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Last updated: Sun, Aug 4, 2024
Pain researchers have commented on the tendency of researchers and practitioners to look for psychological explanations for pain. I will use their own words heavily in this section. I begin with some words of Patrick Wall taken from his excellent 2000 book-length essay, Pain: The science of suffering:
More than fifty years ago, as a medical student, I began to see patients in pain and realized that the explanations given to them and to me by my teachers were overt rubbish. The fantasy explanations often depended on mechanical disorders for which there was no evidence, such as trapped nerves, extra ribs, strained muscles, or floating kidneys. If those failed to convince even the doctors, there was a leap to using as an explanation the supposed inadequate personalities of the patients: neurosis, hypochondria, hysteria, and malingering.1
Herta Flor and Dennis Turk, both extensively-published pain researchers, comment on the same situation:
As is frequently the case in medicine, when physical evidence and explanations prove inadequate to explain the symptoms, psychogenic alternatives are proposed. If the pain reported by a patient cannot be objectively confirmed, is judged to be disproportionate to objectively determined physical pathology, or if the complaint is recalcitrant to "appropriate" treatment, it is often assumed that psychological factors must play a significant causal role....There is no objective way to determine how much pain is proportionate and how much a given amount of tissue damage should hurt....The mere presence of somatic findings [that is, that the symptoms aren't well-accounted for by physical findings] can never qualify as a sufficient precondition for the diagnosis of a psychologically determined pain problem.2
I wonder whether a physician can adequately estimate the pain that "ought to" be caused by a common acute injury, such as a sprained ankle?
The idea of psychogenic pain, as we saw earlier, is an old one that simply won't fade away. The 1959 "pain-prone personality" proposed by Engel was updated in 1982 by Blumer and Heilbronn, who characterized its sufferers as denying emotional and interpersonal problems, inactive, depressed, guilty, unable to deal with anger and hostility, insomniac, craving affection, craving dependency, lacking initiative, and having a family history of depression, alcoholism, and chronic pain.3 (I've been many, but not all, of those things during my sufferings.) Beutler and his colleagues in 1986 extended this analysis. In their view, difficulty expressing anger and other intense emotions was said to lead to chronic pain. Turk and colleagues reviewed the evidence and concluded that these ideas aren't well-supported by evidence and in fact much of their argument is tautological (circular).4 Flor and Turk summarize their position:
In general, one can state that the existence of a pain-related personality has not been empirically demonstrated since differences in the personality profiles of chronic pain patients and healthy controls are often related to the presence of a chronic disease and the accompanying symptoms rather than to psychopathology.5
Notwithstanding the opinions of many leading pain researchers, such views affect not only medical treatment of pain but other aspects of the environment that pain victims must endure:
A variation of the dichotomous somatic-psychogenic view is a conceptualization that is ascribed to by many insurance companies and other third-party payers. With this view, if there is insufficient physical pathology to substantiate the report of pain, the complaint is invalid, the result of symptom exaggeration or outright malingering....No studies have demonstrated dramatic improvement in pain reports subsequent to receiving disability awards....It is important for third-party payers and insurance carriers to understand that the majority of the psychological processes affecting a chronic pain patient fall into this category of implicit or non-declarative learning that fails to enter awareness and therefore cannot be consciously manipulated by the patient. According to the report of the U.S. Social Security Commission on the evaluation of pain, active malingering is extremely rare; outright malingering occurs in less than 5% of people reporting chronic pain. Given the low estimation of the presence of malingering, it would require a very large sample to identify any potential predictors [of malingering].6