The Stubborn Psychologization of Pain (Part 1)

The Issues in Philosophy Series is running a two-part mini-series entitled “The Stubbon Psychologization of Pain.” This mini-series is authored by Tiina Rosenqvist, who has previously written for the blog. This post is the first installment.

I have had persistent widespread pain for more than fifteen years. The pain has no known cause; it is, as some would say, “medically unexplained.” Had I lived 130 years earlier in Western Europe, it would have likely been classified as “hysterical.” Had I been a Viennese person of some social standing, I might have been a patient of Sigmund Freud (1856-1939). I might have even been one of the case studies that inspired and informed much of Freud’s theorizing about the mind.  

Some of those cases are detailed in Studies in Hysteria, a psychoanalytical classic Freud co-authored with his mentor and collaborator, Josef Breuer. The patients present with mystifying paralyses, contortions, sensory disturbances, dizziness, fatigue, tics, and—yes—pains of various sorts. Freud and Breuer claim to uncover the “precipitating causes” for the symptoms during discussions and hypnosis. The causes are, without exception, some unprocessed, and often traumatic, emotional experiences. In Freud’s view, the distressing experiences are repressed from consciousness and later manifest as physical symptoms through the process of conversion.

The issues in Freud’s approach are well known and have been repeated ad nauseam in classrooms and academic literature. At the same time, the tendency to attribute difficult-to-explain pain to primarily psychological causes has stubbornly persisted in Western medicine. My intention in this essay is to show that this tendency relies on misinterpretations of statistical relationships, a failure to consider alternative explanations, and an assumption that medical knowledge is more complete than it actually is. 

In the history of medicine, many attempts have been made to make the diagnosis of primarily psychologically caused pain (also known as “psychogenic” pain) scientifically respectable. Franz Alexander (1891-1964), the founder of psychosomatic medicine, likened the psychoanalytic method to a “psychological microscope” that allowed for a detailed investigation of the patient’s emotional life. He also provided a list of paradigmatic psychosomatic illnesses: peptic ulcer, rheumatoid arthritis, hyperthyroidism, essential hypertension, bronchial asthma, ulcerative colitis, and certain types of skin diseases were all conditions where psychological factors could play a dominant causal role, perhaps in interaction with pre-existing organic vulnerability.

Whereas Alexander focused on a set of diseases, George Engel (1913-1999), discussed pain specifically. He thought that the signature of psychogenesis could be found in patients’ pain reports: in addition to “deviation from understandable anatomic and physiological principles,” vague and elaborate pain reports were suggestive, if not entirely conclusive. Engel also thought that people with certain psychological characteristics were more prone to psychogenic pain. He suggested that these “pain-prone” individuals use pain as a self-punishment and atonement and gravitate towards difficult or abusive situations because they do not feel that they deserve happiness or success.

Engel’s ideas were picked up by subsequent researchers. In 1980, Gordon Waddell and his colleagues sought to specify the so-called nonorganic physical signs of low-back pain. They settled on eight signs, which included nonanatomic or superficial tenderness, regional weakness or sensory disturbances, and overreaction such as “disproportionate verbalization.” Although they explicitly noted that physical pathology and “nonorganic reactions” were not to be seen as mutually exclusive diagnoses, three or more positive signs were taken to correlate with psychological problems. Two decades later, a systematic review found “no firm association between psychological disturbance and [Waddell’s signs]” and suggested that many of the signs might, in fact, be linked to organic pathologies. Still, the idea that certain kinds of pain reports and behaviors indicate psychogenesis has left a mark on clinical practice. 

Others expanded on Engel’s idea that certain psychological traits and psychiatric conditions make people prone to pain. Dietrich Blumer and Mary Heilbronn (1982) proposed that chronic pain of unknown origin should be seen as “a variant of depressive disease.” They observed that depressed individuals often complain of aches and pains and suggested that, in cases where chronic pain patients did not appear depressed, the depression might be masked by pain and other somatic symptoms. On a more general level, the idea that certain types of persistent pains are intimately tied to depression or anxiety has been hugely influential in Western medicine. There has also been sustained interest in the link between chronic pain and traits such as neuroticism and catastrophizing. Although many researchers have been careful to frame their claims in terms of correlation and prediction rather than causation and explanation, the subtlety has not always carried over to clinical practice.

The subtlety is important. It’s true, for example, that the prevalence of depression and anxiety is higher among individuals with chronic pain than among the general population, but the nature of this relationship is complicated. While depression and anxiety might contribute to persistent pain, chronic pain also appears to predispose people to mood and anxiety disorders. The relationship between personality traits and chronic pain is also difficult to pin down. Certain traits might well exacerbate chronic pain, but emerging evidence suggests that chronic pain can also alter personality through its effects on the brain; individuals living with persistent pain tend to become more negative or fearful over time. None of this is surprising, of course, for why wouldn’t living with persistent pain affect how people relate to their bodies and their environments? Pain colors everything, as this passage from Audre Lorde gut-wrenchingly illustrates:

I’m not feeling very hopeful these days, about selfhood or anything else. I handle the outward motions of each day while pain fills me like a puspocket and every touch threatens to breech the taut membrane that keeps it from flowing through and poisoning my whole existence.

So, while we have reason to think that psychological factors play a role in persistent pain, it should be clear that the evidence does not warrant the stronger conclusion that most medically unexplained chronic pains are psychogenic. Even the claim that some such pains are primarily psychologically caused is not well supported. Nevertheless, the psychologization of difficult-to-explain chronic pain has continued since the 19th century, and the diagnosis of psychogenic pain is also included in official medical classification systems. For example, ICD-10, the version of the International Classification of Diseases currently used in many countries, includes the category of persistent somatoform pain disorder. Patients who suffer from medically unexplained chronic pain might be diagnosed with this condition, in which: 

the predominant complaint is of persistent, severe, and distressing pain, which cannot be explained fully by a physiological process or a physical disorder, and which occurs in association with emotional conflict or psychosocial problems that are sufficient to allow the conclusion that they are the main causative influences.

But as we have seen, association with emotional conflict or psychosocial problems is not sufficient to conclude that these are the main causative influences behind a person’s pain. The observed psychological issues might be the effect of persistent pain, and even when they precede the pain, a direct causal relationship is difficult to establish.

Many diagnoses of psychogenic pain have been driven by the assumption that deviations from expectations based on the current state of medical knowledge warrant conclusions of psychological causation. But this is a problematic inference that confuses absence of evidence with evidence of absence. Relegating poorly understood diseases to the wastebasket category of psychogenic illness has been a persisting tendency in Western medicine. As our medical understanding has progressed, this category has shrunk—note that none of Alexander’s paradigmatic psychosomatic diseases are considered to be primarily psychologically caused today. In light of this history, the assumption that medical knowledge is complete enough to draw conclusions of psychogenesis, with or without evidence of psychosocial issues, seems shortsighted.