Mrs. A, age 50, reports recurrent headaches and neck pain from a motor vehicle accident in 1999. At the time, MRI revealed degenerative changes at the C5-C6 vertebrae without bony stenosis or spinal injury. Treatment consisted of conservative measures and physical therapy; she was not a candidate for surgical intervention.
Although Mrs. A can manage activities of daily living, pain prevents her from pastimes she previously enjoyed, including painting and pottery, and is causing problems in her marriage.
Mrs. A’s pain became much worse approximately 1 year ago. In the past year, its severity has lead to multiple clinical presentations and consultations. She uses transdermal fentanyl, 75 mcg/hr every 72 hours, and acetaminophen/ hydrocodone, 5 mg/500 mg every 4 hours up to 6 times a day for breakthrough pain. Even so, she still rates her pain as 7 on a 10-point scale.
Pain is a complex perception with psychological and sensory components. It is the most common reason patients seek treatment at ambulatory medical settings.1 Most pain remits spontaneously or responds to simple treatment, but up to 25% of symptoms remain chronic.1
Chronic pain—defined as pain at ≥1 anatomic sites for ≥6 months—can substantially impair adaptation and vocational and interpersonal functioning. Treatments that focus solely on analgesics are shortsighted and often of limited benefit. Patients with chronic pain need a rehabilitative approach that incorporates psychiatric and psychological intervention.
Complex chronic pain
Most individuals with chronic pain can maintain basic functioning, work, relationships, and interests. They work with healthcare providers and obtain relief from medications or other interventions.
Some, however, are preoccupied with—and entirely debilitated by—their pain. For them, life revolves around the pain and perceived disability. Many if not all aspects of this patient’s life are contingent on pain and fears it might worsen.2 Preoccupation with pain can profoundly affect social activities and prevent employment. The patient may become dependent on others, and being a patient can become a primary psychosocial state. A chronic pain patient also may become increasingly preoccupied with medication use and possibly abuse.
- a general medical condition
- psychological factors
- both.
Pain disorder criteria often are perceived as insufficiently operationalized—there is no checklist of symptoms that collectively define the syndrome.5,6 The clinician must infer whether—and to what extent—psychological factors are involved in the pain.5 There are no guidelines to help psychiatrists ascertain whether psychological factors “have an important role” in pain (criteria C) or if pain is “not better accounted for” by a mood disorder (criteria E).6 This distinction can be indecipherable because of frequent comorbidity of mood disturbances with pain.7,8 Some clinicians have suggested that pain disorder be removed from the somato-form disorder classification and instead confined to Axis III.9
Table 1
DSM-IV-TR diagnostic criteria for pain disorder
| A. Pain in ≥1 anatomical sites |
| B. Produces distress or impairs social, occupational, or other functioning |
| C. Psychological factors have an important role in pain onset, severity, exacerbation, or maintenance |
| D. Not intentionally produced or feigned (as in factitious disorder or malingering) |
| E. Not better accounted for by a mood, anxiety, or psychotic disorder and does not meet criteria for dyspareunia |
| Subtypes |
| Pain disorder associated with psychological factors, which are judged to have the major role in pain onset, severity, exacerbation, or maintenance |
| Pain disorder associated with both psychological factors and a general medical condition, which are judged to have important roles in pain onset, severity, exacerbation, or maintenance |
| Pain disorder associated with a general medical condition.* If psychological factors are present, they do not have a major role in pain onset, severity, exacerbation, or maintenance |
| * Not considered a mental disorder (encoded on Axis III) Source: Adapted from Diagnostic and statistical manual of mental disorders. 4th ed, text rev. Washington, DC: American Psychiatric Association; 2000 |