Dissociative Disorders And Trauma

Chapter 8

Discuss the relationship of trauma to dissociative amnesia and dissociative identity disorder.

Schizophrenia Chapter 13

Review the changes in the diagnosis of schizophrenia that have occurred historically and the changes in the current definition due to the DSM 5 publication. How has brain research advanced the understanding of schizophrenia?

8 somatic symptom and dissociative disorders

learning objectives 8

·  8.1 What are somatic symptom disorders?

·  8.2 What is illness anxiety disorder?

·  8.3 What is conversion disorder (functional neurological symptom disorder)?

·  8.4 What is the difference between a factitious disorder and malingering?

·  8.5 What are the primary features of dissociative disorders?

·  8.6 What is depersonalization/derealization disorder?

·  8.7 What is dissociative amnesia?

·  8.8 What is dissociative identity disorder?

Have you ever had the experience, particularly during a time of serious stress, when you felt like you were walking around in a daze or like you just weren’t all there? Or have you known people who constantly complained about being sure they had a serious illness even though medical tests failed to show anything wrong? Both of these are examples of mild dissociative and somatic symptoms experienced at least occasionally by many people. However, when these symptoms become frequent and severe and lead to significant distress or impairment, a somatic symptom or dissociative disorder may be diagnosed. Somatic symptom disorders (formerly known as  somatoform disorders ) and dissociative disorders appear to involve more complex and puzzling patterns of symptoms than those we have so far encountered. As a result, they confront the field of psychopathology with some of its most fascinating and difficult challenges. Unfortunately, however, we do not know much about them—in part because many of them are quite rare and difficult to study.

As we have seen ( Chapter 6 ), both somatic symptom and dissociative disorders were once included with the various anxiety disorders (and neurotic depression) under the general rubric neuroses, where anxiety was thought to be the underlying cause of all neuroses whether or not the anxiety was experienced overtly. But in 1980, when DSM-III abandoned attempts to link disorders together on the basis of hypothesized underlying causes (as with neurosis) and instead focused on grouping disorders together on the basis of overt symptomatology, the anxiety, mood, somatic symptom, and dissociative disorders each became separate categories.

Somatic Symptom and Related Disorders

The somatic symptom disorders lie at the interface between abnormal psychology and medicine. They are a group of conditions that involve physical symptoms combined with abnormal thoughts, feelings, and behaviors in response to those symptoms (APA,  2013 ).  Soma  means “body,” and somatic symptom disorders involve patterns in which individuals complain of bodily symptoms that suggest the presence of medical problems but where there is no obvious medical explanation that can satisfactorily explain the symptoms such as paralysis or pain. Despite a wide range of clinical manifestations, in each case the person is preoccupied with some aspect of her or his health to the extent that she or he shows significant impairments in functioning.

In DSM-IV a great deal of emphasis was placed on the idea that the symptoms were medically unexplained. In other words, although the patient’s complaints suggested the presence of a medical condition no physical pathology could be found to account for them (Allen & Woolfolk,  2012 ; Witthöft & Hiller,  2010 ). In DSM-5 this idea is less prominent, because it is recognized that medicine is fallible and that a medical explanation for symptoms cannot always be provided. Nonetheless, medically unexplained symptoms are still a key part of some disorders (such as conversion disorder) that we will describe later.

Equally key to these disorders is the fact that the affected patients have no control over their symptoms. They are also not intentionally faking symptoms or attempting to deceive others. For the most part, they genuinely believe something is terribly wrong with them. Not surprisingly, these patients are frequent visitors to their primary-care physicians.

Sometimes, of course, people do deliberately and consciously feign disability or illness. Also placed in the somatic symptoms and related disorders category in DSM-5 is factitious disorder. In  factitious disorder  the person intentionally produces psychological or physical symptoms (or both). Although this may strike you as strange, the person’s goal is to obtain and maintain the benefits that playing the “sick role” (even to the extent of undergoing repeated hospitalizations) may provide, including the attention and concern of family and medical personnel. However, there are no tangible external rewards. In this way factitious disorder differs from malingering. In  malingering  the person is intentionally producing or grossly exaggerating physical symptoms and is motivated by external incentives such as avoiding work or military service or evading criminal prosecution (APA,  2013 ; Maldonado & Spiegel,  2001 ).

In our discussion, we will focus on four disorders in the somatic symptom and related disorders category. These are (1) somatic symptom disorder; (2) illness anxiety disorder; (3) conversion disorder; and (4) factitious disorder.

Somatic Symptom Disorders

This new diagnosis includes several disorders that were previously considered to be separate diagnoses in DSM-IV. The old disorders of (1) hypochondriasis, (2) somatization disorder, and (3) pain disorder have all now disappeared from DSM-5. Most of the people who would in the past have been diagnosed with any one of these disorders will now be diagnosed with a somatic symptom disorder. In each case, individuals must be experiencing chronic somatic symptoms that are distressing to them and they must also be experiencing dysfunctional thoughts, feelings, and/or behaviors. In the past, the diagnosis required evidence that the symptoms were medically unexplained. However, as we noted earlier, this is no longer required for the diagnosis (in part because it is very difficult to prove something is medically unexplainable). Instead the focus in DSM-5 is on there being at least one of the following three features: (1) disproportionate and persistent thoughts about the seriousness of one’s symptoms; (2) persistently high level of anxiety about health or symptoms; and/or (3) excessive time and energy devoted to these symptoms or health concerns (Allen & Woolfolk, 2013). Symptoms have to have persisted for at least six months.

Patients with somatic symptom disorder are usually seen in medical clinics. They are more likely to be female, nonwhite, and less educated than are people with symptoms that have an obvious medical basis. Patients with somatic symptom disorder frequently engage in illness behavior that is dysfunctional, such as seeking additional medical procedures or diagnostic tests when the physician fails to find anything physically wrong with them. Whereas most of us are relieved when tests do not reveal any problems, people with somatic symptom disorder are likely to think something was missed and therefore seek help from another physician, leading to needlessly high medical bills due to unnecessary tests, hospitalizations, and even surgeries. High levels of functional impairment are common, as is comorbid psychopathology—especially depression and anxiety.

Research suggests that people with somatic symptom disorders tend to have a cognitive style that leads them to be hyper-sensitive to their bodily sensations. They also experience these sensations as intense, disturbing, and highly aversive. Another characteristic of such patients is that they tend to think catastrophically about their symptoms, often overestimating the medical severity of their condition.

In the following sections, we will be discussing hypochondriasis, pain disorder, and somatization disorder. It’s important to note that in DSM-5, these disorders were technically dropped and are now part of the somatic symptom disorders. However, the history of and the research on these disorders is still important to understand.

Hypochondriasis

DSM-5 criteria for: Somatic Symptom Disorder

·  A. One or more somatic symptoms that are distressing or result in significant disruption of daily life.

·  B. Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns as manifested by at least one of the following:

·  1. Disproportionate and persistent thoughts about the seriousness of one’s symptoms.

·  2. Persistently high level of anxiety about health or symptoms.

·  3. Excessive time and energy devoted to these symptoms or health concerns.

·  C. Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months).

Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association.

Approximately 75 percent of people previously diagnosed with hypochondriasis will be diagnosed with somatic symptom disorder in DSM-5 (APA,  2013 ). In  hypochondriasis  the person is preoccupied either with fears of contracting a serious disease or with the idea that of having that disease even though they do not. These very distressing preoccupations are thought to all be based on a misinterpretation of one or more bodily signs or symptoms (e.g., being convinced that a slight cough is a sign of lung cancer). Of course the decision that a complaint is hypochondriacal and is based on a misinterpretation of bodily signs or symptoms can only be made after a thorough medical evaluation has failed to find a medical condition that could account for the signs or symptoms. Another typical feature of hypochondriasis is that the person cannot be reassured by the results of a medical evaluation. In other words, the fear or idea of having a disease persists despite lack of medical evidence. Indeed, these individuals are sometimes disappointed when no physical problem is found. The condition has to persist for at least 6 months for the diagnosis to be made so as to not diagnose relatively transient health concerns.

Not surprisingly, people with hypochondriasis usually first see a medical doctor for their physical complaints. Because they are never reassured for long and are inclined to suspect that their doctor has missed something, they sometimes shop for additional doctors, hoping one might discover what their problem really is. Because they repeatedly seek medical advice (e.g., Bleichhardt & Hiller,  2006 ; Fink et al.,  2004 ), it is hardly surprising that their annual medical costs are much higher than average (e.g., Fink et al.,  2010 ; Hiller et al.,  2004 ). People with hypochondriasis are generally resistant to the idea that their problem is a psychological one that might be best treated by a psychologist or psychiatrist.

Prior to DSM-5, hypochondriasis was one of the two most commonly seen somatic symptom disorders with a prevalence in general medical practices of 2 to 7 percent (APA,  2000 ). Hypochondriasis occurs about equally often in men and women and can start at almost any age, although early adulthood is the most common age of onset. Hypochondriasis is regarded as a persistent disorder if left untreated, although its severity can fluctuate over time. Individuals with hypochondriasis often also suffer from mood disorders, panic disorder, or other types of somatic symptom disorders (Creed & Barsky,  2004 ). This is one reason why hypochondriasis is now not differentiated from other somatic symptom disorders in DSM-5.

MAJOR CHARACTERISTICS

Individuals with hypochondriasis tend to be highly preoccupied with bodily functions (e.g., heart beats or bowel movements), or with minor physical abnormalities (e.g., a small sore or an occasional cough), or with vague and ambiguous physical sensations (such as a “tired heart” or “aching veins”). They attribute these symptoms to a particular disease and often have intrusive thoughts about it. The diagnoses they make for themselves include cancer, exotic infections, AIDS, and numerous other diseases.   Watchthe Video Henry: Hypochondriasis on MyPsychLab

Although people with hypochondriasis are usually in good physical condition, they are sincere in their conviction that the symptoms they detect represent real illness. In other words, they are not malingering—consciously faking symptoms to achieve a specific goals such as winning a personal injury lawsuit. Not surprisingly, given their tendency to doubt the soundness of their doctors’ conclusions (i.e., that they have no medical problem) and recommendations, the relationships they have with their doctors are often marked by conflict and hostility.

The following case captures the typical clinical picture in hypochondriasis. It also demonstrates that a high level of medical sophistication does not necessarily protect someone from developing this or a related disorder.

An “Abdominal Mass” This 38-year-old physician/radiologist initiated his first psychiatric consultation after his 9-year-old son accidentally discovered his father palpating (examining by touch) his own abdomen and said, “What do you think it is this time, Dad?” The radiologist describes the incident and his accompanying anger and shame with tears in his eyes. He also describes his recent return from a 10-day stay at a famous out-of-state medical diagnostic center to which he had been referred by an exasperated gastroenterologist colleague who had reportedly “reached the end of the line” with his radiologist patient. The extensive physical and laboratory examinations performed at the center had revealed no significant physical disease, a conclusion the patient reports with resentment and disappointment rather than relief.

The patient’s history reveals a long-standing pattern of overconcern about personal health matters, beginning at age 13 and exacerbated by his medical school experience. Until fairly recently, however, he had maintained reasonable control over these concerns, in part because he was embarrassed to reveal them to other physicians. He is conscientious and successful in his profession and active in community life. His wife, like his son, has become increasingly impatient with his morbid preoccupation about life-threatening but undetectable diseases.

In describing his current symptoms, the patient refers to his becoming increasingly aware, over the past several months, of various sounds and sensations emanating from his abdomen and of his sometimes being able to feel a “firm mass” in its left lower quadrant. His tentative diagnosis is carcinoma (cancer) of the colon. He tests his stool for blood weekly and palpates his abdomen for 15 to 20 minutes every 2 to 3 days. He has performed several X-ray studies of himself in secrecy after hours at his office.

Source: Adapted with permission from DSM-IV-TR Casebook: A Learning Companion to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (pp. 88–90). Washington, DC: (Copyright © 2002). American Psychiatric Association.

CAUSAL FACTORS

Our knowledge of causal factors involved in somatic symptom disorders, including hypochondriasis, is quite minimal. This is especially true when compared to knowledge about the mood and anxiety disorders discussed in the preceding chapters. Currently, cognitive-behavioral views of hypochondriasis are perhaps most widely accepted. These have as a central tenet that it is a disorder of cognition and perception. Misinterpretations of bodily sensations are currently a defining feature of the syndrome, but in the cognitive-behavioral view these misinterpretations also play a causal role. It is believed that an individual’s past experiences with illnesses (in both him- or herself and others, and as observed in the mass media) lead to the development of a set of dysfunctional assumptions about symptoms and diseases that may predispose a person to developing hypochondriasis (Marcus et al.,  2007 ; Salkovskis & Warwick,  2001 ). These dysfunctional assumptions might include notions such as, “Bodily changes are usually a sign of serious disease, because every symptom has to have an identifiable physical cause” or “If you don’t go to the doctor as soon as you notice anything unusual, then it will be too late” (Salkovskis & Bass,  1997 , p. 318; see also Marcus et al.,  2007 ).

Individuals with hypochondriasis are preoccupied with unrealistic fears of disease. They are convinced that they have symptoms of physical illness, but their complaints typically do not conform to any coherent symptom pattern, and they usually have trouble giving a precise description of their symptoms.

Because of these dysfunctional assumptions, individuals with hypochondriasis seem to focus excessive attention on symptoms, with experimental studies showing that these individuals do in fact have an attentional bias for illness-related information (Owens et al.,  2004 ; see also Jasper & Witthöft,  2011 ). Although their physical sensations probably do not differ from those in normal controls (Marcus et al.,  2007 ), they perceive their symptoms as more dangerous than they really are and judge a particular disease to be more likely or dangerous than it really is. Once they have misinterpreted a symptom, they tend to look for confirming evidence and to discount evidence that they are in good health; in fact, they seem to believe that being healthy means being completely symptom-free (Rief et al.,  1998a ). They also perceive their probability of being able to cope with the illness as extremely low (Salkovskis & Bass,  1997 ) and see themselves as weak and unable to tolerate physical effort or exercise (Rief et al.,  1998a ). All this tends to create a vicious cycle in which their anxiety about illness and symptoms results in physiological symptoms of anxiety, which then provide further fuel for their convictions that they are ill.

If we also consider the secondary reinforcements that individuals with hypochondriasis obtain by virtue of their disorder, we can better understand how such patterns of thought and behavior are maintained in spite of the misery these individuals often experience. Most of us learn as children that when we are sick special comforts and attention are provided and, furthermore, that we may be excused from a number of responsibilities. Barsky and colleagues ( 1994 ) found that their patients with hypochondriasis reported much childhood sickness and missing of school. People with hypochondriasis also tend to have an excessive amount of illness in their families while growing up, which may lead to strong memories of being sick or in pain (Pauli & Alpers,  2002 ), and perhaps also of having observed some of the secondary benefits that sick people sometimes reap (Cote et al.,  1996 ; Kellner,  1985 ).

Interestingly, one study retested patients with hypochondriasis 4 to 5 years later and found that those who had remitted at follow-up had acquired significantly more (real) major medical problems than their nonremitting counterparts (Barsky et al.,  1998 ). In other words, it appears that hypochondriacal tendencies were reduced by the occurrence of serious medical conditions. The authors suggested that having a serious medical illness “served to legitimize the patients’ complaints, sanction their assumption of the sick role, and lessen the skepticism with which they had previously been regarded …. As one noted, ‘Now that I know Dr. X is paying attention to me, I can believe him if he says nothing serious is wrong’” ( p. 744 ).

TREATMENT OF HYPOCHONDRIASIS

More than a dozen studies on cognitive-behavioral treatment of hypochondriasis have found that it can be a very effective treatment for hypochondriasis (e.g., Barsky & Ahern,  2004 ; Tyrer,  2011 ; see also Hedman et al.,  2011 , for an example of Internet-based Cognitive Behavioral Therapy). The cognitive components of this treatment approach focus on assessing the patient’s beliefs about illness and modifying misinterpretations of bodily sensations. The behavioral techniques include having patients induce innocuous symptoms by intentionally focusing on parts of their body so that they can learn that selective perception of bodily sensations plays a major role in their symptoms. Sometimes they are also directed to engage in response prevention by not checking their bodies as they usually do and by stopping their constant seeking of reassurance. The treatment is relatively brief (6 to 16 sessions) and can be delivered in a group format. In these studies such treatment produced large changes in hypochondriacal symptoms and beliefs as well as in levels of anxiety and depression.

Somatization Disorder

The DSM-IV diagnosis of somatization disorder is another disorder that has now been subsumed into the broader category of somatic symptom disorder in DSM-5.  Somatization disorder  is characterized by many different physical complaints. To qualify for the diagnosis, these had to begin before age 30, last for several years, and not be adequately explained by independent findings of physical illness or injury. They also had to have led to medical treatment or to significant life impairment. Not surprisingly, somatization disorder has long been seen most often among patients in primary medical care settings (Guerje et al.,  1997 ; Iezzi et al.,  2001 ). Indeed, patients with this variant of somatic symptom disorder are enormously costly to health care systems because they often have multiple unnecessary hospitalizations and surgeries (Barsky et al.,  2005 ; Hiller et al.,  2003 ).

The DSM-IV-TR (APA,  2000 ) criteria required that patients report a large number of symptoms across a wide range of domains (e.g., 4 pain symptoms, two gastrointestinal symptoms, one sexual symptom and one neurological-type symptom). Thus, to qualify for a diagnosis of somatization disorder, a patient had to have experienced at least 8 out of 33 specified symptoms (Rief & Barsky,  2005 ). Over time, the rather arbitrary nature of this became increasing apparent and the formal diagnostic criteria began to be modified by many researchers and clinicians (e.g., Rief & Broadbent,  2007 ). Following suit, in DSM-5 the long and complicated symptom count is no longer required and somatization disorder is now considered to be just another variant of somatic symptom disorder.

Another advantage of the recent change in DSM-5 is that it is no longer necessary for us to be concerned about whether somatization disorder and hypochondriasis are really two different and distinct disorders. There are indeed significant similarities between the two conditions. They also sometimes co-occur (Mai,  2004 ). Some years ago leading researchers in this area expressed concerns about whether somatization disorder and hypochondriasis could really be regarded as separate disorders (e.g., Creed & Barsky,  2004 ). Combining them both into a common category in DSM-5 and considering them to be variants of somatic symptom disorder is probably a wise move.

The main features of somatization disorder are illustrated in the following case summary, which also involves a secondary diagnosis of depression.

Not-Yet-Discovered Illness This 38-year-old married woman, the mother of five children, reports to a mental health clinic with the chief complaint of depression, meeting diagnostic criteria for major depressive disorder …. Her marriage has been a chronically unhappy one; her husband is described as an alcoholic with an unstable work history, and there have been frequent arguments revolving around finances, her sexual indifference, and her complaints of pain during intercourse.

The history reveals that the patient … describes herself as nervous since childhood and as having been continuously sickly beginning in her youth. She experiences chest pain and reportedly has been told by doctors that she has a “nervous heart.” She sees physicians frequently for abdominal pain, having been diagnosed on one occasion as having a “spastic colon.” In addition to M.D. physicians, she has consulted chiropractors and osteopaths for backaches, pains in her extremities, and a feeling of anesthesia in her fingertips. She was recently admitted to a hospital following complaints of abdominal and chest pain and of vomiting, during which admission she received a hysterectomy. Following the surgery she has been troubled by spells of anxiety, fainting, vomiting, food intolerance, and weakness and fatigue. Physical examinations reveal completely negative findings.

DEMOGRAPHICS, COMORBIDITY, AND COURSE OF ILLNESS

Somatization disorder usually begins in adolescence and is believed by many to be about three to ten times more common among women than among men. It also tends to occur more among less educated individuals and in lower socioeconomic classes. The lifetime prevalence has been estimated to be between 0.2 and 2.0 percent in women and less than 0.2 percent in men (APA,  2000 ). Somatization disorder very commonly co-occurred with several other disorders including major depression, panic disorder, phobic disorders, and generalized anxiety disorder. It has generally been considered to be a relatively chronic condition with a poor prognosis, although sometimes the disorder remits spontaneously (e.g., Creed & Barsky,  2004 ).

CAUSAL FACTORS IN SOMATIZATION DISORDER

Despite its prevalence in medical settings, researchers are still not certain about the developmental course and specific etiology of somatization disorder. There is evidence that somatization disorder runs in families and that there is a familial linkage between antisocial personality disorder in men (see  Chapter 10 ) and somatization disorder in women. That is, one possibility is that some common, underlying predisposition, probably at least partly genetically based, leads to antisocial behavior in men and to somatization disorder in women (Cale & Lilienfeld,  2002b ; Guze et al.,  1986 ; Lilienfeld,  1992 ). Moreover, somatic symptoms and antisocial symptoms in women tend to co-occur (Cale & Lilienfeld,  2002b ). However, we do not yet have a clear understanding of this relationship. One possibility is that the two disorders are linked through a common trait of impulsivity.

It has also become clear that people with somatization disorder selectively attend to, and show perceptual amplification of, bodily sensations. They also tend to see bodily sensations as somatic symptoms (Martin et al.,  2007 ). Like patients with hypochondriasis, they tend to catastrophize about minor bodily complaints (taking them as signs of serious physical illness) and to think of themselves as physically weak and unable to tolerate stress or physical activity (Martin et al.,  2007 ; Rief et al., 1998).

TREATMENT OF SOMATIZATION DISORDER

Somatization disorder was long considered to be extremely difficult to treat, and general practitioners experienced a great deal of uncertainty and frustration in working with these patients. However, in the past 15 years some treatment research has begun to suggest that a certain type of medical management along with cognitive-behavioral treatments may be quite helpful and that general practitioners can be educated in how to better manage and treat somatization patients and be less frustrated by them (Rosendal et al.,  2005 ; see also Edwards & Edwards,  2010 ). One moderately effective treatment involves identifying one physician who will integrate the patient’s care by seeing the patient at regular visits (thereby trying to anticipate the appearance of new problems) and by providing physical exams focused on new complaints (thereby accepting her or his symptoms as valid). At the same time, however, the physician avoids unnecessary diagnostic testing and makes minimal use of medications or other therapies (Looper & Kirmayer,  2002 ; Mai,  2004 ). Several studies have found that these patients show substantial decreases in health care expenditures over subsequent months and sometimes an improvement in physical functioning (although not necessarily in psychological distress; e.g., Rost et al.,  1994 ). This type of medical management can be even more effective when combined with cognitive-behavioral therapy that focuses on promoting appropriate behavior, such as better coping and personal adjustment, and discouraging inappropriate behavior such as illness behavior and preoccupation with physical symptoms (e.g., Bleichhardt et al.,  2004 ; Mai,  2004 ).

Pain Disorder

The third DSM-IV diagnosis subsumed into the new category of somatic symptom disorder is pain disorder.  Pain disorder  is characterized by persistent and severe pain in one or more areas of the body that is not intentionally produced or feigned. Although a medical condition may contribute to the pain, psychological factors are judged to play an important role. Indeed psychological factors play a role in all forms of pain. The pain disorder may be acute (duration of less than 6 months) or chronic (duration of over 6 months). When working with patients with pain disorder it is very important to remember that the pain that is experienced is very real and can hurt as much as pain that comes from other sources. It is also important to note that pain is always, in part, a subjective experience that is private and cannot be objectively identified by others.

When one physician integrates a patient’s care, the physical functioning of patients with somatization disorder may improve. Why should this be?

The experience of pain is always subjective and private, making pain impossible to assess with pinpoint accuracy. Pain does not always exist in perfect correlation with observable tissue damage or irritation. Psychological factors influence all forms of pain.

The prevalence of pain disorder in the general population is unknown. It is definitely quite common among patients at pain clinics. It is diagnosed more frequently in women than in men and is very frequently comorbid with anxiety or mood disorders, which may occur first or may arise later as a consequence of the pain disorder. People with pain disorder are often unable to work (they sometimes go on disability) or to perform some other usual daily activities. Their resulting inactivity (including an avoidance of physical activity) and social isolation may lead to depression and to a loss of physical strength and endurance. This fatigue and loss of strength can then exacerbate the pain in a kind of vicious cycle (Bouman et al.,  1999 ; Flor et al.,  1990 ). In addition, the behavioral component of pain is quite malleable in the sense that it can increase when it is reinforced by attention, sympathy, or avoidance of unwanted activities (Bouman et al.,  1999 ). Finally, there is suggestive evidence that people who have a tendency to catastrophize about the meaning and effects of pain may be the ones most likely to progress to a state of chronic pain (Seminowicz & Davis,  2006 ).

TREATMENT OF PAIN DISORDER