Defining Pain Disorders

Pain is not only inevitable, but is crucial to our well-being, as it alerts us when our bodies are being harmed. At times, however, pain does not go away, even after the original cause is no longer present — it becomes chronic. According to a 2001 Canadian survey, 18 per cent of women and 14 per cent of men suffer from chronic pain. ¹ Many people manage to cope with their pain and continue to live fruitful and enjoyable lives despite the limitations it might bring. Others react poorly to pain and gradually become entangled in self-defeating thoughts and behaviours, over-medication and despair. ²

Over the last two decades, the definition of pain disorders has undergone significant change, and has been tied to evolving medical and psychiatric concepts about pain. These changes have caused confusion and have led to frequent misuse of terminology. In the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM IV), the definition included three types of pain disorders: pain disorder associated with psychological factors, pain disorder associated with psychological factors and a general medical condition, and pain disorder associated with a general medical condition. The third condition is not a mental illness at all and should only be diagnosed by a physician.

According to DSM IV, pain disorder associated with psychological factors is a category used when the psychological factors are judged to have the major role in the onset, severity, exacerbation or maintenance of the pain. Pain disorder associated with both psychological factors and a general medical condition is used when both psychological factors and a general medical condition are judged to have important roles in the onset, severity, exacerbation or maintenance of the pain.

Although both of these conditions could be classified as mental disorders, the first condition is closely related to the earlier concepts of psychogenic pain and is more likely a mental illness. This condition requires the clinician to first rule out any physical causes to the pain. The second condition is synonymous with chronic pain syndrome so it is not purely a mental disorder.

“Melzack and Katz (2006) point out that pain patients diagnosed with chronic pain disorder due to psychological factors may be unjustly given a psychiatric diagnosis, especially because there are always physiological underpinnings in cases of pain. They disagree that pain can be constituted by primarily psychological factors factors (presumably excluding cases of malingering). Moreover, they suggest that when clinicians use the label of chronic pain disorder, they may be understood as saying that the pain is fully psychological in origin . . . Moreover, pain patients may be exaggerating their symptoms either consciously (with awareness), or unconsciously (without awareness), they may be experiencing their pain due to stresses related to secondary gain issues rather than to stresses directly related to the original pain onset and its effects . . . Problems such as these could be obviated by more precise diagnostic criteria for chronic pain disorder in DSM IV. The criteria, as they exist, leave room for ambiguity in interpretation,” according to Causation of Psychology Injury. ³

The question that often comes up in disability evaluations is why some people with chronic pain develop disability whereas others appear to be able to cope with the demands of life. Research has shown that certain coping styles may enhance pain such as fear-avoidance, catastrophizing and low self-efficacy. Other researchers have proposed that certain personality styles and pre-existing mental disorders may increase vulnerability to chronic pain.

Distressing emotions understandably accompany chronic pain problems. At times these emotions are sufficiently severe to constitute a comorbid mental disorder. The most common mental disorder to occur with chronic pain is depression. Approximately one-third of chronic pain patients have a full depressive syndrome and close to 50 per cent have a history of depression. ⁴ Other mental conditions that are often associated with chronic pain include anxiety disorders and alcohol and substance related disorders.

Chronic pain patients frequently reject psychological explanations and treatments for their pain. These patients emphasize the physical nature of their pain and seem afraid that psychological explanations of their pain imply they are imagining the pain or putting it on. Often the patient’s family has a shared belief about the cause of the problem and reinforces the search for a physical cause and treatment. Some families encourage passivity to avoid expressions of anger and conflict by investing and colluding in the patient’s disability. ⁵

The assessment of chronic pain patients should always start with an understanding of the physical factors and the type of injury that contributes to the pain. As a fully qualified physician, a psychiatrist is familiar with the

medical terminology used and has an understanding of the organic pathology involved. The next step in a psychiatric evaluation is the understanding — through an in depth interview — of the unique factors that contribute to the perception of pain and suffering in the individual being assessed. Following that is the diagnosis of any comorbid mental disorders that complicate the clinical picture. The psychiatrist is in a unique position to comment on complex medication regimens for pain and emotional issues. Often patients with chronic pain are placed on elaborate cocktails of medications including pain killers, tranquilizers, antipsychotics and antidepressants. There are numerous side effects associated with these medications that often contribute to the perception of disability in addition to creating a multitude of problems including sedation and, at times, dangerous interactions between the various medications.

The treatment of chronic pain involves the delicate interplay of psychotherapy and psychopharmacology: Psychotherapy in the form of cognitive behavioural therapy, mindfulness techniques and supportive therapy and psychopharmacology in the form of antidepressants and other medications needed to treat comorbid conditions.

At the crux of the evolving approach to the treatment of chronic pain is the idea that pain is inevitable, suffering is optional. Unfortunately, it is more often than not that patients go through endless tests and combination of medications to find out that the chronic pain simply can not be eradicated. This realization is the first step in accepting the pain is there to stay. The next realization that patients often do not come to understand is the fact that one does not need to be swept away by the waves of pain, but rather one can learn to surf through the waves. We need to learn to change our relationship with pain, and see pain without judging it. Experience that we are not our pain, and learn to live around it. I often tell patients that “You don’t have to cope forever — just for this moment”.

Dr. Z. Waisman MD, FRCPC is a psychiatrist whose practice is devoted to the assessment and treatment of the psychiatric consequences of personal injury. He is an assistant professor of psychiatry with the faculty of medicine at the University of Toronto and is the current director of education in psychiatry at North York General Hospital and the former director of inpatient psychiatry.

1. Meana, M., Cho, R. & DesMeules, M. (2004). Chronic Pain: The extra burden on Canadian women. BMC Women’s Health, 4, S17

2. Alcock, J., The Psychology of Chronic Pain, presented at the conference on psychological injuries and chronic pain The Law Society of Upper Canada June 7, 2007

3.Young, G. et al Causality of Psychological Injury. Springer 2007

4. Katon W, Egan K, Miller D. Chronic pain: lifetime psychiatric diagnoses and fam
ily history. Am J Psychiatry 1985; 142: 1156-1160

5. Rickarby GA. Compensation neurosis and the psycho-social requirements of the family. Brit J Med Psychology 1979; 52: 333-8

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Diagnosis Of Pain Disorder

The DSM IV TR (revised) criteria for the diagnosis of pain disorder associated with both psychological factors and a general medical condition is:

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.