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Chronic Pain, Psychopathology, and DSM-5 Somatic Symptom Disorder

updated

One article on PainSci cites Katz 2015: Complete Guide to Low Back Pain

PainSci notes on Katz 2015:

The DSM ­IV included a mental disorder that mainly caused pain, but it was dropped from the DSM-5, basically because it was a bit of a Bigfoot of a diagnosis, blurry and elusive. There are too many sneaky ways to hurt, and it’s probably not a great idea to define undiagnosed pain as psychosomatic. There are just too many seemingly psychosomatic cases that eventually turn out to have a clear organic cause.

And, on the other side of the equation, there are ALSO too many cases that seem awfully pathological but never can be explained.

This summary is paraphrasing and slightly elaborating on a point made by Vlaeyen about back pain, who were in turn paraphrasing Katz et al.

original abstract Abstracts here may not perfectly match originals, for a variety of technical and practical reasons. Some abstacts are truncated for my purposes here, if they are particularly long-winded and unhelpful. I occasionally add clarifying notes. And I make some minor corrections.

Unlike acute pain that warns us of injury or disease, chronic or persistent pain serves no adaptive purpose. Though there is no agreed on definition of chronic pain, it is commonly referred to as pain that is without biological value, lasting longer than the typical healing time, not responsive to treatments based on specific remedies, and of a duration greater than 6 months. Chronic pain that is severe and intractable has detrimental consequences, including psychological distress, job loss, social isolation, and, not surprisingly, it is highly comorbid with depression and anxiety. Historically, pain without an apparent anatomical or neurophysiological origin was labelled as psychopathological. This approach is damaging to the patient and provider alike. It pollutes the therapeutic relationship by introducing an element of mutual distrust as well as implicit, if not explicit, blame. It is demoralizing to the patient who feels at fault, disbelieved, and alone. Moreover, many medically unexplained pains are now understood to involve an interplay between peripheral and central neurophysiological mechanisms that have gone awry. The new Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, somatic symptom disorder overpsychologizes people with chronic pain; it has low sensitivity and specificity, and it contributes to misdiagnosis, as well as unnecessary stigma. Adjustment disorder remains the most appropriate, accurate, and acceptable diagnosis for people who are overly concerned about their pain.

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