Abstract
In the early 1960s the Medical School of the University of Adelaide decided to add a bit of culture to the curriculum with a first-year course called ‘Medicine and the Humanities’. We were told that the definition of an educated gentleman was someone who knew everything about something and something about everything. It may have even been an educated British gentleman that was being defined; it certainly did not refer to any other sex. The subtitle ‘what psychiatrists need to know’ suggests, rightly, that this is a useful brush up for those psychiatrists who do not deal with patients with pain as a matter of choice. It will also be useful for those of us who do see such patients regularly. As pain is such a common symptom it is particularly important that psychiatrists who do not regard themselves as experts can understand the language of pain as well as that of mental illness expressed in psychological terms. The nature of this understanding is that it is multifactorial: anyone with one theory to explain pain should not be believed. So a multiauthor book is appropriate with the usual risk that the different contributions can be of varying quality.
There are only four chapters. The first two, on general principles and ‘pharmacological and non-pharmacological modalities’ respectively have the same three authors, none of them a psychiatrist. A criticism which is applied to American review literature is that the references are exhaustive rather than selective and critical. Perhaps the inclusion of a psychiatrist in the authorship of these chapters would add a touch of scepticism lacking in the authors who did write them. A simple example is the discussion of the place of tricyclic antidepressants in the treatment of chronic pain. A wide variety of literature is confidently quoted to support their usefulness with a rather bland comment that it is probably because of the effects of serotonin or norepinephrine on the synaptic cleft. No mention of the difficulty demonstrating effectiveness when placebo rates approach 50%, or of considering the pharmacology of such ‘dirty’ drugs where, if there is an effectiveness, it could be some quite extraneous effect. Indeed much of the literature confidently quoted is before 1992 when Richardson and Williams [1] in a letter following a paper presenting a meta-analysis [2], suggested that the operating principle was ‘garbage in, garbage out’. Nevertheless, all of the possible modalities are there and there are times when exhaustive references can be useful. The chapter on ‘Psychological models of chronic pain’ is by a psychologist. It is curious that the American Psychiatric Association could not find a psychiatrist to bind the biopychosocial model together. Indeed the author of the chapter, having described theories of ‘psychogenic pain’ notes, ‘It is past due for pain clinicians to adopt a multivariate perspective of chronic pain and its related morbidity… A biopsychosocial model offers a blueprint for the future of pain medicine’. For anaesthetists, orthopaedic surgeons and psychologists perhaps, but surely already the mainstream of the psychiatric approach for decades. The psychiatrists are admitted in the last chapter of the book devoted to some apparently real-life discussions of cases. Personally I can take or leave such writing but some readers might like it. In conclusion, a useful if uncritical review which, with its faults will be useful for psychiatrists experienced or inexperienced in the treatment of pain, provided they do not relinquish their critical faculties.