DSM-III

In DSM-III, this disorder is called Psychogenic Pain Disorder

Diagnostic Criteria

A. Severe and prolonged pain is the predominant disturbance.

B. The pain presented as a symptom is inconsistent with the anatomic distribution of the nervous system; after extensive evaluation, no organic pathology or pathophysiological mechanism can be found to account for the pain; or, when there is some related organic pathology, the complaint of pain is grossly in excess of what would be expected from the physical findings.

C. Psychological factors are judged to be etiologically involved in the pain, as evidenced by at least one of the following:

  1. a temporal relationship between an environmental stimulus that is apparently related to a psychological conflict or need and the initiation or exacerbation of the pain
  2. the pain's enabling the individual to avoid some activity that is noxious to him or her
  3. the pain's enabling the individual to get support from the environment that otherwise might not be forthcoming

D. Not due to another mental disorder.

Differential Diagnosis

Organic pain

The dramatic presentation of organic pain, which may seem excessive to an observer because of only slight physical findings, is not sufficient for diagnosing the disorder, and may be only a function of histrionic personality traits or a cultural style of communication.

Somatization Disorder, Depressive Disorders, and Schizophrenia

Individuals with Somatization Disorder, Depressive Disorders, or Schizophrenia may complain of various aches and pains, but the pain rarely dominates the clinical picture, and Psychogenic Pain Disorder should not be diagnosed if the pain is due to any other mental disorder.

Malingering

In Malingering, the symptom production is under the individual's voluntary control, and is in pursuit of a goal that is obviously recognizable given the individual's environmental circumstances. For example, an individual with Opioid Dependence complains of pain in order to obtain opioids.

Tension headaches

The pain associated with muscle contraction headaches ("tension headaches") is not to be diagnosed as Psychogenic Pain Disorder because there is a pathophysiological mechanism that accounts for the pain.

Complete disappearance of pain through suggestion, hypnosis, or narcoanalysis suggests Psychogenic Pain Disorder. Temporary improvement due to suggestion has little diagnostic value since it may also occur in true physical illness.

DSM-IV

Diagnostic Criteria

A. Pain in one or more anatomical sites is the predominant focus of the clinical presentation and is of sufficient severity to warrant clinical attention.

B. The pain causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

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

D. The symptoms or deficit is not intentionally produced or feigned (as in Factitious Disorder or Malingering).

E. The pain is not better accounted for by a Mood, Anxiety, or Psychotic Disorder and does not meet criteria for Dyspareunia.

Record as follows:

  • Pain Disorder Associated With Psychological Factors: psychological factors are judged to have the major role in the onset, severity, exacerbation, or maintenance of the pain. (If a general medical condition is present, it does not have a major role in the onset, severity, exacerbation, or maintenance of the pain.) This type of Pain Disorder is not diagnosed if criteria are also met for Somatization Disorder.
  • Pain Disorder Associated With Both Psychological Factors and a General Medical Condition: both psychological factors and a general medical condition are judged to have important roles in the onset, severity, exacerbation, or maintenance of the pain. The associated general medical condition or anatomical site of the pain is recorded.

Specify if:

  • Acute: duration of less than 6 months
  • Chronic: duration of 6 months or longer

Note: The following is not considered to be a mental disorder and is included here to facilitate differential diagnosis.

  • Pain Disorder Associated With a General Medical Condition: a general medical condition has a major role in the onset, severity, exacerbation, or maintenance of the pain. (If psychological factors are present, they are not judged to have a major role in the onset, severity, exacerbation, or maintenance of the pain.)

Subtypes and Specifiers

Subtypes

Pain Disorder Associated With Psychological Factors

This subtype is used when psychological factors are judged to have the major role in the onset, severity, exacerbation, or maintenance of the pain. In this subtype, general medical conditions play either no role or a minimal role in the onset or maintenance of the pain. This subtype is not diagnosed if criteria for Somatization Disorder are met.

Pain Disorder Associated With Both Psychological Factors and a General Medical Condition

This subtype is used when both psychological factors and a general medical condition are judged to have important roles in the onset, severity, exacerbation, or maintenance of the pain. The anatomical site of the pain or associated general medical condition is recorded.

Pain Disorder Associated With a General Medical Condition

This subtype of Pain Disorder is not considered a mental disorder. It is listed in this section to facilitate differential diagnosis. The pain results from a general medical condition, and psychological factors are judged to play either no role or a minimal role in the onset or maintenance of the pain.

Specifiers

For Pain Disorder Associated With Psychological Factors and Pain Disorder Associated With Both Psychological Factors and a General Medical Condition, the following specifiers may be noted to indicate the duration of the pain:

Acute

This specifier is used if the duration of the pain is less than 6 months.

Chronic

This specifier is used if the duration of the pain is 6 months or longer.

Differential Diagnosis

Somatization Disorder, Dyspareunia, and Conversion Disorder

Pain symptoms are included in the diagnostic criteria for Somatization Disorder. If the pain associated with psychological factors occurs exclusively during the course of Somatization Disorder, an additional diagnosis of Pain Disorder Associated With Psychological Factors is not made. Similarly, if the pain presentation meets criteria for Dyspareunia (i.e., pain associated with sexual intercourse), an additional diagnosis of Pain Disorder is not given. Pain complaints may be prominent in individuals with Conversion Disorder, but by definition, Conversion Disorder is not limited to pain symptoms.

Other mental disorders

Pain symptoms are common associated features of other mental disorders (e.g., Depressive Disorders, Anxiety Disorders, Psychotic Disorders). An additional diagnosis of Pain Disorder should be considered only if the pain is an independent focus of clinical attention, leads to clinically significant distress or impairment, and is in excess of that usually associated with the other mental disorder.

Factitious Disorder and Malingering

Pain symptoms may be intentionally produced or feigned in Factitious Disorder or Malingering. In Factitious Disorder, the motivation is to assume the sick role and to obtain medical evaluation and treatment, whereas more obvious goals such as financial compensation, avoidance of duties related to military service or incarceration, evasion of criminal prosecution, or obtaining drugs are apparent in Malingering.

DSM-5

See Somatic Symptom Disorder

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