REHABILITATION OF CHRONIC PAIN AND CONVERSION DISORDERS
Marisa A. Wiktor and Stacy J. B. Peterson (A. Chronic Pain)
Michelle Miller (B. Conversion Disorders)
Chronic pain and conversion disorders continue to be a diagnostic and treatment challenge for many physicians. They both require a creative, multidisciplinary approach for optimal outcomes. This chapter will summarize the current opinions, diagnostic strategies, and treatment protocols regarding these two conditions.
A. CHRONIC PAIN
Historically, pain was considered a symptom of a disease and if the underlying cause were cured it would no longer exist. The International Association for the Study of Pain (IASP) defines pain as "An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage" (1). As our knowledge about pain continues to expand, there is evidence that chronic pain may cause more long-term harm than the initial disease or injury (2). Chronic pain is further defined as persistent and recurrent; it is a significant problem in the pediatric population estimated to affect 20% to 35% of children under the age of 18 around the world (3). Chronic pain can cause significant disruption in many facets of the patienf s life. It is not uncommon to observe in the pediatric population that suffers from chronic pain to be avoidant of school and social activities and demonstrate symptoms of clinical depression (4).
The system that controls pain is complex and involves both ascending and descending pathways. A change in the pain conducting system occurs after tissue injury. Chronic pain may be due to neurons being pushed to their limits. Nociceptors that once only responded to noxious stimuli begin to fire in response to nonpainful stimuli causing receptors to evoke activity in the nociceptive system that is then interpreted as pain or central sensitization (2,5). Pain may be upregulated in order to receive immediate attention and withdraw from a stimulus or downregulated during a "fight or flight" response.
Pain is necessary, as it allows us to process a potentially harmful situation and withdraw from or investigate the source to prevent further injury. Pain is one of the most common reasons that people seek medical attention. Inadequately controlled pain may result in unnecessary suffering resulting in compromised care of the underlying disease and lead to depression (6).
Caregivers of children who do not feel pain or have "congenital insensitivity to pain," need to be consistently vigilant to maintain a safe environment for their young (7). However, not all circumstances are preventable and these children may suffer severe injuries from painful events such as biting their tongue or burning their mouth with a hot beverage. Fortunately, this is an uncommon condition. Not all insensitivities to pain are congenital and some can be developed over time, for example, diabetic peripheral neuropathies or other peripheral nerve disorders / injuries.
There was a time when many health professionals believed that babies could not perceive pain and their response was reflexive with little if any emotional ties. It was theorized that the nervous system of babies is underdeveloped at birth and their ability to experience pain was altered (8,9). During the 1980s in the United States, pediatric pain became a topic of focus after infant Jeffrey Lawson underwent surgical correction of a patent ductus arteriosus (PDA) with only pancuronium bromide (neuromuscular blocker) and no analgesia, causing his mother to go to the press. After Jeffrey Lawson's story made national headlines, pain control for even the youngest of patients became a priority.