Essential Feature of Pain Disorder

The predominant feature of somatoform pain disorder is the patient’s preoccupation with feelings of
severe and continuous pain for at least six months’ duration which has no adequate medical explanation.
The pain is often inconsistent with the anatomical distribution of the nervous system, but it may
sometimes closely mimic the pain distribution of a known disease.

Patients suffering from somatoform pain disorder often have long histories of medical and surgical care.
Also, patients have been found to visit many doctors to request medications for their feelings of pain and
their intent to insist their desire for surgery. Indeed, they are completely preoccupied with their pain, citing
it as the source of all their misery. Such patients often deny any emotional dysphoria and maintain that
their lives are blissful except for the pain. They frequently have a history of drug abuse or alcoholism.

Major depression is present in about 25 to 50 percent of all somatoform pain disorder patients, and
Dysthymia or depressive symptoms are reported in 60 to 100 percent of these patients. Some
investigators believe the chronic pain is almost always a variant of depressive disorder, that it is a masked
or somatized form of depression. The most prominent depressive symptoms in such pain patients are
anergia, anhedonia, decreased libido, insomnia, and irritability. Diurnal variation, weight loss, and
psychomotor retardation appear to be less common.

Perspectives:

Psychodynamic factors: Pain has unconscious meanings, which originate in infantile and childhood
experiences. Pain can function as a method of obtaining love, a punishment for wrongdoing, and a way of
expiating guilt and of atoning for an innate sense of badness. Among the defense mechanisms used are
displacement, substitution, and repression. Identification plays a role when the patient takes on the role of
an ambivalent love object who also had pain, such as a parent. The defense of symbolization is used
when the pain represents a nonarticulated affective equivalent.

Behavioral factors: Pain behaviors are reinforced when rewarded and are inhibited when ignored or
punished. For example, pain symptoms may become more intense when followed by the solicitous and
attentive behavior of others, monetary gain, or the successful avoidance of distasteful activities.

Interpersonal factors: Intractable pain has been conceptualized as a means for manipulation and gaining
advantage in interpersonal relationship-for example, to ensure the devotion of a family member or to
stabilize a fragile marriage. Such secondary gain is most important to patients with somatoform pain
disorder.

Neurological factors: The cerebral cortex can inhibit the firing of afferent pain fibers. Serotonin is probably
the main neurotransmitter in the descending inhibitory pathways, and endorphins also probably play a
role in the central modulation of pain. Endorphin deficiency seems to correlate with the augmentation of
incoming sensory stimuli. Particular patients may develop somatoform pain disorder, rather than other
psychiatric disorders, because of sensory and limbic structural or chemical abnormalities that predispose
them to experience pain.

Online:

Lianos, D., Pataki, C. (2008). “Somatoform Disorder, Pain.”

http://emedicine.medscape.com/article/914594-overview Sep 10, 2008

Somatoform Pain Disorder. http://www.nlm.nih.gov/medlineplus/ency/article/000922.htm