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FREE BOOK CHAPTER: What Is Pain? (From 'A Practical Guide to Chronic Pain Claims' by Pankaj Madan)

22/06/17. The International Association for the Study of Pain (IASP) defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”.

There is no unanimity on the definition of “pain” but the consensus of medical opinion uses this IASP definition. Until 1979 there was no published definition. The key to understanding the definition is to note that firstly, whilst most patients with pain had tissue damage, the definition embodied the patients who had no identifiable tissue damage but nevertheless experienced pain.

Pain is an experience and therefore it is to a degree, subjective. Under the accepted medical IASP definition of pain, there is no pain which is imagined rather than real because pain is an experience.

It is important to remember that most pain is not chronic at all but transient. Even pain which is not transient usually resolves. Pain serves as a biological reminder of the dangers of the world in which we live and serves a useful function to keep us safe from danger or to alert us to dysfunction or disease within the body.

As pain is an experience it is not surprising that the attempts to classify and define pain have been made by both the World Health Organisation and the American Psychiatric Association. The World Health Organisation produce the International Classification of Disorders currently in its 10th edition. This is the so called “ICD10”.

The American Psychiatric Association produce the Diagnostic and Statistical Manual of Mental Disorders, now in its fifth Edition commonly referred to as “DSM V”

The ICD10 Classification is the one most commonly used in the UK. It provides a classification of Pain Disorder and Persistent Somatoform Pain Disorder. The pain is a persistent, severe and distressing pain that cannot be fully explained by a physiological process or physical disorder. Traditional thinking is that the pain is presumed to be of a psychological origin.

Under the former DSM IV criteria, the word “somatoform” was dropped. The key point was that the pain could not be intentionally produced or feigned. There were two principal disorders:

pain disorder associated with psychological factors,”

And

pain disorder associated with both psychological factors and a general medical condition.”

In this condition a physical condition may be present but not sufficient to account for the degree of pain experienced. Both psychological factors and a general medical condition are judged to have important roles in the onset, severity, exacerbation, or maintenance of the pain.

The latest DSM V Criteria has caused a degree of controversy in the psychiatric world. This now has a category called “Somatic Symptom Disorder” thereby removing four criteria of “somatisation Disorder”, Hypochondriasis, Pain Disorder and “Undifferentiated Somatoform Disorder”.

Patients must complain of at least one somatic symptom that is distressing or disruptive of their daily lives.

The Claimant must have at least one of the following:-

  • emotional/cognitive behavioural disturbances:

  • high levels of health anxiety,

  • disproportionate and persistent concerns about the medical seriousness of the ‘symptoms,’ and

  • an excessive amount of time and energy devoted to the symptoms and health concerns.

The duration of symptoms and later concerns must have lasted for at least six months.”


Triggers for Chronic Pain

There are three principle triggers for “Chronic Pain”. Firstly, it may be caused by a major or by a minor injury.

Secondly it can be a symptom of a painful or psychiatric medical condition not caused by a physical injury.

Thirdly, it may arise out of surgery or other deliberate medical intervention.

Unfortunately, the term “chronic pain” is not used consistently. It can refer to pain that has been present for a defined period of say 6 months or more or it can be a shortened term meaning “Chronic Pain Disorder”. There are two terms in use that we need to define, “Chronic Pain Disorder” and “Chronic Pain Syndrome”. They are not entirely the same.

Chronic Pain Disorder” is the presentation of combined physical and psychological changes which occur due to the presence of chronic pain.

Chronic Pain Syndrome” refers to persistent pain that usually has no identifiable source and is associated with abnormal illness behaviours, including expressions of pain, that are grossly disproportionate to any underlying cause.

It is hardly surprising that given such definitions and the adversarial system in which Claimants must prove their injury, and an age which brings considerable challenges in respect of the veracity of claims, that scepticism exists about the existence of Chronic Pain Disorder and Chronic Pain Syndrome.

As we will see there is a basis to chronic pain problems. It is not a fictitious condition. It very much occurs outside litigation and in the absence of discernible secondary gain factors but litigation also probably causes its own problems. The incidence of malingering or exaggeration in chronic pain cases within litigation approaches between 20 and 50% according to one study by Greve et Al conducted in 2009 but that is far short of all claims.

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