Pain syndromes

While the ICD and DSM classification systems both define somatoform pain disorders, the two systems differ in their descriptions of the clinical features. In the ICD diagnostic system, somatoform pain disorder is defined as persistent pain without clear medical explanation. (5) The DSM system(4) specifies that 'psychological factors are judged to have an important role in the onset, severity, exacerbation, or maintenance of the pain'. Both definitions are somewhat problematic. Recent findings regarding neural changes associated with persistent pain raise doubts about the distinction between pain with and without a biomedical explanation. (31) As discussed below, longitudinal research supports the view that persistent pain causes psychological disorder as much as it supports the DSM view that pain results from psychological distress. Recent epidemiological research has attempted to avoid questions of aetiology and has examined the prevalence and correlates of persistent pain.

Epidemiological studies consistently find that pain syndromes are among the most common problems presenting to general medical providers. Population surveys indicate that over 25 per cent of community residents suffer from recurrent or persistent pain symptoms and that 2 to 3 per cent experience disabling pain syndromes/3,33) The recent WHO primary care survey(34) found that approximately 20 per cent of primary care patients suffered from persistent pain (one or more pain symptoms present for most of the last 6 months). Pain syndromes are approximately twice as prevalent in women as in men.(1 ,17,35)

All available data indicate that pain symptoms are strongly associated with anxiety and depressive disorders. This relationship has been consistently demonstrated in both community^36 and primary care(34) studies across a broad range of cultural and socio-economic divides. Psychological distress is most strongly associated with pain occurring at multiple sites and pain associated with functional impairment. (3 38> While epidemiological studies strongly support an association between pain complaints and psychological distress, this does not necessarily imply that pain is a consequence of psychological distress. Some studies find that the presence of psychological distress predicts the onset of pain syndromes, (3M0) while others support the opposite relationship—that persistent pain predicts subsequent psychological disorder.(38)

The limited data available do not allow definite conclusions about cross-cultural or cross-national variability in pain syndromes. Some studies have documented cross-national or cross-cultural differences based on small samples of patients treated for pain syndromes—often in specialist pain clinics. (41,4 aDd 43) The WHO primary care survey(34> included both the largest number of patients with pain syndromes as well as the broadest range of culture and economic development. In that study, both the prevalence and correlates of persistent pain varied widely across sites. No clear pattern (e.g. a higher prevalence in developing or non-Western countries) was evident.

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