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Linus Geisler: Doctor and patient - a partnership through dialogue   © Pharma Verlag Frankfurt
Discussion with the patient in pain
Acute versus chronic pain
The perception of pain
The diagnosis of pain
Influencing the perception of pain in discussion
Treating pain in those with tumors
Discussion with the patient in pain
Discussion with the patient in pain is a frequent, important and often very difficult task for the general practitioner. 11% of patients in general practices suffer from chronic pain, and 10% of all prescriptions are those of pain medication. There are about 3 million patients suffering from chronic pain in West Germany, and of these, Zimmermann has estimated up to one half pose problems for the doctor.

The "secret" of a discussion which helps these patients in pain corresponds to the factors at the root of every understanding discussion: emotional warmth, empathetic approach and active listening, along with the ability to verbalize the feelings of the patient.
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Acute versus chronic pain
Most difficulties with patients in pain arise from the fact that the majority of doctors only have experience in treating acute pain. However there are very basic differences between acute and chronic pain. Acute pain has an alarm or warning function, and is like a "barking dog". Chronic pain has usually lost this warning function. It determines his physical, mental and social attitudes to life and to the disease: chronic pain overwhelms the characteristics of a disease and itself becomes a disease entity.

For reasons which affect therapy, it is useful to differentiate between chronic pain without (rheumatoid arthritis) or with carcinoma, as pain due to cancer raises a series of other considerations. In theses cases, there is no obvious reason or end to the suffering, it continually reminds the patient of the disease process and raises thoughts of death (E. Aulbert, 1990).

The objectives of discussion with patients in pain are:
to make the subjective experience of the pain less unpleasant by the use of communication
to make it possible for the patient to come to terms with the pain as far as possible and
to make him aware of certain ways of behaving and techniques for the control of pain by which he himself can have an influence on it.
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The perception of pain
The pain introduces a signal which psychologically alerts the body amid the "noise" of diffuse, non-specific mixed impulses. This means that the alarm raised by the pain appears to be less intense whenever the noise level of these diffuse non-specific impulses can be raised. This can for example be achieved with distraction techniques.

The perception of pain includes various components:
a sensory component, which is referred to as the perception of pain itself
cognitive reactions such as thoughts, graphic suppositions and accompanying emotions such as anxiety, depression etc.
motor behaviour to pain such as moaning, crying, writhing or pacing backwards and forwards.
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The diagnosis of pain
A thorough diagnosis of the pain is vital for its effective treatment. The following points must be established:
localization of the pain
type and character
development and course over time
factors which induced it
factors which accentuate or ameliorate it
associated phenomena

In order to grasp as clearly as possible the subjective experience of the pain, the following questions are important: "What has changed in your life because of the pain?" "What is it that most relieves the pain?" "What is the worst thing about your pain?"

An objective assessment of the intensity of the pain should always be attempted, even though this is only possible to a certain degree as pain by its very nature is markedly subjective.

Means of being objective include such methods as the VRS (Verbal Rating Scale). This scale extends from 1 (= the most severe pain imaginable) over intermediate steps such as 4 (= moderate pain) to 6 (= pain-free). A patient who finds it difficult to verbalize his experience of pain may manage the VAS (Visual Analogue Scale) better, where the perception of the pain can be graded anywhere on a line between 0-100 mm with 0 meaning pain-free and 100 the worst pain that can be thought of. A pain-diary is also important for the assessment of the progress of the pain and the effect of therapy.

Taking a history of the pain not only has a diagnostic component, but is also of therapeutic importance: it shows the patient that the doctor takes his chronic pain seriously.
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Influencing the perception of pain in discussion
There is a series of factors which can lower the pain threshold. These include:
social dependence
isolation (R. Twycross).

This implies that the threshold for pain can be raised by measures which work in the other direction: freedom from associated symptoms, mitigation of sleeplessness, mediation of hope and understanding, involvement of others (especially to take time), support of the family, occupation and distracting strategies.

In general the following possibilities effect alleviation of pain:
distraction techniques
"suggestion" strategies
reducing anxiety (see chapter on discussion against anxiety link) and insecurity, both of which otherwise increase pain
prayer and meditation
relaxation techniques

Distraction techniques have the objective of lowering self-awareness of the body and thereby of pain. Imagination exercises teach the patient to separate body signals from those of the surroundings and to allow pleasant ideas (which are incompatible with pain) to grow. For example he can practice imagining a scene from the sea shore "in complete details" (climate, landscape, deck-chairs, view of the sea, cool drinks), and introduce this graphic scene when the pain worsens.

Suggestion strategies are carried out by verbal therapy, in some cases under hypnosis. The personality of the doctor is very decisive here: the doctor who has charisma and vitality is most likely to have success by radiating security and removing anxiety. The motto: "the physician as physic" is particularly relevant here. Prayer and meditation lower self-awareness to a minimum. They are particularly appropriate for those who are very aware of themselves and of their pain. Autogenic training and the progressive relaxation techniques of Jacobson are two relaxation techniques. However they, like all other techniques for overcoming pain, should be learnt, if possible in groups, in moderately pain-free periods in order that they can be introduced at the time they are most needed.
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Treating pain in those with tumors
About 40% of patients with advanced cancer have pain, and 60% suffer from severe pain terminally. The problem does not seem to lie so much in the severity of the pain as its persistence. It continually reminds the patient that this disease will lead to his death. The degree of freedom from pain is of major concern for the quality of life of the patient (Aulbert). These patients have no need of "specialists". Personal involvement, time and availability with sensitive and supportive words are far more important. The relief of pain which can be achieved by this intensive caring relationship of the doctor to his patient cannot be rated highly enough. Nevertheless a prerequisite of this is that the doctor himself has come to terms with his feelings towards suffering and death, and does not convey insecurity and his own anxieties to the patient. Treating pain in cancer patients at the very end of their illness is, as Aulbert explains, "one of the most personal and basically one of the most intimate tasks because it confronts one's own attitude to one's own death, and stirs up one's own anxieties about suffering and death".
The basic rules for treating pain due to cancer (mod. from E. Klaschik) are: 
 1. Do not doubt what the patient says about the pain.
 2. Do not keep him waiting.
 3. Deal with one problem at a time, always showing that you have time.
 4. Prescribe doses of analgesic which you know will be effective.
 5. Create a therapy plan.
 6. Discuss the therapy plan with the patient and relatives.
 7. Check how the patient is managing soon afterwards.
 8. Create a stable relationship with the patient.
 9. Treat the psychological and social background.
10. Do not go away, even if it appears (!) that you can do nothing more for this patient.
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Linus Geisler: Doctor and patient - a partnership through dialogue
© Pharma Verlag Frankfurt/Germany, 1991
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