慢性疼痛合併雙相症患者的整合治療：案例報告

A Case Report of Integrating Treatment on a Patient with Chronic Pain Comorbid with Bipolar Disorder

心因性疼痛是一個範圍廣泛的疾病，多數描述心理因素產生或加劇病人疼痛症狀的臨床現象。除了憂鬱症之外，雙相症患者出現慢性疼痛症狀的風險也較一般人高，而雙相症患者出現慢性疼痛症狀時用藥上需要考慮避免因藥物使用而轉鬱期為躁期，因此對抗鬱劑，抗癲癇藥物，乃至含tramadol成分之止痛藥物需有特殊考慮。我們要報告一位39歲的女性病人，於26歲時出現鬱症後躁症發作並有割腕及跳樓行為，因騎車跌倒及反覆跳樓受傷導致慢性下背及右腳疼痛，其因反覆到醫院要求打針止痛，自殺或對家人攻擊的行為而9次入住精神科性病房住院。配合藥物的調整、行為改變，壓力調適技巧，及彈性式的結構化生活安排，其雖仍疼痛，但行為上逐漸穩定。本文強調在處方抗憂鬱劑或含tramadol成分的藥物前需詢問雙相症病史的重要性。如何與此類病人溝通引導其聚焦在功能而非疼痛症狀也是除了藥物治療之外重要治療因素。

Psychological pain is a broad concept, covering psychological factors that might generate or aggravate pain symptoms. In addition to depressive disorders, patients with bipolar disorder are at a higher risk of chronic pain. To avoid switching bipolar-disorder patients with chronic pain from a depressive to a manic phase, special consideration is necessary when prescribing antidepressants, anticonvulsants, or tramadol-containing analgesics to them. We report the case of a 39-year-old female with depressive then manic symptoms that first appeared when she was 26. She also suffered from long-term pain in her lower back and right lower leg that resulted from a bicycle accident and multiple suicide attempts. She had a total of nine admissions to psychiatric wards due to her repeated and vigorous demands for analgesic injections, suicide risk, or violence against family members. Following adjustments to her medication, behavior-modification training, coping-skills education and the arrangement of a flexible psychiatric daily-care schedule, her mood and behavior stabilized despite her chronic pain continuing. This case highlights the importance of inquiring into chronic-pain patients' history of bipolar disorder before prescribing tramadol or antidepressants for their pain. In addition to treating them pharmaceutically, it is therapeutically important to communicate with such patients and shift their focus onto function rather than pain symptoms.