Understanding Chronic Pain

Anger, Narcolepsy, Bipolar Disease, Attention Deficit Disorder, and Pain

I have long known that many victims of chronic pain feel very angry, and I have felt the need many times to address the issue of anger with patients in whom I felt this was excessive and maybe even self-destructive. My conversation wiould go along this line:

"I'm sorry you feel so angry. Let me tell you that I think it's probably   justified, considering your circumstances, but I want to remind you that anger is not a healthy emotion, and I wish that somehow you could discard it. If you could, I think it would be quite helpful. In my experience, angry patients do poorly."

Angry patients indeed do poorly, but I recognize now, and this has been a revelatory experience to me, that they do poorly not because they are angry, but because I have failed to recognize -- and treat -- their bipolar disorder. With this in mind, I want to explore anger as a symptom of bipolar disease and to illustrate that both are frequently comorbid (two diseases running together) with chronic pain.

Carolyn and I began our relationship with a very difficult interview. She was frequently tearful and expressive of her frustration and her anger over the way she had been treated by her physicians. She had hurt her back at work a year before. Her workup revealed little, and surgery was not advised. She consulted a rheumatologist, and a diagnosis of fibromyalgia was made. She adamantly denied depression and told me quite forcefully that she was not going to take antidepressant pills. Other doctors had tried them, and they didn't work.  She acknowledged that her sleep was erratic, sometimes sleeping too much and sometimes too little. She admitted to a lack of mental focus and distractibility. She also told me that she felt very irritable, and, indeed, she demonstrated it to me many times -- often snapping at me in response to my questions.

I prescribed imipramine and clonazepam. She demanded to know the exact purpose of each of the drugs. I did the best I could to explain, telling her that imipramine was an antidepressant but little used for that purpose now. Its primary usefulness was for the treatment of pain. She recoiled at my explanations and told me she didn't believe in medicines, and she wasn't going to take them. She was angrier when she left than when she came, and that is saying a lot.

To my surprise she returned 10 days later, smiling and coyishly charming. She had decided, she told me, to give the medicine a try. Within a few days she felt better. She admitted that she had been feeling depressed, and that was less of a problem now. Her pain was diminishing, and she would, she told me, be quite happy to continue the medicine. It was not to be. A couple of weeks later she told me that the drugs were disagreeable to her and that she had discarded them.

As time went by, Carolyn and I evolved into a repetitive pas de deux. I would prescribe a drug, and after a couple of weeks she would discard it, telling me that it changed her disposition. This went on through some 6 months -- and 6 different medicines. Her temper and explosiveness became more evident, and I realized that Carolyn could be a different person at different times -- occasionally charming, but more often curt, hostile, angry, and confrontational. I prescribed Lithium, and she told me for the first time that her mother was bipolar, and that Lithium had disagreed with her. She refused to take it.

On one of her visits, she initiated the conversation by saying, "I bought your book."

"Why thank you, Carolyn. What do you think of it?"

 "It is no good. I don't like it. It is too wordy."

"Well, Carolyn, I appreciate your candor. I can see how you might consider it too wordy."

I remember it all so well -- how she looked at with an air of smug defiance, as if she was glad she had hurt me.

Unable to control her pain or her very evident shifting in mood and behavior with psychopharmaceuticals, I prescribed the only thing I had left -- opiates. She found the hydrocodone quite disagreeable because it upset her stomach. She requested a different painkiller, and I gave her oxycodone.

"I think I can tell a little difference now. My pain is not nearly so bad."

"How about your mood? I have always sensed that you have had a problem with shifting moods. Has that changed any?"

She smiled and said, "Yes, I do have mood shifts, and I think they are a little bit better. I want to keep taking the oxycodone. It is helping me."

"Okay with me, Carolyn."

It was a month or so later when she returned to tell me, as she had so many times before, that her medicine was no longer working. We needed, she said, to make a change.

"Well, the oxycodone worked for a while. I am going to give you some OxyContin, which is actually the same drug, but I can give it in a bigger dose. We will try that for a month, and then I will see you again. By the way, Carolyn, you and I have talked several times about whether you have bipolar disease. I don't know if you do, but it is a possibility, and I would like to explore some more medicine for that. You recall that I gave you the Lithium before, but you refused to take it. What do you think about trying a different kind of mood stabilizer?

"No! I am not a manic-depressive, and I want you to quit talking about it. I just want you to give me some more pain medicine!"

"As you say, Carolyn."

She returned at the scheduled time to report a remarkable development. She said  that with the OxyContin she was back to her old self. Her mood swings were not nearly so bad, and she was getting splendid pain control, but that this had lasted only 2 weeks. She experimented, as she was wont to do, and doubled the dose of OxyContin without any additional benefit at all.

Never give up. Keep trying. Somehow there has got to be an answer.

"Carolyn, I am sorry you are not doing any better, but this kind of thing seems to come up over and over with you, doesn't it? You take medicine, and it works for a while, but then it quits working. All of them have quit working. Isn't that correct?"

"Yes, that is exactly what happens, and I wish I knew why."

"Let's talk about your mood swings."

"I'll admit that I do have mood swings, but I want you to know I am not bipolar! I don't have the big mood swings that real bipolars do. I have read about that. I know what it is like. That is not me."

"How are you sleeping now, Carolyn?

"Pretty good. I slept real good the first 2 weeks on OxyContin."

"Do you ever have dreams, really vivid dreams?

"Why to you ask that?"

"It is because I am trying to help you."

 "Well, I do. I have real vivid dreams. I have had them for a long time., I don't see what that has to do with my pain, though."

"Have you ever had a vivid dream from which you awoke feeling paralyzed and unable to move?

"Well, yes, but it always goes away. I have never let it bother me."

"Do you feel sleepy through the day or do you have sleep attacks where you just doze off when you shouldn't?" 

"No, I have nothing like that."

"Carolyn, there is a disorder called cataplexy. It is a sudden loss of muscle strength that people can experience just out of the blue, or sometimes when they are startled or emotional. It can cause them  to suddenly drop things they are holding, and sometimes their legs go out from under them, and they fall. Have you ever had anything like that?"

"Oh my God. I sure do. It happens to me occasionally. It just comes on me suddenly, and I will find myself on the floor. Then I get up and go about my business. Dr. Cochran, you are beginning to kind of interest me."

 "You are beginning to interest me, too. I am prescribing Methadone. It is a painkiller, but it is different from the ones you have taken before. I want you to take it 3 times daily and check back with me in short order -- something like 2 weeks."

"Methadone -- that is what heroin addicts use, isn't it?"

"Yes, that is what heroin addicts use, but I am giving it to you for pain."

"I am not going to take it!"

"Carolyn, you are going to take it, and it is going to cure you."

"You really think so?"

"Yes, I really think so."

Carolyn had the full expression of the bipolar spectrum. She was mood-labile and behavior-erratic. She was ridden with anger, and she suffered narcolepsy and probably attention deficit disorder also.

"I couldn't believe it. Within an hour of taking the Methadone, I felt the pain leaving my body. I had the sense that something was coming over me, and I felt an evenness like I had never known. None of the other drugs affected me this quickly. I really think we are on to something." 

"I am happy for you, Carolyn. My instincts tell me this is not going to be a flash in the pain. I think this effect is for realy, but I will have to follow you closely."

"I have to tell you something. Since I have been on the Methadone, my memory is actually improving. My mental focus is much better and I can concentrate. It is amazing what has happened to me."

"That's good, Carolyn. I forgot to ask you about that, but it is important information. That reminds me, how about your dreams and your falling spells? Have they changed any?"

"Yes, I am not dreaming as much, not nearly as much, and as far as those catty things you talked about, I haven't had any, but it is too early to know about that. They happen only a few times a year. So I can't speak to that. Dr. Cochran, you've got me  thinking -- a lot. Everything is better now, and I want to know why. You told me you thought I was bipolar, and maybe I am, but what's that got to do with my dreams, and my catty spells and my memory and mental focus?"

 "They are part of your disease, just as are your mood swings, and, if I may say so, also your anger."

"Okay, I don't want to accept it, but I will, and thank you for taking care of me. I want you to know something else. I am reading your book, and I really like it."

"Well, thank you, Carolyn, but just a few months ago you told me you didn't like my book. You said it was too wordy. I remember it well."

"This may be hard for you to understand, but back then I couldn't comprehend it. By the time I had finished a chapter, I had forgotten the first part. It was too wordy because I couldn't remember. I can remember now, and thanks for writing the book. It has helped me a lot."

"I do understand, Carolyn. Really I do."

Along with curing Carolyn's pain and mood swings, the Methadone seems to have cured her narcolepsy, her attention deficit disorder, and her anger. I would not, but 6 months ago, have imagined that possible. 

Last Updated: May 1, 05:03 PM

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Trichotillomania, Pain, Bipolarity and the Curious Effects of Polypharmacy