DSM and pain I (1952) I (1952) Psychophysiological disorders“ Psychophysiological disorders“ “Psychoneurotic Disorders” “Psychoneurotic Disorders” II (1968) II (1968) Hysterical neurosis Hysterical neurosis
DSM and pain III (1980) III (1980) Psychogenic Pain Psychogenic Pain “incompatible” or “INXS” “incompatible” or “INXS” Etiologically related Etiologically related III-R (1987) III-R (1987) Somatoform pain Somatoform pain Dropped etiology part Dropped etiology part
DSM and pain IV IV Pain Disorder Pain Disorder Pain=predominant focus Pain=predominant focus Substantial distress/impairment Substantial distress/impairment Psych factors “have role” Psych factors “have role” Onset or expression Onset or expression Not malingering/factitious disorder Not malingering/factitious disorder
Problems with DSM Utility Utility How to judge? How to judge? Physical versus Psychological Physical versus Psychological Etiology Etiology DSM-IV DSM-IV Mind-body dichotomy remains Mind-body dichotomy remains Division of pain based on this. Division of pain based on this.
DSM-IV pain tested Psychological vs. Psychological+Medical Distinction Psychological vs. Psychological+Medical Distinction No difference on No difference on Pain measures Pain measures Intensity Intensity Type Type Level of disability Level of disability (Aigner et al, Compr Psychiatry 1999)
IASP 5 axis system I. Anatomical region II. Organ system III. Temporal characteristics/patterns IV. Intensity, time since onset V. Etiology
IASP Psychological pain Psychological pain “Pain specifically attributable to the thought process, motional state, or personality of the patient in the absence of an organic or delusional cause or tension mechanism.” “Pain specifically attributable to the thought process, motional state, or personality of the patient in the absence of an organic or delusional cause or tension mechanism.”
Other approaches Dimensional Dimensional Take into account various aspects of pain Take into account various aspects of pain Objective findings/physical etiology Objective findings/physical etiology Perceptual influences Perceptual influences Presentation Presentation
Pharmacologic Pharmacologic Psychological Psychological Other somatic treatments Other somatic treatments Importance of Multimodal Importance of Multimodal Cormorbid treatments Cormorbid treatments Role of C/L Psychiatrist Role of C/L Psychiatrist
Pharmacological Treatment “True” Analgesics “True” Analgesics Everything Else Everything Else “Yes Billy, but Mr. Phillips pushes legal drugs.”
“True” Analgesic NSAIDS NSAIDS Opioids Opioids Local agents Local agents
NSAIDS Mechanism Mechanism Indication Indication Side effects Side effects
NSAIDS Standard Standard Acetaminophen Acetaminophen Ketorolac Ketorolac COX-2 inhibitors COX-2 inhibitors
Opioids Mechanism of action Mechanism of action Indication Indication Side effects Side effects Common Common Uncommon but problematic Uncommon but problematic
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