Persistent Somatoform Pain Disorder F454

The main complaint in this disorder is of persistent, severe, and distressing pain, which cannot be explained fully by any bodily process or physical disorder. Furthermore, this occurs in association with emotional conflict or psychosocial problems that are considered to be the main cause.9 In a different diagnostic classificatory schedule, DSM-IV,10 the diagnosis of pain disorder can be made as long as "psychological factors are judged to have an important role in the onset, severity, exacerbation or maintenance of the pain.'' It can be seen that the threshold for a diagnosis of pain disorder in DSM-IV is lower than in ICD-10.

Particular skills are required to manage these patients. An agenda should be set early on, with a limit on investigations. It is essential to allocate one single treating doctor, who communicates directly with all other therapists and advises on all proposed treatment.

There are two established treatments for this condition, antidepressants and CBT. Antidepressants that inhibit both serotonin and norepinephrine uptake, such as amitriptyline and venlafaxine, are more effective than the SSRI group of antidepressants.19,25 [II] CBT has been shown to be of definite value in those who have reached the stage to accept that medical or surgical interventions are not indicated.34[I] The value of biofeedback is yet to be established, despite suggestions that this treatment may be valuable in chronic headache.65[II]

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