Excerpted from Understanding
Chronic Pain: A Doctor Talks to His Patients Uk Can
by Robert T., Jr. Cochran M.D.
The bipolar (manic-depressive) patient experiences times of wellness and emotional equilibrium alternating with intervals of depression and others of manic hyperactivity. With these swings in mood and behavior, the entire neural axis reconfigures and exhibits almost unbelievable effects. Some bipolars suffer tremors, even dyskinesia, during depressive interludes with disappearance of these, totally, during mania. A change in dominant handedness may occur: left-handed when depressed, right-handed when manic! In a notable case reported many years ago, a bipolar patient was conversant only in the Gaelic language when he was depressed. During mania, he became fluent only in the English language! In another case, even more remarkable, a brain-damaged, hemiplegic, and aphasic patient experienced the restoration of speech and movement during manic intervals. If bipolar disease can do these things, what can it not do?
Henry was a mechanic, retired on account of chronic back pain incurred in an industrial accident. He suffered a compression fracture and a ruptured lumbar disc. He came to surgery, and his spine was fused. Vertebral alignment was stabilized, but Henry remained painful and unable to work. Most of the time his discomfort was tolerable and responsive to low-grade analgesics, but occasionally he experienced sudden sieges of excruciating pain. A reasonably effective treatment form evolved. During the attacks his orthopedist would admit him to the hospital and treat him with intravenous opiates and muscle relaxants. After a few days – the sieges were all rather brief – Henry would settle down, go home, and resume with only modest inconvenience his sedentary life. This pattern extended over more than a decade with a hospital admission once or twice a year. Henry's orthopedist, a very wise man, recognized this as a very unusual behavior. Chronic pain due to an injured back is certainly well-known to orthopedists, but the intermittency of Henry's attacks was very queer.
Henry resisted referral to me. He was doing just fine, he said, on this treatment program and was quite happy with it. His attacks were always short-lived and opiate-responsive. Gradually, however, they became more frequent, and he finally accepted my consultation. Henry was not a very charming man, laconic and a bit on the gruff side. I saw him during an interval of relative wellness, and I couldn't find much to work with. His behaviors were quite unremarkable. His sleep was slightly disturbed, appropriate to his painfulness, but it was not a major handicap, and Henry evidenced no depression. I knew there was something odd about this, but it seemed reasonable to begin therapy with a tricyclic antidepressant, hopefully to abort future attacks of pain. Several weeks into his treatment, Henry called me complaining of another attack of back pain. He requested hospitalization and opiate treatment and demanded that the orthopedist, to whom he was very attached, remain in attendance. I arranged the admission and began the treatment protocol which had been initiated by his surgeon. I anticipated uncovering some clues during his hospitalization. Lord knows I had found none thus far. Henry was quite uncomfortable and back-stiffened when he arrived at the hospital, but there was otherwise no change in his neurologic status, nor was there any discernible change in behavior. He was neither restless nor despondent. Henry seemed to be pretty much the same man when he was painful as when he was not.
After a week in the hospital during which, with opiates, he achieved a high degree of comfort, he declared that he was ready to go home. I discontinued the tricyclic therapy, which had been quite ineffective, and prescribed Darvon. On his return, Henry was his usual opinionated self. He told me that this siege had been like all the rest, sudden severe upper lumbar back pain without radiation. He emphasized again that his opiate therapy was profoundly helpful to him, and he would not countenance being denied that treatment when his severe pain recurred.
I couldn't figure Henry out. Opiate-responsive pain, nothing startling there, but a cyclical opiate-responsive pain. This was certainly not addictive behavior. After a short course of opiates, he had no further need. He received them on an intermittent, never a regular basis. I chose Lithium. A long shot maybe, but the strange cyclicity of his pain merited attention. Lithium can be very helpful in the treatment of manic depressive illness. It prevents the episodic cycling of mania. It can also be helpful in some forms of migraine, those known as cluster headaches, which are characterized by cycling attacks of headache. The drug is reasonably safe in low dosage and a convenient agent for therapeutic trial. I instructed Henry that if the drug disagreed with him to simply discard it, but if he felt any benefit at all to continue taking it 300 milligrams each night.
I saw him a month later, and he did seem different. Usually dour, he exhibited more spontaneity. There was a twinkle in his eye, and Henry was not a person in whom you would expect a twinkle.
"I like that Lithium."
"What do you mean you like Lithium?"
"I just feel different. Everything is better now"
"Is your pain any better?"
"Yes, sort of, I guess. It is still there, but it doesn't bother me the way it used to."
Often in the treatment of pain the physician finds the absolutely perfect drug. I had seen it many times with tricyclic antidepressants and on other occasions with anticonvulsants. This time it was Lithium, conventionally known as a mood-stabilizer. I had elected to use it simply on the basis of the cyclicity of Henry's pain. Did his response to Lithium mean Henry was bipolar? Probably, but not certainly. You don't have to be bipolar to get a feeling of relaxation with Lithium. But when the doctor hears the phrase, "everything is better now," it usually means that the doctor is treating the very core of the disease.
I was happy with what I had achieved. I had stumbled upon a drug which seemed to be helping Henry, and I suspected that he might be bipolar, but I did not know for sure. I referred him to a psychiatrist. She recorded, as had I, a history of a self-inflicted gunshot wound in his abdomen many years ago. He told me it was an accident, and I accepted his lie. She obtained a history of periodic attacks of rapid speech, hyperactivity, and financial disinhibition. Henry would sometimes go on spending sprees, exhausting his financial resources. Uncontrolled spending is an important feature of bipolar disease, a manic, irresponsible behavior.
The psychiatrist continued the Lithium and added Depakote, another mood stabilizer, and Henry has done well. He remains even-tempered, free of depression, free of spending binges, and free of attacks of back pain. For seven years now, Henry has not required a hospital admission for treatment of his pain!
Henry suffers bipolar disease. He experienced intervals of depression, on occasion to the point of a suicide attempt. On other occasions, he had experienced intervals of hyperactivity and disinhibition. And on others, remarkably, attacks of back pain.
Why does bipolar disease express itself as painfulness? The best answer to that question is another one. Why not? Pain is a cerebral and behavioral experience just as are depression and mania. They frequently coexist in the same mind-soul. There is, without question, a high concordance of bipolar disease and painfulness. Unfortunately, this association is not widely recognized.
Dr. Cochran is the author of Understanding
Chronic Pain: A Doctor Talks to His Patients Uk Can
(Providence Publishing Corp., ISBN: 1-57736-302-7, 224 pages, hardcover). For more information, please see Dr. Robert Cochran’s website, www.understandingpain.com.
