Diagnostic and clinical features

Persistent somatoform pain disorder in ICD-10 is the only somatoform disorder that is essentially characterized by pain. The diagnostic requirements are as follows:

1. 'persistent, severe, and distressing pain';

2. pain 'cannot be explained fully by a physiological process or a physical disorder';

3. 'pain occurs in association with emotional conflict or psychosocial problems that are sufficient to allow the conclusion that they are the main causative influences'.

There are also likely to be features that occur in the other somatoform disorders, such as failure to be reassured by appropriate assessments and explanation, excessive consultations, investigations, and unsuccessful physical treatments, and disability and dependence on others, which can be extreme. The pain can be localized, as in low back pain, or generalized, as in fibromyalgia.

This diagnosis is not made if pain, which is presumed to be mainly psychological in origin, occurs in the course of schizophrenia or depressive disorder. It is also excluded if pain is believed to be due to psychophysiological mechanisms such as muscle tension. The main differential diagnosis, according to ICD-10, is the histrionic elaboration of pain due primarily to organic causes, particularly if this has not yet been diagnosed. In practice, it is uncommon for pain that has been properly investigated, and has persisted for more than 6 months, to be found subsequently to have a specific organic cause.

The DSM-IV diagnosis of 'pain disorder' also needs to be considered because the requirements for diagnosis and the underlying rationale are rather different. This diagnosis is divided into three subtypes.

1. 'Pain disorder associated with psychological factors', in which psychological factors are judged to play the major role, and physical disorders play either no part or only a minor part in its onset or maintenance.

2. 'Pain disorder associated with both psychological factors and a general medical condition', in which both psychological processes and an organic disorder are judged to make important contributions to causation. 3. 'Pain disorder associated with a general medical condition', due to an organic disorder and in which psychological factors are judged to make no contribution or to play only a minor role. This subtype is not regarded as a mental disorder but is coded on Axis III.

For the first two subtypes the diagnostic criteria, all of which must be satisfied, are summarized as follows:

A. Pain, localized or more general, is the predominant symptom and its severity warrants clinical attention.

B. Pain results in distress, and impairment in social, occupational, or other areas of functioning.

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

D. It is not intentionally produced or feigned (factitious disorder and malingering are specifically excluded).

E. Pain is not better accounted for by a mood, anxiety, or psychotic disorder and does not meet criteria for dyspareunia.

Pain disorder can also be coded according to whether it is acute or chronic (less or more than 6-months' duration.

The diagnoses of pain disorder in ICD-10 and DSM-IV share a number of characteristics. Pain disorder can be diagnosed as a mental disorder if psychological factors are thought to make a significant contribution to predisposition, precipitation, or maintenance, or to the severity of pain. In ICD-10, there should be evidence that emotional conflict or psychosocial problems are the main 'causative influences', whereas in DSM-IV psychological factors are judged to play either the 'major role' or 'an important role'. In both, the diagnosis can be made even though there may be possible or definite evidence of an organic disorder that contributes to pain (for instance a prolapsed intervertebral disc), provided that this is judged to be insufficient to account fully for the features of pain. Both classifications stress the severity of pain and the distress caused by it, but only DSM-IV specifically requires a degree of disability as a diagnostic feature. The implication is that diagnosis requires detailed physical and psychiatric evaluation, including an assessment of the family and social context as well as of disability.

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