The true incidence of pain disorder is unknown, but some research suggests that it’s quite common. Pain disorder has no specific cause, but it may be related to severe psychological stress or internal conflict. The patient is not aware that psychological factors are central to the onset, severity, and exacerbation of the pain. The patient does not consciously create or fabricate the symptoms, and he’s not malingering.

Pain disorder is thought to be more common in women than in men and usually has an onset between ages 30 and 40.

Researchers are using positron emission tomography (PET) scanning and functional magnetic resonance imaging (fMRI) to explore the anatomy and metabolic activity of the brain during the experience of pain in order to understand it and develop better treatments.

The cardinal feature of pain disorder is a history of chronic, consistent complaints of pain without confirming physical disease. The patient’s history and physical may reveal:

• long history of evaluations and procedures at multiple settings

• multiple treatment without much pain relief

• familiarity with pain medications and tranquilizers and knowledge of correct dosages and administration routes

• impaired motor movements

• normal laboratory and diagnostic results

• pain that does not follow anatomic pathways

• absence of typical nonverbal signs of pain, such as grimacing or guarding (Sometimes such reactions are absent in the patient with chronic organic pain. Palpation, percussion, and auscultation may not reveal expected associated signs.)

• anger with practitioners because they have failed to relieve the pain

• anger with the suggestion that psychological factors may be impacting the patient’s experience of pain.

• Impaired work and school functioning

• Impaired family relationships

• Impaired social functioning

• Potential addiction to prescription pain medication

• Potential injury from undergoing multiple diagnostic tests and procedures

For characteristic findings in patients with this condition, see Diagnosing pain disorder.

In pain disorder, the goal of treatment is to decrease the pain and help the patient resume activities of daily living. Thus, long, invasive evaluations and surgical interventions are generally avoided. Treatment at a comprehensive pain center may be indicated. Cognitive behavioral therapy helps the individual to identify negative thoughts and behaviors and helps him develop strategies to manage his pain.

A continuing, supportive relationship with an understanding practitioner is essential for effective management; regularly scheduled follow-up appointments are helpful.

Additional supportive measures for pain relief may include:

• hot or cold packs

• exercise and physical therapy

• distraction techniques

• cutaneous stimulation with massage

• transcutaneous electrical nerve stimulation

• acupuncture

• meditation techniques

• relaxation techniques

• yoga.

•; Observe and record characteristics of the pain: severity, duration, and any precipitating factors.

• Provide a caring atmosphere in which the patient’s complaints are taken seriously and every effort is made to provide relief. This means communicating to the patient that you’ll collaborate on a plan of treatment, clearly stating the limitations.

• Don’t tell the patient that she’s imagining the pain or can wait longer for medication that’s due. Assess her complaints and help her understand what’s contributing to the pain.

• Develop a collaborative treatment plan to provide other comfort measures, such as repositioning or massage, relaxation techniques, and distraction when appropriate.

• Encourage the patient to maintain independence and normal daily activities despite pain.

• Refer the patient to a comprehensive pain control clinic.

• Consider psychiatric referrals; however, realize that the patient may resist psychiatric intervention, and don’t expect it to replace analgesic measures.

Between 2 and 6 million people in the United States are affected by panic disorder. The typical age of onset is late adolescence through the late 30s. Like other anxiety disorders, panic disorder may stem from a combination of genetic, environmental, or biological factors. Recent evidence indicates that alterations in brain biochemistry, especially in norepinephrine, serotonin, and gam-ma-aminobutyric acid activity, may contribute to panic disorder. Panic disorder is more common in individuals who have a childhood history of sexual or physical abuse, have suffered a severely traumatic event or accident, or have a severely ill loved one. It may also be triggered by severe childhood separation anxiety.

The patient with panic disorder typically complains of repeated episodes of unexpected apprehension, fear or, rarely, intense discomfort. These panic attacks may last for minutes or hours and leave the patient shaken, fearful, and exhausted. They may occur several times a week, sometimes even daily. Because the attacks occur spontaneously, without exposure to a known anxiety-producing situation, the patient generally worries between attacks about when the next episode will occur. This is referred to as anticipatory anxiety.

Physical examination of the patient during a panic attack may reveal signs of intense anxiety, such as:

• hyperventilation

• tachycardia

• trembling

• profuse sweating

• difficulty breathing

• digestive disturbances

• chest pain or pressure.

• Additional phobias

• Depression

• Suicidal thoughts

• Work and school problems

• Impaired social and family relationships

• Substance or alcohol abuse

For characteristic findings in patients with this condition, see Diagnosing panic disorder, page 116.

Because many medical conditions can mimic panic disorder, a thorough physical examination is necessary to rule out an organic basis for the symptoms. Diagnostic tests may include:

• serum glucose levels to rule out hypoglycemia

• urine levels of catecholamine and vanillylmandelic acid to rule out pheochromocytoma

• thyroid function tests to rule out hyperthyroidism

• electrocardiography, cardiac enzymes, and echocardiography to exclude myocardial infarction and other cardiac diseases

• urine and serum toxicology tests to check for psychoactive substances, such as alcohol, barbiturates, and amphetamines.

The goal of treatment is to eliminate all of the symptoms of panic disorder. Treatment is individual and may include:

• cognitive behavioral therapy to identify and change negative thoughts and behaviors

• supportive psychotherapy

• behavioral therapy, which works best when agoraphobia accompanies panic disorder because the identification of anxiety-inducing situations is easier.

• Stay with the patient until the attack subsides. If left alone, he may become even more anxious.

• Maintain a calm, serene approach. Statements such as “I won’t let anything here hurt you,” and “I’ll stay with you,” can assure the patient that you’re in control of the immediate situation. Avoid giving him insincere expressions of reassurance.

• The patient’s perceptual field may be narrowed, and excessive stimuli may cause him to feel overwhelmed. Dim bright lights or raise dim lights as needed.

• If the patient loses control, move him to a smaller, quieter space.

• The patient may be so overwhelmed that he can’t follow lengthy or complicated instructions. Speak in short, simple sentences, and slowly give one direction at a time. Avoid giving lengthy explanations and asking too many questions.

• Allow the patient to pace around the room (provided he isn’t belligerent) to help expend energy. Show him how to take slow, deep breaths if he’s hyperventilating.

• Avoid touching the patient until you’ve established a rapport. Unless he trusts you, he may be too stimulated or frightened to find touch reassuring.

• Administer drugs as prescribed.

• During and after a panic attack, encourage the patient to express his feelings. Discuss his fears, and help him identify situations or events that trigger the attacks.

• Teach the patient relaxation techniques, and explain how he can use them to relieve stress or avoid a panic attack.

• Review with the patient any adverse effects of the drugs he’ll be taking. Caution him to notify the practitioner before discontinuing any drug because abrupt withdrawal could cause severe symptoms.

• Encourage the patient and his family to use community resources such as the Anxiety Disorders Association of America.

The cause of paraphilia is unknown, but multiple contributing factors have been identified. These include changes in the neurobiology and anatomy of the brain, abnormal hormonal levels, neurologic disorders, chromosomal abnormalities, poor socialization, and environment. For example, many people with these disorders come from dysfunctional families and have childhoods characterized by isolation and sexual, emotional, or physical abuse. Many individuals have poor social skills, and others suffer from personality or psychoactive substance use disorders.

The patient’s history will reveal the particular pattern of abnormal sexual behaviors associated with one of the eight recognized paraphilias.

• Impaired work and school function

• Impaired family and social function

• Legal problems and incarceration

• Substance and alcohol abuse

• Death from dangerous behavior such as autoasphyxiation

A paraphiliac has ongoing, intense, sexually arousing fantasies, urges, or behaviors involving various aberrant sexual expressions that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), recognizes eight paraphilias. The standard diagnostic criteria for paraphilias include not only specific criteria for each paraphilia but also general features. (See Diagnosing paraphilias.)

Sex offenders who have committed crimes may be required to undergo various diagnostic tests such as:

• sex hormone profiles

• sexual history and questionnaires

• physiological sexual preference testing.

Paraphilias require mandatory treatment when the patient’s sexual
preferences result in socially unacceptable, harmful, or criminal behavior. Depending on the paraphilia, treatment may include:

• individual psychotherapy

• group therapy

• cognitive behavioral therapy and restructuring (to change deviant sexual interests and behavior and break down the individual’s justification for sexual victimization)

• pharmacologic therapy to suppress deviant sexual urges and behavior and prevent further victimization.

• Use a nonjudgmental approach when dealing with the patient.