Psychiatric aspects of chronic pain

Chronic pain complaints often reflect or are influenced by psychiatric factors. Physicians commonly encounter "illness-affirming behaviors" in which patient complaints or symptoms go beyond what should be expected from a specific disease process. In this paper, I describe common psychiatric conditions that often feature pain as part of the illness: somatization disorder, hypochondriasis, factitious physical disorders, pain associated with psychological factors (new DSM-IV nomenclature), and malingering. These conditions can be distinguished based on the conscious awareness (or lack of awareness) of both motivation and symptom production. Other psychiatric disorders may strongly influence chronic pain without directly causing it--depression, anxiety, panic, and post-traumatic stress disorders. Except for malingering and factitious pain, chronic pain should be regarded as genuine. Effective management requires psychiatric as well as biological considerations.