Assessing And Treating Clients With Pain


This week, a 43-year-old white male presents at the office with a  chief complaint of pain. He is assisted in his ambulation with a set of  crutches. At the beginning of the clinical interview, the client reports  that his family doctor sent him for psychiatric assessment because the  doctor felt that the pain was “all in his head.” He further reports that  his physician believes he is just making stuff up to get “narcotics to  get high.”


The client reports that his pain began about 7 years ago when he  sustained a fall at work. He states that he landed on his right hip.  Over the years, he has had numerous diagnostic tests done (x-rays, CT  scans, and MRIs). He reports that about 4 years ago, it was discovered  that the cartilage surrounding his right hip joint was 75% torn (from  the 3 o’clock to 12 o’clock position). He reports that none of the  surgeons he saw would operate because they felt him too young for a  total hip replacement and believed that the tissue would repair with the  passage of time. Since then, he reported development of a strange  constellation of symptoms including cooling of the extremity (measured  by electromyogram). He also reports that he experiences severe cramping  of the extremity. He reports that one of the neurologists diagnosed him  with complex regional pain syndrome (CRPS), also known as reflex  sympathetic dystrophy (RSD). However, the neurologist referred him back  to his family doctor for treatment of this condition. He reports that  his family doctor said “there is no such thing as RSD, it comes from  depression” and this was what prompted the referral to psychiatry. He  reports that one specialist he saw a few years ago suggested that he use  a wheelchair, to which the client states “I said ‘no,’ there is no need  for a wheelchair, I can beat this!”

The client reports that he used to be a machinist where he made  “pretty good money.” He was engaged to be married, but his fiancé got  “sick and tired of putting up with me and my pain, she thought I was  just turning into a junkie.”

He reports that he does get “down in the dumps” from time to time  when he sees how his life has turned out, but emphatically denies  depression. He states “you can’t let yourself get depressed… you can  drive yourself crazy if you do. I’m not really sure what’s wrong with  me, but I know I can beat it.”

During the client interview, the client states “oh! It’s  happening, let me show you!” this prompts him to stand with the  assistance of the corner of your desk, he pulls off his shoe and shows  you his right leg. His leg is turning purple from the knee down, and his  foot is clearly in a visible cramp as the toes are curled inward and  his foot looks like it is folding in on itself. “It will last about a  minute or two, then it will let up” he reports. Sure enough, after about  two minutes, the color begins to return and the cramping in the  foot/toes appears to be releasing. The client states “if there is  anything you can do to help me with this pain, I would really appreciate  it.” He does report that his family doctor has been giving him  hydrocodone, but he states that he uses is “sparingly” because he does  not like the side effects of feeling “sleepy” and constipation. He also  reports that the medication makes him “loopy” and doesn’t really do  anything for the pain.


The client is alert, oriented to person, place, time, and event. He  is dressed appropriately for the weather and time of year. He makes good  eye contact. Speech is clear, coherent, goal directed, and spontaneous.  His self-reported mood is euthymic. Affect consistent to self-reported  mood and content of conversation. He denies visual/auditory  hallucinations. No overt delusional or paranoid thought processes  appreciated. Judgment, insight, and reality contact are all intact. He  denies suicidal/homicidal ideation, and is future oriented.

Diagnosis: Complex regional pain disorder (reflex sympathetic dystrophy)

Decision Point One

Amitriptyline 25 mg po QHS and titrate upward weekly by 25 mg to a max dose of 200 mg per day


  • Client returns to clinic in four weeks
  • Client comes to the office still using crutches. He states that the pain has improved but he is a bit groggy in the morning
  • Client’s pain level is currently a 6 out of 10. The PMHNP questions  the client on what would be an acceptable pain level. He states, “I  would rather have no pain but don’t think that is possible. I could live  with a pain level of 3.” He states that his pain level normally hovers  around a 9 out of 10 on most days of the week before the amitriptyline  was started. The PMHNP asks what makes the pain on a scale of 1-10  different when comparing a level of 9 to his current level of 6?” The  client states, “I’m able to go to the bathroom or to the kitchen without  using my crutches all the time. The achiness is less and my toes do not  curl as often as they did before.” The client is also asked what would  need to happen to get his pain from a current level of 6 to an  acceptable level of 3. He states, “Well, that is kind of hard to answer.  I guess I would like the achiness and throbbing in my right leg to not  happen every day or at least not several times a day.  I also could do  without my toes curling in like they do. That really hurts.”
  • Client denies suicidal/homicidal ideation and is still future oriented

Decision Point Two

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