Douleur chronique : la place du psychiatre

RésuméLa douleur chronique présente des liens étroits avec certains troubles psychiatriques, notamment la dépression et les pathologies post-traumatiques. Il n’existe pas de profils psychologiques particuliers des patients douloureux chroniques mais ils présentent davantage de troubles de personnalité que la population générale. Il convient d’en tenir compte en proposant des stratégies thérapeutiques adaptées au contexte psychopathologique du sujet afin d’en optimiser les bénéfices. Pour ce faire, le psychiatre doit être associé aux situations d’évaluation et de traitement de la douleur. Il peut proposer des stratégies thérapeutiques spécialisées dans le cadre d’une prise en charge multidisciplinaire. Par exemple, les thérapies cognitivo-comportementales et les inhibiteurs de recapture de la sérotonine répondent à un rationnel de prescription solide dans ce contexte.

ObjectivesChronic pain affects nineteen percent of the European adult population and its impact on morbidity is major. Considering psychosocial factors allows improving functional re-establishment. Psychiatric comorbidities are under-diagnosed and worsen the prognosis. The psychiatrist has an important role to play in the assessment and treatment of these subjects.MethodsWe will detail the relationship between chronic pain and some psychiatric diseases as well as their psychological and biological correlation. Then, we will discuss the therapeutic implements available to the psychiatrist.ResultsWe have to distinguish the psychosomatic disorders, which is a somatic disorder closely intertwined with a psychic disorder, from the somatoform disorder which is a body complaint to indicate a psychosocial distress. These disorders induce huge medico-economic costs: high prevalence and wrong care pathways, rarely using the psychiatrist expertise. The subjects with post-traumatic disorder combined with chronic pain have more severe post-traumatic symptoms with greater functional impairment. Twenty to fifty percent of subjects suffering of chronic pain have a depressive syndrome and fifty percent of the depressed subjects complain about chronic pain. Their symptoms are more numerous, more intense and longer lasting. Regardless of the used assessment tools, there are more pathological personality traits in chronic pain subjects with heterogeneous profiles than in general population which is useful for offering more targeted therapeutic strategies. Neurobiological integration of painful experience is based on two components : A somatosensory component (S1 and S2 areas) and an affective component with a central role of the anterior cingulate cortex. Functional dysfunctions involved in chronic pain affects the affective component of the pain experience and this component can be modulated. The psychiatrist should definitely avoid psychological explanation for the pain. He should focus on a multidisciplinary approach with partnership and complementarity. Its assessment identifies involved psychosocial factors, not for disqualifying the complaint but for considering all its aspects. Among drug treatments, antidepressants have a specific analgesic action particularly for IRS and MAOIs. Among non-drug treatments, reconditioning through physical activity combined or not with behavioral experiments can be associated with psycho education. Mindfulness, therapy of acceptance and commitment are used to promote voluntary consciousness of the body, of the pain and of thoughts. In some situations, transcranial magnetic stimulation can provide a useful aid. Analytical inspired therapies allow the subjects who are questioning about the meaning of the pain, better understanding a broader suffering.ConclusionChronic pain is closely linked to some psychiatric disorders. We should propose specific therapeutic strategies to each patient and the psychiatrist should be involved in assessment and treatment of chronic pain. In particular, the fear related to pain should be always assessed and supported. There are drug and non-drug strategies available for the psychiatrist to help taking care of these patients.