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The Future of the DSM Pain Disorder Category

Key Words: Pain Disorder

TO THE EDITOR:  We read with interest the recent summary of the key questions and preliminary recommendations of the Conceptual Issues in Somatoform and Similar Disorders (CISSD) Project.¹ It was suggested that Pain Disorder be eliminated from the DSM because this classification system was intended to be "atheoretical and free of unsupported mechanisms (p 282)." Indeed, there is a problem with the DSM–IV formulation² because it does not specify explicit psychological factors that may be judged to have a major or important role in the onset, severity, exacerbation, or persistence of pain. However, the field of chronic pain research has been moving in the direction of mechanism-based classification,³ and there is voluminous literature on the effect of psychological factors in pain perception, behavior, and disability, including functional-imaging studies possibly addressing the psychophysiological interface.

Over the past 25 years, our group at the Toronto Western Hospital has gained extensive experience in the assessment and treatment of chronic pain. Physicians working in our clinic routinely use the DSM–IV Pain Disorder classification to provide medical, psychological, and other services to chronic-pain patients. We have published studies using the current classification system,^4,5 and there are other papers submitted for publication and many more in the preparation stage from our extensive patient series. At least in Ontario, this nosology is extensively used by medical, psychiatric, psychological, or other practitioners providing services to chronic-pain patients, as well as in courts of law.

In our view, the primary value in diagnosing a pain disorder is that it can direct treatment of chronic pain. For those with a pain disorder associated with psychological factors, it directs treatment away from possibly harmful or unnecessary medical interventions (e.g., surgery, escalating doses of opioids, useless blocks, etc.) and toward psychological, psychosocial, psychiatric, and multidisciplinary treatments. For those with a pain disorder associated with both psychological factors and a general-medical condition, medical interventions may be considered appropriate, but caution would be exercised, and interventions to address psychological factors may be also necessary.

We foresee multiple problems with the proposal to list any pain condition on Axis III, with concomitant psychiatric comorbidity, or under the rubric of a newly-formed category of Psychological Factors Affecting a General Medical Condition, on Axis I. As it stands, the CISSD proposal offers a solution possibly much worse than the current situation, because it lumps indiscriminately pain problems with a specific location (e.g., low back pain) or those with a nonspecific cluster of symptoms with no discrete or definable pathophysiology (e.g., fibromyalgia) together with entities that have discrete etiopathologic mechanisms (e.g., post-herpetic neuralgia or diabetic neuropathy) necessitating specialized treatments. We should stress that our group is in the process of further detailing our experience working with the DSM–IV classification system that we hope will contribute to changes codified in DSM–V.

REFERENCES

1. Kroenke K, Sharpe M, Sykes R: Revising the classification of somatoform disorders: key questions and preliminary recommendations. Psychosomatics 2007; 48:277–285[Abstract/Free Full Text]
2. Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. Washington, DC, American Psychiatric Association, 1994
3. Woolf CJ, Bennett GJ, Doherty M, et al: Towards a mechanism-based classification of pain? Pain 1998; 77:227–229[CrossRef][Medline]
4. Mailis-Gagnon A, Yegneswaran B, Lakha SF, et al: Pain characteristics and demographics of patients attending a university-affiliated pain clinic in Toronto, Canada. Pain Res Manage 2007; 12:93–99
5. Mailis-Gagnon A, Yegneswaran B, Nicholson K, et al: Ethnocultural and gender characteristics of patients attending a tertiary-care pain clinic in Toronto, Canada. Pain Res Manage 2007; 12:101–106

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