Last updated: Wed, Jul 31, 2024
Prior to DSM-III, which was issued in 1980, there was no separate diagnostic category for psychogenically-caused pain. DSM-III defined the psychogenic pain disorder with both physical and psychic criteria. Physically, the patient must have prolonged severe pain that was inconsistent with the known distribution of pain receptors (that is, differing from the dermatomes and myotomes), or without a detectable organic cause or physiologic explanation. Psychically, the patient must have had psychological factors involved in production of the pain. Adequate psychological evidence of this could include a traumatic event that preceded the pain; pain that allowed avoidance of unwanted responsibilities; or pain providing nurturance that otherwise would not have been available to the patient. These criteria forced the evaluator to make difficult physical and psychological judgments.1 2
(It may be unnecessary for me to point out that responsibilities become unwanted when they result in sufficient pain, and that people who are ill often need nurturance.)
Beginning with DSM-IV and continuing through DSM-IV-TR, the disorder has been renamed simply "pain disorder." The criteria are now: 1) the pain must be the main focus of clinical findings; 2) it must cause significant distress and impairment, and 3) psychological factors must play an important role in the onset, severity, exacerbation, and maintenance of pain.
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A 2008 fMRI study compared patients with a diagnosis of pain disorder with normal patients (patients without pain problems). The study found distinct differences in brain activation between the two groups of patients in areas of the brain that are part of the brain's pain matrix. While this finding doesn't eliminate the possibility that behavioral or psychic factors can influence pain development and presentation, it certainly does suggest that the concept behind psychogenic pain is not the only one that may yield useful treatments. Authors included in pain textbooks have made the following comments about what is left of the concept of psychogenic pain:
...pain disorder has the quality of a "wastebasket diagnosis": It is given only when a patient's pain complaints seem to be affected by psychological factors and no specific Axis I diagnosis can be made.4
They [the DSM-IV-TR working group] wanted to have all the factors relevant to the onset or maintenance of the pain delimited and also to have a diagnostic category that would not require more training than the majority of DSM-IV users would be expected to have. These two requirements may not be compatible. Furthermore, no guidance is given in determining when psychological factors have a major role in pain or are considered important enough in the presence of a painful medical disorder to be coded as a separate mental disorder....Thus, the diagnosis continues covertly as a diagnosis of exclusion, with neither clear inclusion criteria nor implications for therapy....It may be more accurate and productive to think of somatization as a process present in varying degrees throughout the population rather than as a set of disorders affecting a small subset of the population.5
...this research indicates that the diagnosis of pain disorder has little validity in separating CPPs with explainable pain from those with unexplainable pain whose pain fits the conceptual paradigm behind this diagnosis.6