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13 Articles in Volume 18, Issue #6
Advice for the Advanced Practice Provider
Authorities’ Use of Big Data May Harm—or Help—Your Chances of Investigation
Considering Comorbidities When Selecting Medications (Part 2)
Gaps in the Pharmacist’s Pain Management Role
How can cyproheptadine manage complicated chronic pain cases?
Letters to the Editor: Trackable Pills; Buprenorphine; CRPS Diagnosis
Managing Opioid Use Disorder
Mobile Trackers and Digital Therapeutics
New Insights in Understanding Chronic, Central Pain
Nocebo Effects: How to Prevent them in Patients
Polarizing Topics in Chronic Pain
The Fight to End Peripheral Neuropathy
Urine Drug Monitoring

Polarizing Topics in Chronic Pain

A review of the less reported DSM-5 categories.
Page 1 of 3

Despite numerous studies documenting a strong association between chronic pain and psychopathology,1 there is still scant research into certain related mental health categories, such as neurodevelopmental, feeding and eating, elimination, sexual dysfunction, gender dysphoric, paraphilic, and “process” or behavioral addictive disorders. Some of these mental conditions are less polarizing, or “taboo,” than they were in the past while others are considered more opposing than ever. Even though these disorders seem very different, they all may bring discomfort to patients when discussed. The following summary describes these conditions according to the most recent edition of the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM-5),2 and provides insights into their relationship with pain as well as available treatments for each. Table I provides the prevalence rates of these disorders.

Neurodevelopmental Disorders

Neurodevelopmental disorders categorized in DSM-5 include intellectual disability, communication, autism spectrum, attention deficit/hyperactive, motor disorders, and specific learning disorders.2-4 Diagnostic criteria for intellectual disability (previously termed mental retardation) include deficits in cognitive capacity beginning in the developmental period. Communication disorders include language, speech sound, childhood-onset fluency (stuttering), and social (pragmatic) communication disorders. Autism spectrum disorder encompasses autism, Asperger’s, childhood disintegrative, and pervasive developmental disorders, and is characterized by deficits in social communication and social interaction, and restricted repetitive behaviors, interests, and activities. Attention-deficit/hyperactivity disorder (ADHD) diagnostics have remained unchanged since DSM-IV, but the condition was moved into the neurodevelopmental disorders chapter of DSM-5 to reflect brain developmental correlates. Motor disorders include developmental coordination, stereotypic movement, Tourette’s, persistent (chronic) motor or vocal tic, provisional tic, and other tic disorders. Specific learning disorders combine reading (dyslexia), mathematics (dyscalculia), written expression, and so forth.2

Chronic pain has been shown to be a significant problem for individuals with intellectual disabilities.5 Caregivers in one study of chronic pain in adults with an intellectual disability reported that 15.4% of their sample experienced chronic pain for an average of 6.3 years. Significantly more females than males reported pain, although age, communication ability, and level of intellectual disability were not found to be associated with pain.

The presence of pain was also associated with other disabilities/healthcare problems, including physical disability, cerebral palsy, or problems with mobility. In addition, the study investigated the impact of pain on emotional well-being. Caregivers reported that the chronic pain led to anxiety, self-injury, depression, and challenging behaviors.5

Feeding and Eating Disorders

Disorders categorized underfeeding and eating include pica, rumination, avoidant/restrictive food intake, anorexia nervosa, bulimia nervosa, and binge-eating disorders.2,6-10 Pica and rumination disorder have been revised in DSM-5 for clarity and to indicate that the diagnoses may be made for individuals of any age. Avoidant/restrictive food intake disorder is a broad category intended to capture those who substantially restrict their food intake and experience significant associated physiological or psychosocial problems but do not meet criteria for other eating disorders. Anorexia nervosa has remained conceptually unchanged from DSM-IV, including that the individual must be at a significantly low body weight for their developmental stage. Bulimia nervosa also remains unchanged with the patient engaging in binge eating and inappropriate compensatory behavior once a week. Binge-eating disorder requires the person to engage in a minimum average frequency of binge eating at least once weekly over the prior 3 months. Of note, lifetime bulimia nervosa and binge eating disorders have significant associations with numerous physical conditions.2 The odds of bulimia nervosa and binge eating disorder predicting musculoskeletal pain (1.6 to 2.8) and other pain conditions (1.9 to 2.8) are generally comparable.11 There is no research currently available linking the other feeding and eating disorders to chronic pain.

Elimination Disorders

Elimination disorders listed in DSM-5 include enuresis and encopresis; primarily affecting children, their descriptions essentially remain unchanged from previous DSM versions.2 Along with these conditions, gastrointestinal symptoms, like constipation, may also be experienced by some patients. Functional urological and gastrointestinal disorders are interrelated and characterized by a chronic course and considerable treatment resistance. A study led by Walker et al. investigated whether functional abdominal pain among adolescents predicted functional gastrointestinal disorders with chronic pain in adults.12 The study found that two-thirds of adolescents with a high pain dysfunctional profile would later develop a pain-related gastrointestinal disorder.12 These adolescents were characterized by low perceived pain coping efficacy and high levels of negative affect, pain catastrophizing, and functional disability.12 The most frequent problem in adults in urologic practice is recurrent or chronic genital pain with no physical cause.13 Despite the frequency of the problem, very little has been written about genital pain and various approaches to treatment have been generally ineffective.13

Last updated on: September 5, 2018
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Anger Expression & Chronic Pain
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