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Pain Disorder

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Pain as a Somatoform disorder:

Creed and Barsky ([1]) performed a systematic review of the epidemiology of somatisation disorder and hypochondriasis.

They found that in population-based studies the prevalence of somatisation disorder and hypochondriasis was too low to examine associated features reliably. They noted a close relationship with anxiety and depressive disorders, with a linear relationship between numbers of somatic and other symptoms of distress in several studies, including longitudinal studies.

They concluded,

"On existing evidence, somatisation disorder and hypochondriasis cannot be regarded as definite psychiatric disorders. There is some evidence that numerous somatic symptoms or illness worry may be associated with impairment and high health care utilisation in a way that cannot be solely explained by concurrent anxiety and depression, but further research using population-based samples is required."

In patients attending general medical clinics the prevalence of either somatization disorder or hypochondriacal disorder is as high as 12%, ([2]) as compared with a community prevalence of 0.1-0.7% ([3]).

The Psychiatric disorder classification DSM-IV (1994) defines Pain Disorder as a somatoform disorder, and one in which pain is the predominant focus of clinical attention, and psychological factors are judged to have an important role in its onset, severity and progression (307.80).

Pain causes clinically significant distress or impairment in social, occupational or other important functional areas.

However, importantly, it is stipulated that symptoms are not deliberately produced or feigned.  The pain is not accounted for by a mood or psychotic disorder. General medical conditions may also be present in the absence of objective findings.

Pain disorder may be associated with a general medical condition (307.89). In this case, the medical condition has a major role in the onset, severity and course of the pain. Particular categories include low back pain (724.2), sciatic (724.3) pelvic (625.9) and headache (784.0). Dyspareunia is also identified as a separate condition.

Ballas and Staab stated,

"Chronic pain that exceeds identifiable medical pathology was given the new diagnosis of somatoform pain disorder in DSM-IV, but it is not certain that this separation from other somatoform disorders has yielded any new insights into the etiology or treatment of chronic pain."

The authors propose that

"grouping somatic symptoms together by system (e.g. visceral, chronic pain) allows an association to specific Axis I disorders."

[1] Creed F, Barsky A. J Psychosom Res. 2004 Apr;56(4):391-408. A systematic review of the epidemiology of somatisation disorder and hypochondriasis.

[2] van Hemert AM, Hengeveld MW, Bolk JH, Rooijmans HG, Vandenbroucke JP.  Psychol Med1993; 23:167 -73 Psychiatric disorders in relation to medical illness among patients of a general medical out-patient clinic

[3] Bhui K, Hotopf M. Br J Hosp Med 1997;58:145 -9 Somatization disorder.