Last updated: Thu, Aug 1, 2024
"Psychogenic pain" means pain caused not by the body, but by the mind. The idea is an ancient one. In recent history, different variations of it have been called pain disorder, somatoform disorder, and conversion disorder. This section discusses these ideas in terms of their definitions and the evidence behind them. In the section How We Understand Pain I discuss why these ideas persist and how they fit into the overall medicopolitical dialog concerning pain.
Pain isn't the only symptom that often has unexplained causes. David Fishbain points out that while 14 common symptoms are responsible for half of primary care visits, only 10-15% of them are found to be caused by an organic illness.
1 What this means is that the doctor fails to make a diagnosis that explains them. In rheumatology clinics, more than a quarter of patient symptoms are at least somewhat unexplainable. Unexplained symptoms are hardly uncommon. In the case of non-specific low back pain, symptoms are left unexplained as a matter of policy (Assessment of Lower Back Pain).
Unexplained symptoms seem to be hard on patients. The existence of many unexplained symptoms correlates with much depression and anxiety. What are the possible explanations of unexplained symptoms aside from psychogenic pain?
Almost 80% of chronic pain patients are diagnosed with non-specific low back pain. As I discuss elsewhere (Assessment of Lower Back Pain), this is a diagnosis of exclusion. If you don't have obvious radicular pain and there is no sign of spinal cancer or collapsed vertebrae, practice guidelines specify that it is non-specific low back pain. This is true regardless of whether more specific causes might be found, because they aren't looked for. In effect the diagnosis says, "We don't know anything about this patient except that he says his back hurts." Fishbain comments that it is important to keep in mind that the problem of unexplained medical symptoms may be a function of the limitations of our diagnostic acumen and technology.
2 Why doctors should need to be chivvied in this way isn't clear to me. He doesn't mention that it may also be a function of twelve-minute appointments and of doctors who aren't well-qualified to deal with the problem.
Which symptoms are explainable and which are explained is a function of medical knowledge and medical practices. Fibromyalgia was until recently a set of unexplained symptoms. Due to the work of the American College of Rheumatologists, it is now a set of more-or-less explained symptoms, despite that little is known about its causes and little is known about how to treat it effectively. (See Causes of Fibromyalgia and Myofascial Pain). A recent study has concluded that up to 20% of patients diagnosed with non-specific low back pain may have compromised nerve roots. This could be identified with metered neurological testing, but has not been.3 Fishbain and co-researchers examined 283 consecutive chronic lower back patients and found that all of them had physical findings that indicated the presense of myofascial pain syndrome (trigger points.) Vulvodynia (pain in the vulva in the absence of infection or skin irritation) gives no clinical physical or neurologic findings, yet biopsies show high immunoreactivity, high sensitivity of nociceptors, and high density of superficial nerve endings.4
In 1959 doctor George Engel published Psychogenic Pain and the Pain-prone Patient, which was influential in re-establishing modern medical interest in psychogenic pain. According to Engel, psychogenic pain comes from guilt and intolerance of success. It is a substitute for aggression. According to him, patients with conversion hysteria constitute the largest percentage of the pain-prone population.
5 A very astute man. The book is based on nothing but clinical cases overseen by Engel.
Any discussion of psychiatric disorders in patients with chronic pain is haunted by the concept of psychogenic pain. We are drawn to the concept of psychogenic pain because it fills the gaps left when our attempts to explain clinical pain exclusively in terms of tissue pathology fail. Psychogenic pain, however, is an empty concept. Positive criteria for the identification of psychogenic pain, and specific therapies for psychogenic pain are lacking.6
I would add to Sullivan's comment just quoted that modern science indicates that the pain system can become deranged with no tissue pathology. The history of "psychogenic disorders" as the DSM has evolved from 1980 forward is illustrative of a conclusion looking for a haven.
Within this section...
Conversion Disorders or Hysteria (Last updated: Mon, Jul 3, 2017)
"Unexplained Symptoms" (This page is incomplete.)
Psychogenic Pain Disorder (Last updated: Wed, Jul 31, 2024)
Somatization (Last updated: Wed, Jul 31, 2024)
Somatoform Pain Disorder (Last updated: Mon, Jul 3, 2017)
Waddell's Signs (Last updated: Thu, Aug 1, 2024)
Postscript (Last updated: Mon, Jul 3, 2017)
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Placebo Analgesia (Last updated: Thu, Aug 1, 2024)