Pain disorder consists of pain in one or more anatomic sites severe enough to warrant clinical attention and to cause clinically significant distress or impairment of social, occupational, or other functioning. Mental factors are judged to have an important role in the onset, severity, exacerbation, or maintenance of symptoms, but the pain is not intentionally produced or feigned. Some patients may recall an initial stimulus that produced acute pain. Diagnosis is based on history. Treatment begins by establishing a consistent, supportive physician-patient relationship; drug therapy and psychotherapy can also help.
The proportion of people whose chronic pain is strongly influenced by mental factors is unknown. However, pain is rarely, if ever, “all in a patient's head”; apperception of pain involves sensory and emotional components (see Pain). In some cases, both mental and physical factors have important roles in the onset, severity, exacerbation, or maintenance of the pain.
Symptoms and Signs
Physical pain may occur in mood and anxiety disorders, but in pain disorder, pain is a major complaint and is severe enough to warrant clinical attention. Any body part may be affected; the back, head, abdomen, and chest are commonly involved. The pain may be acute or chronic (≥ 6 mo).
Diagnosis is based on history after excluding a physical disorder that would adequately explain the pain and its onset, severity, duration, and maintenance and the degree of disability. Detection of mental or social stressors may help explain the disorder.
A thorough medical evaluation, followed by reassurance, may be sufficient. Sometimes, empathetically pointing out a relationship with an obvious mental or social stressor is effective. However, many patients develop chronic problems and are difficult to treat. They may visit many physicians with an expressed wish to find a cure and are at risk of developing dependence on opioids or benzodiazepines.
For acute pain, the primary goal is to relieve the pain with analgesics, most commonly NSAIDs and acetaminophen. Antidepressants and anticonvulsants are sometimes added.
For chronic pain (lasting ≥ 6 mo), it is important to not only manage the pain but also to reduce the pain's effect on the patient's life and functioning. Psychotherapy and various drugs (eg, analgesics, antidepressants, anticonvulsants) may help. Opioids can be safely and effectively used for chronic pain, although some patients abuse and become dependent on them, especially those with a history of substance abuse and dependence. All patients need ongoing monitoring for abuse and dependence. Thorough regular reevaluations by a caring, empathetic physician, who remains alert to the possibility of a new significant physical disorder while protecting the patient from unnecessary tests or procedures, offers hope for long-term palliation.
Last full review/revision June 2008 by Katharine A. Phillips, MD
Content last modified November 2013