Pain Disorders and the New DSM-5

By Robert G. Rassp. Esq.

“Pain is relevant to mental impairment, since mental illness may change the perception of pain, for example, making it the object of an obsession or a somatic (bodily) expression of an emotional problem. However, it can be extremely difficult to determine whether pain is a symptom of a mental impairment. Usually a multidisciplinary approach is required.” – Occupational Injuries and Illnesses (LexisNexis)

In May 2013, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) was published by the American Psychiatric Association. There are many changes in the names and diagnostic criteria of certain psychiatric disorders that are frequently encountered in work related injury cases. The diagnostic criteria for pain disorder that was included in the DSM-IV-TR has been eliminated in the DSM-5.

Instead, pain disorders are now included within a new diagnostic criteria called Somatic Symptom and Related Disorders. The common feature of this disorder category is that individuals have “somatic symptoms associated with significant distress and impairment.” The introduction to this new disorder includes the description of the diagnosis is to be made “on the basis of positive symptoms and signs (distressing somatic symptoms plus abnormal thoughts, feelings, and behaviors in response to these symptoms) rather than the absence of a medical explanation for somatic complaints.” (See DSM-5, p. 309.)

This is not to say that every pain disorder results in a mental diagnosis, let alone one that is described in the Somatic Symptom and Related Disorders category. Many pain disorders do have a medical explanation for symptoms, such as arachnoiditis from failed lumbar surgery, or complex regional pain syndrome (CRPS Type 1 or Type 2), which have independent medical diagnostic criteria of their own.

However, the DSM-5 authors agree that if there is a somatic component (as opposed to an objective explanation) for chronic pain, then the “somatic component adds severity and complexity to depressive and anxiety disorders and results in higher severity, functional impairment, and even refractoriness to traditional treatments.” (See DSM-5, p. 310.)

The DSM-5 authors also have included “psychological factors affecting other medical conditions” as part of the new rubric of Somatic Symptom and Related Disorders. The essential feature of psychological factors affecting other medical conditions “is the presence of one or more clinically significant psychological or behavioral factors that adversely affect a medical condition by increasing the risk for suffering, death, or disability.” (See DSM-5, p. 310.)

The term “chronic pain” is mentioned in the DSM-5 only a few times, including on page 813 of the DSM-5, which states: “Some individuals with chronic pain would be appropriately diagnosed as having somatic symptom disorder, with predominant pain. For others, psychological factors affecting other medical conditions or an adjustment disorder would be more appropriate.” As was true in the DSM-IV TR, you have to read the specific diagnostic criteria for Somatic Symptom and Related Disorders, psychological factors affecting other medical conditions, and adjustment disorder to determine which diagnostic criteria is the most accurate in a given case.

Somatic Symptom and Related Disorders have three categories—A, B, and C—that provide the diagnosis. Category A requires “[o]ne or more somatic symptoms that are distressing or result in significant disruption of daily life” and requires the diagnostician to specify “with predominant pain.” Category B requires “[e]xcessive thoughts, feelings or behaviors related to the somatic symptoms” as manifested by at least one of the following: “…[d]isproportionate and persistent [severe symptoms lasting for more than 6 months] thoughts about the seriousness of one’s symptoms”; “…[p]ersistently high level of anxiety about health or symptoms”; or “…[e]xcessive time and energy devoted to these symptoms or health concerns.” The Category B symptoms must be described as mild, moderate or severe as defined on page 311 of the DSM-5. Category C requires somatic symptoms to last at least six months. (See DSM-5, p. 311.)

Attorneys will have to first determine whether there is any objective evidence of a pain disorder. If there is, then a mental disorder diagnosis may not be applicable, or one may exist concurrently with a pain disorder that is supported by objective evidence, e.g., traumatic amputation of a hand. If there is not objective evidence of a pain disorder, then the diagnostic criteria on page 311 of the DSM-5 may apply. Counsel must make sure that a clinician who diagnoses a pain disorder evaluate the case using the Somatic Symptom Disorder criteria and, as the text advises, also evaluate a case using the diagnostic criteria separately for adjustment disorders and psychological factors affecting a medical condition. (See DSM-5, p. 322.)

Author’s Note: I plan to expand on this topic for purposes of California workers’ compensation. Specifically, Calif. Labor Code section 3208.3 requires that we use DSM-III or later nationally accepted diagnostic criteria publication. Does the DSM-5 trump the GAF score method of determining WPI in psyche cases? Stay tuned….

© Copyright 2013 LexisNexis. All rights reserved. This article is excerpted from the upcoming 2013 Edition of Occupational Injuries and Illnesses (LexisNexis).