What is the diagnosis for a patient with psychologically driven pain?

Somatic Symptom Disorder and Related Conditions

When patients present with pain that has no identifiable physiological cause after appropriate medical workup, the diagnosis is typically a somatic symptom disorder or related condition, with psychological factors playing a central role in pain perception and perpetuation. 1

Understanding the Diagnosis

The pain these patients experience is real and physiologically mediated through the brain's pain processing networks, not imaginary or fabricated. 1 The key diagnostic features include:

• Pain persists despite negative medical workup including imaging, laboratory tests, and specialist evaluations that fail to identify structural or inflammatory causes 1
• Psychological factors drive pain amplification through mechanisms including central nervous system-visceral interactions, lowered pain thresholds, heightened body vigilance, and sympathetic nervous system activation 1, 2
• Pain catastrophizing is often present, characterized by viewing pain as threatening despite lack of serious pathology, and feelings of helplessness over managing the pain 1

Specific Diagnostic Categories

Somatic Symptom Disorder

This diagnosis applies when patients present with one or more somatic symptoms (like pain) that are distressing or result in significant disruption of daily life, with excessive thoughts, feelings, or behaviors related to the somatic symptoms. 1 Studies show this accounts for approximately 9.2% of chest pain presentations in emergency departments. 1

Noncardiac Chest Pain

For chest pain specifically, when cardiac workup is negative, the diagnosis often involves psychological syndromes including anxiety, panic disorder, depression, somatoform disorder, or cardiophobia. 1 In low-risk chest pain patients without cardiac disease, depression and anxiety each exceed coronary artery disease by almost 10-fold. 1

Pain in Disorders of Gut-Brain Interaction

For gastrointestinal pain, the diagnosis falls under disorders of gut-brain interaction (DGBI), where chronic pain results from complex interactions between peripheral nerve impulses and brain networks that amplify the painful experience out of proportion to actual sensory input. 1

Key Diagnostic Pitfalls to Avoid

Never diagnose psychologically-driven pain before completing appropriate medical workup to exclude serious pathology including cardiac disease, pulmonary embolism, aortic dissection, inflammatory conditions, or malignancy. 1, 2 This is particularly critical because:

• Some life-threatening conditions can present with atypical symptoms 2
• Patients may have both organic disease and psychological amplification of symptoms 1
• Premature attribution to psychological causes damages the therapeutic relationship and delays appropriate treatment 1

Associated Clinical Features

Patients with psychologically-driven pain commonly demonstrate:

• Multiple somatic complaints beyond the primary pain symptom 1
• High healthcare utilization with extensive, repetitive testing and low referral rates to mental health services (less than 10% of cases) 1
• Comorbid psychological conditions including anxiety (81% in pediatric chest pain studies), panic disorder (28%), depression, and post-traumatic stress 1
• Pain-related behaviors including hypervigilance (constantly checking for pain), avoidance of activities due to fear of symptom occurrence, and pain solicitation from support systems 1
• Psychological inflexibility with overfocusing on finding a cause or solution, which interferes with pain acceptance and treatment response 1

Evidence-Based Management Approach

Referral to cognitive-behavioral therapy is the primary treatment recommendation (Class 2a recommendation from the American College of Cardiology). 1 The evidence shows:

• Cognitive-behavioral therapy reduces chest pain frequency by 32% in patients with non-cardiac chest pain over 3 months 1
• Antidepressants and anxiolytics have mixed evidence for efficacy in treating psychologically-driven pain 1
• Opioids should never be prescribed for chronic pain related to disorders of gut-brain interaction due to ineffectiveness, risk of narcotic bowel syndrome (occurs in 6% of long-term opioid users), and potential for opioid use disorder 1

Neuromodulator Medications

When pain is severe, chronic, or associated with functionally impairing anxiety or depression, consider:

• Low-dose tricyclic antidepressants as first-line neuromodulators 1
• Serotonin-norepinephrine reuptake inhibitors (SNRIs) as alternative first-line agents 1
• Mirtazapine for patients with comorbid sleep disturbance 1
• Higher doses of SSRIs or bupropion only if significant psychiatric comorbidity (anxiety/depression) is present 1

Patient Education Framework

Explain to patients that:

1. Their pain is real, not imaginary, and results from how the brain processes sensory signals 1
2. The brain can amplify normal sensations based on prior experiences with infection, injury, or inflammation, continuing to scan for threats even when none exist 1
3. Factors that initiated the problem (infection, surgery, stressful event) are not always the same as those perpetuating it 1
4. Pain is modifiable through changes in how one approaches and responds to pain 1

Monitoring and Reassessment

• Establish baseline pain levels using validated instruments (Visual Analog Scale, pain indices) to measure treatment effects 1
• Periodically reassess treatment efficacy and stop ineffective treatments 1
• Implement multimodal pain management including pharmacological approaches, stress management, and manual therapy when available 1
• Continually assess pain management effectiveness due to its importance for quality of life 1