Are pain disorder and somatization disorder valid diagnostic entities?

Evaluating malingering in contested injury or illness

An interdisciplinary task force of physicians and neuropsychologists with advanced training in impairment and disability assessment provided a review of the literature on malingering in chronic pain, medical disorders, and mental/cognitive disorders. Our review suggests that treating health care providers often do not consider malingering, even in cases of delayed recovery involving work injuries or other personal injuries, where there may be a significant incentive to feign or embellish symptoms or delay recovery. This report discusses the implications of this issue and offers recommendations to evaluating physicians and other health care professionals.

[The psychosomatics of chronic back pain. Classification, aetiology and therapy]

An overview is given on the current classification, description and treatment of chronic pain with causally relevant psychological factors. It is based on the "practice guidelines on somatoform disorders" and on a thematically related meta-analysis. The classificatory problems, especially of the demarcation of somatoform and other chronic pain, are presented. Additional descriptive dimensions of the relevant psychosocial factors are: pain description, other organically unexplained pain- and non-pain-symptoms, anxiety and depression, disease conviction and illness behaviour, personality and childhood abuse. A modified psychotherapy for (somatoform) chronic pain is outlined. Finally, this aetiologically oriented psychosomatic-psychiatric approach is compared to psychological coping models for chronic pain.

Pain: psychiatric aspects of impairment and disability

Patients with chronic pain frequently experience a complex and convoluted journey through the health care system that often is unrewarding for all involved. As job satisfaction and financial security diminish during our economic recession, the impact of the disability epidemic becomes more profound. There often is no direct correlation between objective impairment and a patient's request for disability status. Injured workers maintained on workers' compensation may have an increased risk for developing chronic pain syndromes unresponsive to conventional treatments. These patients may have significant financial, psychosocial, and environmental reinforcement for maintenance of their disability and little incentive to return to work. Excessive pain behavior may lead to unnecessary diagnostic testing or invasive procedures and result in iatrogenic complications and prolonged disability. Patients with chronic pain syndrome who have not had psychosocial treatment may not be at maximum medical improvement. The purpose of this paper is to help the readership identify types of psychiatric, psychologic, and psychosocial issues that can coexist in patients with chronic pain who are applying for disability, and to help treating physicians avoid contributing to iatrogenic pain and disability by performing needless and potentially harmful procedures on patients who may be better served with an emphasis on psychiatric or psychologic care.

Topiramate as a treatment for pain in multisomatoform disorder patients: an open trial

Multisomatoform disorder (MSD), defined as 3 or more medically unexplained, currently distressing physical symptoms in addition to a long (> or =2 years) history of somatization, is a prevalent and disabling disorder in which few pharmacological trials have been referred to in the literature. Thirty-five MSD patients from the Somatoform Disorders Unit of the Miguel Servet University Hospital, Zaragoza, Spain, with pain of more than 3 months as the main symptom, were treated with topiramate in doses ranging from 300-400 mg/day. Patients were assessed at baseline and at one and six-months follow-up with the McGill Pain Questionnaire (MPQ), Pain Visual Analogue Scale (PVAS), Clinical Global Impresión (CGI), Global Assessment Functioning (GAF) and Hospital Anxiety Depression Scale (HADS). Eight patients (22.8%) dropped from the study, 3 due to side-effects and the other 5 because of lack of efficacy. All the outcome measures showed significant improvements at one-month except the ratings on the Hospital Anxiety Depression Scale. At six-months follow-up, clinician-rated assessments (CGI and GAF) still showed significant differences with baseline but less significant than at one-month follow-up. However, patient-rated assessments (MPQ and PVAS) did not present significant differences with baseline. Despite limitations of the study, topiramate seems to be effective in treating multisomatoform disorder patients with pain as the main symptom and a controlled randomized trial in these patients appears warranted. A possible "decay effect" in patient-rated assessments with any drug in somatoform disorder patients is discussed.

Pain management in the opioid-dependent patient

The opioid-dependent patient presents great challenges for pain management. These challenges are not limited to potential addictive behaviors. In contrast to the profound pain relieving effects of acute opioid intake, chronic opioid intake can promote a counterintuitive state of enhanced pain sensitivity. Multiple biologic mechanisms inducing opioid tolerance and hyperalgesia have recently been elucidated. The potential hyperalgesic state accompanying opioid dependence complicates pain management somewhat for acute pain and cancer pain, but it especially does so for chronic pain. Guidelines for treatment of opioid dependence in the pain patient are proposed. Treatment oriented toward the long term requires limit setting and psychologic support that go beyond simple medication management.