Functional disorders and chronic pain

Editor – I read the article by Eccles and Davies with great interest.¹ I think they have highlighted well the overlapping issues of chronic pain and fatigue symptoms and the diagnostic overlap between patients with fibromyalgia and myalgic encephalomyelitis / chronic fatigue syndrome (ME/CFS).

I was, however, disappointed to note that there are a number of deficiencies within the article. While they are correct to note that there are multiple referral pathways for patients with chronic pain, pain clinics within anaesthetic departments across the UK provide significant input into pain management and are often one of the ‘last resorts’ in the patient treatment pathway.^2,3

While Eccles and Davies note the presence of cognitive dysfunction in patients with chronic pain conditions, they seem to not acknowledge that chronic pain is a biopsychosocial condition and must be approached as such, as identified within the International Association for the Study of Pain revised definition of pain and the proposed International Statistical Classification of Diseases and Related Health Problems 11th revision (ICD-11) classification criteria.^4,5 It is well recognised that psychological contributions to chronic pain and functional conditions are significant.^6,7

While I applaud the descriptions used by Eccles and Davies to describe various approaches to chronic pain patient management as embraced by different doctors (particularly that used by Dr B), it seems to me that they then proceed further along the biomedical route by exploring hypermobility syndromes, small fibre neuropathy, mast cell activation disorders and inflammatory reactivity. This approach, in my experience, further entrenches ‘illness behaviour’ and distress among patients with functional chronic pain conditions and fails to approach pain management through a biopsychosocial approach. This then becomes a ‘barrier to progress’.⁸

The impact of psychological illness on chronic pain symptom presentation is well recognised and a holistic approach to managing these patients through illness de-escalation and promoting improved self efficacy is, in my opinion, more appropriate.