Painful Patients Psychiatric Interpretations of Pain Behaviours

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Painful Patients Psychiatric Interpretations of
Pain Behaviours

• Dr Joe Dunn
• MBChB DipObst FRNZCGP FRANZCP

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The Conundrum

• Pain behaviours in a medical assessment of
  incapacity
• Diagnosis of Psychiatric Stuff (formerly
  malingering)
• Then psychiatric assessment
• Which diagnoses mood disorder
• Surveillance
• Between the cracks
• Expensive claims

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Somatoform Disorders

• Symptoms more than Signs
• DSM4 (Major Disappointment Disorder!)
• Somatisation Disorder
• Hypochondriasis
• Conversion Disorder
• Pain Disorder
• Body Dysmorphic Disorder
• Undifferentiated, NOS etc

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My Angle

• Symptoms more than Signs
• Identity (patient/victim)
• Histrionics (drama, vs delusion)
• Obsessionality
• Schizotypia (unorthodoxy)
• Counter-transference
• Non-specific symptoms
• Medical merry-go-round

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A.K.A.

• Chronic Fatigue Syndrome
• Chronic Pain Syndrome
• Fibromyalgia
• IBS BPPV MVP ?Chronic Prostatitis
  ?Vaginismus/Vulvodynia etc

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Medicolegal Psychiatry

• -Psychiatrists
• unfamiliar with physical diagnosis
• minimal training in somatoform disorders
• no physical examination (need to trust opinions
  of others mountain of reports)
• subtlety of some neurological diagnoses
• non-specific nature of symptoms
• multiple medical pseudodiagnoses
• medicolegal paranoia
• gutlessness

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Pain Behaviours Again

• Do Your Perceptions Change with Time?
• Life stage
• Erotic love
• Im never going to use drugs again
• When Im up, thats my reality
• The Cult
• The Model
• The Anorectic
• Tinnitus
• Whats a Normal Mood?
• Now dont think about Pink Elephants

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Just like

• Every victim-patient-fanatic mentality
• Also vexatious litigant, stalker, fundamentalist
  and anything to do with Workers Compensation

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Somatoform Triad

• (1) Physical
• (2) Depression
• (3) Personality
• ?Post-traumatic
• Group dynamics Contagion-competition-suggestibili
  ty
• Definitely neuropsychiatric!

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Take Home Message?

• Painful Patients are real, expensive,
  frustrating, strange, complex, misunderstood,
  common, scandalous, incomprehensible, mad
  control-freaks
• So good luck with them
• But dont pretend theyre not there