Pain Disorders

Pain Disorders Introduction

Mark D. Sullivan, M.D., Ph.D.

Determining where pain should fit within the domain of mental disorders has been controversial. Pain itself is not a mental disorder. Yet psychological factors and processes are an intrinsic and essential part of all clinical pain. The Subcommittee on Taxonomy of the International Association for the Study of Pain defines pain as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage...Activity induced in the nociceptor and nociceptive pathways by a noxious stimulus is not pain, which is always a psychological state". The Institute of Medicine's Committee on Pain, Disability, and Chronic Illness Behavior has stated that "the experience of pain is more than a simple sensory process. It is a complex perception involving higher levels of the central nervous system, emotional states, and higher order mental processes".

Despite the emphasis on psychological factors evident in these definitions, psychiatrists have traditionally played a limited role in the evaluation and management of many forms of pain. Psychiatrists have shown limited interest in patients with chronic pain problems. It has also been difficult to integrate psychiatrists into the management of patients with pain in a way that is acceptable and nonstigmatizing for these patients. In this chapter, I address the practical role of the psychiatrist in the management of pain. The recent changes made in the diagnostic nomenclature of pain disorders in DSM-IV (American Psychiatric Association 1994) are also briefly reviewed, and a broad overview of the assessment and the psychological and pharmacological management of chronic pain is presented. I include recommendations for further detailed reading on the treatment of specific pain syndromes at the end of the chapter.