Differential diagnosis of pain disorder

Pain can occur in the setting of virtually any mental disorder. TableJ lists the ICD-10 diagnoses and their DSM-IV equivalents in which pain may be a predominant feature. The general description of most of these disorders is provided in other chapters of this book and the following account focuses only on aspects relevant to pain.

Organic disorders

Many painful disorders have a well-recognized organic pathology that accounts for the occurrence of pain (for example angina, sickle cell arthropathy), but psychosocial processes tend to modify the severity of pain and associated disability. Thus psychological and social interventions may make an important contribution to management, and as pain becomes more chronic, or fails to respond to usually effective physical treatments, psychosocial interventions assume greater significance. These disorders can be diagnosed in ICD-10 within the diagnoses headed 'Psychological interactions with physical disorders' in Table 1...

Pain syndromes of uncertain origin

There are many disorders characterized by pain, which are essentially syndromes with no known consistent organic pathology ( Table ,,). Psychological and social factors are thought to contribute to the development and maintenance in many cases,(1) but psychological causes specific to these different syndromes have not been identified. Patients with these pain syndromes tend to have a greater prevalence of non-psychotic mental disorders than is found in the general population. The pain itself can usually be accommodated in ICD-10 within the categories of somatoform autonomic dysfunction or somatoform pain disorder (see below), although this is unlikely to result in more effective management. Treatments for these disorders generally include physical approaches, often of limited efficacy, as well as a range of psychosocial interventions which are described below.

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Table 2 Disorders of uncertain origin, presenting primarily with pain, in which psychosocial factors are thought to contribute to predisposition, precipitation, or course

Pain and mental disorders Psychoses

At the beginning of the twentieth century, French psychiatrists described coenestopathic states as disorders characterized by unpleasant sensations, particularly pains, thought to be of central origin, but unrelated to organic brain disease. (2) Such disorders were a daily occurrence in psychiatric clinics, regarded as amongst the most frequent features of the psychoses, and in this setting were related to somatic hallucinations and systematized delusional states. Such presentations are now described infrequently in Europe and North America.

Patients with any psychotic disorder may complain of pain, sometimes with bizarre descriptions of quality and delusional attribution. In practice, it is difficult to differentiate between a somatic hallucination and an illusion (arising from physiological or pathological processes). Complaints of pain in psychotic disorders have no psychiatric diagnostic specificity. Pain has been described particularly in association with schizophrenia and depressive psychoses, but may occur in any psychotic disorder. It has been described as an uncommon presenting feature of Pick's disease, taking the form of extreme generalized hyperalgesia. In the course of a psychotic disorder, illusions and delusional interpretations of pain may arise from unrelated organic disorders and therefore require careful physical assessment.

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