ask them many questions.  The way that a patient afflicted with a chronic pain syndrome answers questions is dramatically different from those patients that do not have this added psychological and emotional challenge.  The chronic pain syndrome involves all aspects of a patient’s person.  It involves not only the physical part, but also the mental, emotional, social, relationship, and spiritual aspects of the patient’s life.  ___58:58____ the chronic pain syndrome is one that the patient can apply themselves and requires a multidimensional type of pain treatment.  The patient must apply treatment both on the physical plane in addition to utilizing medications.  The patient must exercise both their mind and body.  They need to bring their emotions under control.  The patient’s need to spend a part of every day in an effort to include themselves.  They must become true auto-dyadic patients.  They must become intensely responsible for their personal health.  Patients afflicted with chronic pain syndrome must be willing to abandon long held ideas and prejudices about their chronic pain.  They must be willing to jettison a lot of their beliefs about why they are afflicted.  They must be willing to face in a straightforward fashion the very real nature of secondary gain.  They must be willing to settle all disagreements and oftentimes in a compromised fashion so that they can get on with their lives and stop being afflicted with the chronic pain syndrome.  The patients must make the decision that they will no longer be victims of chronic pain, but they will become masters over their chronic pain, which takes a lot of effort and initiative on the patient’s part.  But I know that it is definitely possible.  I have personally observed it numerous times in patients that I did not think that they had the wherewithal to overcome their chronic pain syndrome.  Fortunately, they were able to prove my guarded skepticism to be unwarranted.  I love to be proved wrong when I have opinions like that.  It is my hope and my prayer that if you are suffering from the chronic pain syndrome, that you overcome this utilizing whatever technique is required to help you to lead a fuller and happier life.

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