The psychiatric assessment of pain requires a full psychiatric history and mental state examination, with particular attention to those additional features relevant to the somatoform disorders. The history of pain should include total duration (often underestimated by the patient), a detailed inquiry about the location and distribution of pain, including direct questions aimed at a total body survey, and the timing of first onset, subsequent periods of relapses and remissions, and their relationship to life events and difficulties. Patients who somatize will tend to deny concurrent psychosocial events and their significance. For example, a patient of the author was consistently unable to recall any distressing events in the year prior to the onset of severe, persistent, and disabling headache. His wife gave an account of the deaths of his father, brother, and closest friend during that year, and moreover described him as so distressed by these bereavements that he felt unable to attend any of the funerals. It is essential to take a history from other informants, and this can also provide an opportunity to assess the attitudes, knowledge, and beliefs of carers, and their interaction with the patient.
The patient's pain beliefs and behaviours (described below) are key aspects of the mental state examination. Patients often attribute chronic pain to an organic disorder and offer diagnoses; it is essential to review their medical records to assess the clinical findings and investigations and the extent to which they support any diagnosis which has been made.
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