Pain Disorder in DSM-IV

The primary diagnostic category addressing pain in DSM-IV is simply called "pain disorder." The diagnostic criteria for pain disorder, including its subtypes, are presented in Table 60-1.

This category represents a departure from the way pain was conceptualized in the previous editions of this manual. DSM-II (American Psychiatric Association 1968) had no specific diagnosis pertaining to pain. Painful conditions caused by emotional factors were considered part of the "psychophysiological disorders." DSM-III (American Psychiatric Association 1980) introduced a new diagnostic category for pain problems, "psychogenic pain disorder." To qualify for this diagnosis, a patient needed severe and prolonged pain inconsistent with neuroantomical distribution of pain receptors or without detectable organic etiology or pathophysiological mechanism. Related organic pathology was allowed, but the pain had to be "grossly in excess" of what was expected on the basis of physical examination. Acceptable evidence that psychological factors were involved in the production of the pain included the following: 1) a temporal relationship was found between pain onset and an environmental event producing psychological conflict, 2) pain appeared to allow avoidance of some noxious event or responsibility, and 3) pain promoted emotional support or attention the individual would not have otherwise received. It is important to note that this kind of evidence never proves that psychological factors have caused a pain complaint.

Difficulties in establishing that pain was psychogenic led to changes in the chronic pain diagnostic criteria in DSM-III-R (American Psychiatric Association 1987; Stoudemire and Sandhu 1987). In DSM-III-R, the diagnosis was renamed "somatoform pain disorder," and three major changes were made in the diagnostic criteria. The requirements for etiological psychological factors and lack of other contributing mental disorders were eliminated, and a requirement for "preoccupation with pain for at least 6 months" was added. In DSM-III-R, therefore, somatoform pain disorder became purely a diagnosis of exclusion. The diagnosis was made when medical disorders were excluded in a patient "preoccupied" with pain.