139 Pain Disorder (307)

DSM-IV-TR criteria

A. Pain in one or more anatomical sites is the predominant focus of the clinical presentation and is of sufficient severity to warrant clinical attention.

B. The pain causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

C. Psychological factors are judged to have an important role in the onset, severity, exacerbation, or maintenance of the pain.

D. The symptom or deficit is not intentionally produced or feigned (as in Factitious Disorder or malingering).

E. The pain is not better accounted for by a Mood, Anxiety, or Psychotic Disorder and does not meet criteria for Dyspareunia.

Code as follows:

307.80 Pain Disorder Associate With Psychological Factors: psychological factors are judged to have the major role in the onset,severity, exacerbation, or maintenance of the pain. (If a general medical condition is present, it does not have a major role on the onset,severity, exacerbation, or maintenance of the pain.) This type of Pain Disorder in not diagnosed if criteria are also met for Somatization Disorder.

Specify if:

• Acute: duration of less than 6 months
• Chronic: duration of 6 months or longer
• 307.89 Pain Disorder Associated with both psychological factors and general medical condition: both psychological factors and a general medical condition are judged to have important roles in the onset, severity, exacerbation, or maintenance of the pain. The associated general medical condition or anatomical site of the pain(see below) is coded on Axis III

Specify if:

• Acute:duration of less than 6 months
• Chronic: duration of 6 months or longer

Note: The following is not considered to be a mental disorder and is included here to facilitate differential diagnosis.

Pain Disorder Associated with a General Medical Condition: a general medical condition has a major role in the onset, severity, exacerbation, or maintenance of the pain. (If psychological factors are present, they are not judged to have a major role in the onset, severity, exacerbation, or maintenance of the pain.) The diagnostic code for the pain is selected based on the associated general medical condition if one has been established(see Appendix G) or on the anatomical location of the pain if the underlying general medical condition is not yet clearly established-for example, low back(724.2) sciatic (724.3), pelvic (625.9), headache (784.0), facial (784.0), chest (786.5), joint (719.4), bone (733.9), abdominal (789.0), breast (611.71), renal(788.0), ear (388.70), eye (379.91), throat(784.1), tooth (525.9), and urinary (788.0).

Associated features

Pain may severely disrupt different aspects of a person’s daily life. It may lead to unemployment, disability, and family problems. It may also have an effect on Iatrogenic Opiod Dependence or Abuse and Benzodiazepine Dependence or Abuse as well as Substance Dependence or Abuse. It is also associated with severe depression with terminal illness as well as a risk to suicide. It may lead to inactivity and social isolation, reduction in physical endurance, and fatigue. Also, other associated features include: musculoskeletal conditions, neuropathies, malignancies. There is comorbidity with Osteoporosis, Osteoarthritis, and Fibromyalgia.

Child vs. Adult presentation

It may occur at any age but there are not any known differences.

Gender and cultural differences

• Females will appear to experience certain chronic pain conditions, most migraine and tension-type headaches and musculoskeletal pain more often than males.
• It is different in each individual therefore it is hard to determine cultural differences.

Epidemiology

• 10-15 % of adults in the United States
• Depressive Disorders, Alcohol Dependence, and chronic pain may be more common in the first degree biological relatives with Pain Disorder.

Etiology

• Pain disorder may develop due to a conversion mechanism and some patients may have what is called a “pain-prone personality:” where they have old feelings of guilt and worthlessness about themselves, and they constantly feel that they are in need of punishment, pain gives them this.
• Physical pain may play such a role, and the onset of the pain may be seen in these patients when things seem to be going otherwise unexpectedly well in their lives. There is some connection between this personality style and a history of childhood abuse. Others, often women, experience pain for which no cause can be found. It appears unexpectedly, usually after a stress, and may fade away in days or it can last years.

Empirically supported treatments

It’s associated with a General Medical Condition may be treated with a course of general pain killers. This term is used for any patient who has pain that is mainly caused, worsened or maintained by a general medical condition, so long as any psychological factors play at most a minor role. This is not considered to be a mental disorder.

DSM-5 Changes (taken from DSM5.org)

The work group is recommending that this disorder be subsumed into a new disorder: Complex Somatic Symptom Disorder.
The following optional specifiers may be applied to a diagnosis of CSSD where one of the following dominates the clinical presentation:
3. Pain disorder. This classification is reserved for individuals presenting predominantly with pain complaints who also have many of the features described under criterion
B. Patients with other presentations of pain may better fit other psychiatric diagnoses such as major depression or adjustment disorder.

Rationale:

Major Change #1: Rename Somatiform disorders to Somatic Symptom Disorders and combine with PFAMC factitious disorders
The workgroup suggests combining Somatoform Disorders, Psychological Factors Affecting Medical Condition (PFAMC), and Factitious Disorders into one
group entitled “Somatic Symptom Disorders” because the common feature of these disorders is the central place in the clinical presentation of physical symptoms and/or concern about medical illness. The grouping of these disorders in a single section is based on clinical utility (these patients are mainly encountered in general medical settings), rather than assumptions regarding shared etiology or mechanism.

Major Change #2: Combine Somatization disorder hypochodriasis, undifferentiated somatiform disorder, and pain disorder into a new category entitled “Complex Somatic System Disorder” (CSSD).

Combine somatization disorder, hypochondriasis, undifferentiated somatoform disorder, and pain disorder into a new category entitled “Complex Somatic Symptom Disorder” (CSSD) which emphasizes the symptoms plus the patients’ abnormal cognitions (Barsky, Lowe, Rief). The term “complex” is intended to denote that in order for this diagnosis to be made, the symptoms must be persistent and must include both somatic symptoms (criterion A) as well as cognitive distortions (criterion B).

This is a major change in the diagnostic nomenclature, and it will likely have a major impact on diagnosis. It clarifies that a diagnosis of CSSD is inappropriate in the presence of only unexplained medical symptoms. Similarly, in conditions such as irritable bowel syndrome, CSSD should not be coded unless the other criterion (criterion B—attributions, etc) is present.
It is unclear how these changes would affect the base rate of disorders now recognized as somatoform disorders. One might conclude that the rate of diagnosis of CSSD would fall, particularly if some disorders previously diagnosed as somatoform were now diagnosed elsewhere (such as adjustment disorder). On the other hand, there are also considerable data to suggest that physicians actively avoid using the older diagnoses because they find them confusing or pejorative. So, with the CSSD classification, there may be an increase in diagnosis.
The proposal is to group together these heretofore separately recognized disorders because in fact, there are 3 diverse sources suggesting considerable overlap among them.
1. A 2009 study found that 52% of physicians surveyed indicated that there was “a lot of overlap” and an additional 38% thought that there was “some overlap” across these disorders. In contrast, less than 2% of physician respondents felt that these were “distinctly different disorders (Dimsdale, Sharma, & Sharpe, unpublished).
2. There are limited data regarding overlap in clinical settings. One primary care study, for instance, found that 20% of somatization disorder patients also had hypochondriasis (Escobar, 1998). In primary care patients, somatization disorder was 5 times ( Fink et al 2004) to 20 times (Barsky et al 1992) more common in hypochondriasis patients as compared to primary care patients without hypochondriasis.
3. Treatment interventions are similar in this group of disorders. Cognitive behavior therapy (CBT) and antidepressant medications appear to be the most promising therapeutic approaches for hypochondriasis, somatization disorder, and pain disorder (Kroenke 2007; Sumathipala 2007). Although several variations of CBT have been employed, they share many elements in common. These include the identification and modification of dysfunctional and maladaptive beliefs about symptoms and disease, and behavioral techniques to alter illness and sick role behaviors and promote more effective coping. The literature on the use of antidepressants is more limited, but it too does not suggest any major distinctions in therapeutic response across these different disorders. In addition to these patient centered commonalities of treatment, all of these disorders benefit from specific interventions with the patient’s non-psychiatric physician (e.g. scheduling regular appointments as opposed to prn appointments, limiting testing and procedures unless clearly indicated) (Allen 2002).
A key issue is whether the guidelines for CSSD describe a valid construct and can be used reliably. A recent systematic review (Lowe, submitted for publication) shows that of all diagnostic proposals, only Somatic Symptom Disorder reflects all dimensions of current biopsychosocial models of somatization (construct validity) and goes beyond somatic symptom counts by including psychological and behavioral symptoms that are specific to somatization (descriptive validity). Predictive validity of most of the diagnostic proposals has not yet been investigated.
Severity:

Severity metrics are readily available for somatic symptoms (viz PHQ, Kroenke 2002) and for the cognitive distortions and misattributions associated with CSSD (viz Whiteley Index, Pilowsky. 1967).