Indeed, 24 years ago when I first started seeing individuals in chronic pain who had been referred to me in a pain clinic because it was thought that organic factors were insufficient to explain the complaint of pain,
I looked carefully for psychiatric and psychological explanations.
1) The vast majority of people I see in a multidisciplinary pain clinic have a clear organic cause for pain either in the present or past, and
2) it is rare to have a patient with pain arising purely from emotional causes
A sizeable number of people in distress from chronic pain do not have enough signs of illness to persuade doctors that organic factors are sufficient to explain their symptoms.
They are undoubtedly in distress and they score highly on symptoms of depression and, to a lesser extent, other psychiatric illnesses. Why these people present in the way they do cannot be deduced solely through application of the medical model.
The profound influence of Freud shaped the belief in psychological and psychiatric circles that persistent pain associated with emotional distress in the absence of organic findings is primarily due to a psychiatric illness.
Dr Livingston, a surgeon writing in the middle of the past century, disagreed with the concept supported by many doctors at the time that pain, without physical findings, is hysterical or due to malingering.
PSYCHIATRISTS AND PAIN
The established physician and truncated phonemic associate George Engel believed that, although pain may originally develop from an external source, it often becomes a psychological phenomenon (Engel, 1959).
He described risk factors for developing chronic pain, including a history of defeat, significant guilt, unsatisfied aggressive impulses and a history of real or imagined loss.
Later, Blumer & Heilbronn (1982) described a group of patients who developed chronic pain who had a strong work ethic and were preoccupied with their pain.
As these individuals later developed many of the vegetative symptoms of depression, these authors unwisely generalised that chronic pain in such people is a manifestation of depression.
EFFECTS OF PAIN ON PERSONALITY
studies showed that the development of psychiatric illness more usually follows the development of the chronic painful condition, and ‘pain-proneness’ is not demonstrable in most patients (Gamsa, 1990)
The reason why most people in pain complain of distressing symptoms is because of the debilitating and demoralising effects of the pain itself.
This might be the only sensible statement in this paper.
This contention was supported by an intriguing study carried out 20 years ago. At that time the Minnesota Multiphasic Personality Inventory (MMPI) was a widely used tool in the investigation of those with chronic pain.
The typical profile of an individual who had developed chronic pain and had the psychological disposition to do so was a component of high scores on the neurotic triad, the depression, hypochondriasis and hysteria sub-scales, of this instrument.
This picture was found in a large proportion of a group of patients being assessed for backpain surgery. By chance, a number of the individuals concerned had previously been tested with this instrument in an earlier epidemiological study.
In these people it was found that their premorbid profiles were within normal limits, strongly suggesting that the painful condition from which they were suffering was responsible for the apparent change in the personality picture (Hagedorn et al, 1985)
Love & Peck (1987) later showed that this particular MMPI profile found in patients with chronic pain did not represent previous personality functioning but was a consequence of disability.
A minority of patients with chronic pain do fulfil the criteria for the diagnosis of a somatoform disorder. In such conditions there is continued presentation of physical symptoms together with persistent requests for medical investigations despite negative findings of organic illness and reassurance by doctors that the symptoms have no physical basis. The diagnosis
par excellence of a somatoform disorder is somatisation disorder, where pain is just one of many symptoms exhibited by the (usually) female patient.
This diagnosis is not common, ranging from 0.2% of patients referred to a liaison psychiatry service (Smith et al, 2000) to 5% of medical patients (Fink et al, 2004).
This figure is higher than the previous figure of Smith et al (2000) because Fink et al (2004) used ICD-10 criteria.
The ICD-10 diagnosis of persistent somatoform pain disorder was 1.5% in this same population (Fink et al, 2004).
This low figure is not too surprising, as the latter diagnosis can be made only if the pain described by the patient “occurs in association with emotional conflict or psychosocial problems that are sufficient to allow the conclusion that they are the main causative influences’” (World Health Organization, 1992: p. 168)
Contrast this with the diagnosis of pain disorder listed in the somatoform disorders section in DSM-IV (American Psychiatric Association, 1994). For this diagnosis to be made, ‘psychological factors are judged to have an important role in the onset, severity, exacerbation, or maintenance of the pain’ (p. 461).
Although cases largely due to physical illness are excluded, [the problem is that not all physical illnesses can be promptly diagosed] as also are cases where the pain is ‘better accounted for by a mood, anxiety or psychotic disorder’, more cases with pain and emotional sequelae achieve this level of diagnosis on the DSM-IV schedule than on ICD-10.
The problem with the diagnosis of somatoform disorders in general and of somatoform pain disorders in particular is the judgement required that the symptoms manifest are due to psychological factors. It is not easy to determine this objectively and most psychiatrists working in the area are aware that physical and psychological factors both contribute significantly to the presentation. (Mayou, 1991; Merskey, 2000)
Not only isn’t it easy, but objectivity is impossible when evaluating behaviors of human beings, especially when it requires speculation about motives and inner thoughts, as these diagnoses do.
The evidence of psychological causation cannot be assumed from a history of previous risk factors
The reporting of unexplained pain symptoms as due to previously experienced psychological trauma has been found to be an artefact of retrospective self-report rather than a consequence of actual events (Raphael et al, 2001).
So they are saying that my decades of complaints about increasing pain from a genetic disorder are just an “artefact of retrospective self-report”.
The value of the present classifications of these syndromes has been brought into question because of the imprecise categorisation of such disorders and the fact that many patients fall into the category of undifferentiated somatoform disorder, a watered-down version of somatisation disorder (Bass et al, 2001; Sharpe & Mayou, 2004).
Dimensional assessment of pain on the axes of nociception, evaluation of pain, mood consequences of the pain and pain behaviour (Karoly & Jensen, 1987; James, 1992) may be of greater clinical relevance.
The specialty of pain has grown considerably over the past 25 years and the influence of the psyche on painful symptoms and vice versa has become much more widely recognised.
Psychological causes have now become the fashionable scapegoat for chronic pain.
The difficulty in disentangling the mechanisms involved in this relationship will be clear to those who have read to the end of this piece.
Those wishing to obtain more information are recommended to contact the International Association for the Study of Pain (IASP; http://www.iasp-pain.org).