Introduction

Persistent somatoform pain disorder is an ICD-10 diagnosis which is included in the group of somatoform disorders. The term pain disorder is used in DSM-IV, and for convenience that is the term used here to refer to both classifications, unless a distinction needs to be made. Earlier classifications also included diagnoses based essentially on the presence of pain, but these were used infrequently, perhaps due to ambiguity in the diagnostic criteria, the limited value of these diagnoses, and uncertainty about the relationship of pain to mental disorders. This chapter aims to clarify these issues, first by considering the relationship of pain to mental disorders, second by examining the diagnosis of pain disorder and the differential diagnosis of pain and mental disorders, and third by considering psychosocial factors that contribute to pain, the treatments that stem from them, and the psychiatrist's potential contribution.

Pain has been defined by the International Association for the Study of Pain (IASP) as 'an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage'. 'Pain' is used here in this sense; it is not used primarily to indicate mental distress or anguish.

The IASP definition of pain introduces a fundamental paradox. Pain is essentially a subjective experience, and only the patient knows whether or not he has it. One person's pain is not directly accessible to others. A physician either accepts the patient's complaint of pain, or regards the patient as a liar. By contrast, tissue damage can be assessed by others, and the relationship with pain severity is variable, modulated within the central and peripheral nervous system.

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