BackgroundHypersensitivity of the central nervous system is widely present in pain patients and recognized as one of the determinants of chronic pain and disability. Electronic pressure algometry is often used to explore aspects of central hypersensitivity. We hypothesized that a simple pain provocation test with a clothes peg provides information on pain sensitivity that compares meaningfully to that obtained by a well-established electronic pressure algometer. "Clinically meaningful" was defined as a medium (r = 0.3-0.5) or high (r > 0.5) correlation coefficient according to Cohen's conventions.MethodsWe tested 157 in-patients with different pain types. A calibrated clothes peg was applied for 10 seconds and patients rated the pain intensity on a 0 to 10 numerical rating scale. Pressure pain detection threshold (PPdt) and pressure pain tolerance threshold (PPtt) were measured with a standard electronic algometer. Both methods were performed on both middle fingers and ear lobes. In a subgroup of 47 patients repeatability (test-retest reliability) was calculated.ResultsClothes peg values correlated with PPdt values for finger testing with r = -0.54 and for earlobe testing with r = -0.55 (all p-values < 0.001). Clothes peg values also correlated with PPtt values for finger testing with r = -0.55 (p < 0.001). Test-retest reliability (repeatability) showed equally stable results for clothes peg algometry and the electronic algometer (all r-values > 0.89, all p-values < 0.001).ConclusionsInformation on pain sensitivity provided by a calibrated clothes peg and an established algometer correlate at a clinically meaningful level.

Objective: In psychiatry, pain disorders not explained by structural lesions have been classified for decades as somatoform pain disorders, the underlying concept being somatization. In a parallel move, somatic medicine has defined an expanding group of similar pain disorders, known as functional pain syndromes. Functional pain syndromes are characterized by enhanced pain sensitivity. The aim of our study was to investigate the proportion of patients with somatoform pain disorders who also meet the criteria of functional pain syndromes and the extent to which patients with somatoform pain disorders also show enhanced pain sensitivity.Methods: Data on pain sensitivity in 120 hospitalized patients were obtained by means of two algometric methods. The group of patients with somatoform pain disorders was further divided into two subsets: patients with and those without a co-diagnosis of a functional pain syndrome. Patients with nociceptive pain served as control group.Results: Of the 120 in-patients selected, 67 fulfilled the criteria of a somatoform pain disorder of which 41 (61%) also met the co-diagnosis of a functional pain syndrome. Patients with somatoform pain disorder differed from controls in that they showed enhanced pain sensitivity, irrespective of whether a functional pain syndrome was concomitantly present (p<0.001).Conclusions: Somatoform pain disorders show considerable overlap with functional pain syndromes, including enhanced pain sensitivity. This suggests the relevance of integrating somatosensory aspects of pain into a modified understanding of somatoform pain disorders. A C C E P T E D M A N U S C R I P TACCEPTED MANUSCRIPT 3 BackgroundFor decades, pain disorders not or not adequately explained by structural somatic injury (or any other physiological processes such as inflammation) have been classified as somatoform pain disorders especially if they occur in the context of depression, anxiety disorders, or psychosocial stress. Under the DSM-IV section on somatoform disorders, somatoform pain disorder is defined as "pain disorder associated with psychological factors" (307.80) [1]. In its definition of 'persistent somatoform pain disorder' (F45.40), ICD-10 even explicitly attributed a causal significance to the psychological factors [2]. The rationale of DSM-IV and ICD-10 in categorizing somatoform pain disorders relies on the traditional concept of somatization. In the psychoanalytical theory, somatization was conceived as an experience of "bodily symptoms" caused by (repressed) psychological distress. As a consequence, somatoform pain disorders were classified as "mental disorders". Patients, therefore, were referred to psychiatric care.In a parallel move, somatic medicine defined an increasing group of so-called functional somatic syndromes [3,4] or, more specifically functional pain syndromes [5]. In 1990, The American College of Rheumatology, for instance, recognized fibromyalgia as a clinical entity. For the first time, hyperalgesia (with respect to the tender points) was proposed ...

volume was 77 mL/kg, twice the laboratory's top normal range in women (28 mL/kg). Serum erythropoietin level was repeated and was found to have decreased below normal at 3.0 mU/mL. A diagnosis of PV was made, and a therapeutic phlebotomy was initiated.To date, the patient has undergone 38 therapeutic phlebotomies during a 6-year period, and the patient continues with elevated hemoglobin concentrations and platelet counts. Her symptoms are well controlled, although she continues to have splenomegaly according to both physical examination and radiographic imaging results. She has never had a thrombotic event, nor has she ever received a cytotoxic agent.Result of a repeated bone marrow biopsy, performed 12 years after the initial diagnosis of PMF and 6 years after the diagnosis of PV, was a markedly hypercellular presence, without reticulum or fibrosis. Genetic study results showed a normal karyotype, and fluorescence in situ hybridization testing results did not reveal abnormalities. A quantitative JAK2 assay result showed an allele burden of 54%. At this point in the course of the disease, there is no evidence of prior MF in this patient.The case of this patient demonstrates the evolution of transfusiondependent PMF into phlebotomy-dependent PV, a reversal of the usual progression. According to the DPSS-plus risk system, the patient had 3 adverse features on presentation, placing her in the Intermediate-2 group with a median survival time of 3.6 years. Despite these adverse features on presentation, she has now survived 13 years after the intial presentation and is behaving in an indolent fashion, typical of PV and not PMF.

BackgroundPain drawings are a diagnostic adjunct to history taking, clinical examinations, and biomedical tests in evaluating pain. We hypothesized that somatoform-functional pain, is mirrored in distinctive graphic patterns of pain drawings. Our aim was to identify the most sensitive and specific graphic criteria as a tool to help identifying somatoform-functional pain.MethodsWe compared 62 patients with somatoform-functional pain with a control group of 49 patients with somatic-nociceptive pain type. All patients were asked to mark their pain on a pre-printed body diagram. An investigator, blinded with regard to the patients’ diagnoses, analyzed the drawings according to a set of numeric or binary criteria.ResultsWe identified 13 drawing criteria pointing with significance to a somatoform-functional pain disorder (all p-values ≤ 0.001). The most specific and most sensitive criteria combination for detecting somatoform-functional pain included the total number of marks, the length of the longest mark, and the presence of symmetric patterns. The area under the ROC-curve was 96.3% for this criteria combination.ConclusionPain drawings are an easy-to-administer supplementary technique which helps to identify somatoform-functional pain in comparison to somatic-nociceptive pain.