Practicing rheumatology is hearing the word pain - patient in and patient out, on every clinic day, making the practice a class all its own. The rheumatologist sees that pain is handled in as many ways as there are individuals with arthritis. On some occasions, patients react to pain violently enough to create a "transference" of sorts that causes many a rheumatologist to find the last patient's pain already in his own joint.
While pain is the most important protective mechanism of all of animal kingdom, pain lasting longer than 6 weeks or so becomes a "disease". Arbitrarily, 6 is not a magic number, but denotes chronicity and a duration where many processes in the nervous system have been activated to transform the pain complaint into the "pain disease".
I invite you to recall the last time you had a headache. Normally, headaches make a person moody, withdrawn and quiet. Some would try to sleep it off, but not before taking the favorite pain pill for relief. Even then, knowing that this pain would go away does not keep bad mood at bay. Invariably, all sorts of pain, the quick ones like stubbing the toe, or the headaches you can sleep off, can spoil a well meaning day.
Pain of arthritis is a different story. It can be of varying intensity, with gout pain possibly occupying top spot, followed by the pain of ankylosing spondylitis and reactive arthritis. Add to that duration- arthritis pain can be "forever". But wait till a rheumatoid arthritis patient comes in in tears, wanting never to wake up, and you know that this is a different kind of pain. It is as if dying is relief and the only hope. But a patient with arthritis who wants to die is pathetic. Many arthritides mame but do not kill.
We recently held a symposium on mood disorders in the arthritides. This was prompted by our paper which uncovered that about 40% of our lupus patients have anxiety/ depression. This is a high rate and is disturbing, since mood disorders can affect the way patients view the illness, but more important, accept treatment. Likewise, treatment for different forms of mood disorders is available and can spell the difference between a difficult-to-treat patient and the rest of them. Putting principles learned from this symposium, let me cite a case.
Mr D. was admitted yet again for a bout of gout affecting this time, as many as 6 joints. He is bad case of chronic tophaceous gout, with crops of urate deposits, 5X6 cm masses over the hands, elbows, knees and ankles. Dehydrated and irritable, he would only take the medications he was familiar with but had poorly complied. Suggestions to bring in a physical therapist and to call another doctor for his other problems were met with a flat no. Arthritis improved over the next 7 days, but by the 10th day, he still refused to budge from bed due to pain. Finally, I decided to give an antidepressant. He was smiling the following day (!) and was moving his lower extremities, finally sitting up and dangling legs on the 12th day. He consented to calling the second doctor to check his other problems. It could not have been just the arthritis treatment - the overall recovery was amazingly fast. While anecdotal, it validated what I long wanted to do- treat the patient and not just the arthritis.
One sees the importance of recognizing mood disorders that accompany medical problems that cause prolonged pain. Additional treatment for such disorders may actually make sending a happier patient home easier.
While pain is the most important protective mechanism of all of animal kingdom, pain lasting longer than 6 weeks or so becomes a "disease". Arbitrarily, 6 is not a magic number, but denotes chronicity and a duration where many processes in the nervous system have been activated to transform the pain complaint into the "pain disease".
I invite you to recall the last time you had a headache. Normally, headaches make a person moody, withdrawn and quiet. Some would try to sleep it off, but not before taking the favorite pain pill for relief. Even then, knowing that this pain would go away does not keep bad mood at bay. Invariably, all sorts of pain, the quick ones like stubbing the toe, or the headaches you can sleep off, can spoil a well meaning day.
Pain of arthritis is a different story. It can be of varying intensity, with gout pain possibly occupying top spot, followed by the pain of ankylosing spondylitis and reactive arthritis. Add to that duration- arthritis pain can be "forever". But wait till a rheumatoid arthritis patient comes in in tears, wanting never to wake up, and you know that this is a different kind of pain. It is as if dying is relief and the only hope. But a patient with arthritis who wants to die is pathetic. Many arthritides mame but do not kill.
We recently held a symposium on mood disorders in the arthritides. This was prompted by our paper which uncovered that about 40% of our lupus patients have anxiety/ depression. This is a high rate and is disturbing, since mood disorders can affect the way patients view the illness, but more important, accept treatment. Likewise, treatment for different forms of mood disorders is available and can spell the difference between a difficult-to-treat patient and the rest of them. Putting principles learned from this symposium, let me cite a case.
Mr D. was admitted yet again for a bout of gout affecting this time, as many as 6 joints. He is bad case of chronic tophaceous gout, with crops of urate deposits, 5X6 cm masses over the hands, elbows, knees and ankles. Dehydrated and irritable, he would only take the medications he was familiar with but had poorly complied. Suggestions to bring in a physical therapist and to call another doctor for his other problems were met with a flat no. Arthritis improved over the next 7 days, but by the 10th day, he still refused to budge from bed due to pain. Finally, I decided to give an antidepressant. He was smiling the following day (!) and was moving his lower extremities, finally sitting up and dangling legs on the 12th day. He consented to calling the second doctor to check his other problems. It could not have been just the arthritis treatment - the overall recovery was amazingly fast. While anecdotal, it validated what I long wanted to do- treat the patient and not just the arthritis.
One sees the importance of recognizing mood disorders that accompany medical problems that cause prolonged pain. Additional treatment for such disorders may actually make sending a happier patient home easier.
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