The Issues in Philosophy Series is running a two-part mini-series entitled “The Stubborn Psychologization of Pain.” This mini-series is authored by Tiina Rosenqvist, who has previously written for the blog. This post is the second and final installment.
My own pain started out mild and then gradually got worse. A few years in, I started seeing a physical therapist who mentioned that the pain might be caused by an autoimmune condition and recommended that I get tested. After I moved to the United States for graduate school, I made an appointment at the university clinic. The clinician asked me if I had a history of mental illness. When I said I didn’t, she suggested that the stress of graduate school might be manifesting physically. I reminded her that my pain had started years before graduate school and had also persisted through periods of very little stress. She then insinuated that I was at the clinic for prescription painkillers, and only reluctantly ordered some basic diagnostic tests.
The encounter felt so deeply invalidating that I did not seek medical help for years afterwards. After connecting with others living with persistent pain, I realized that my experience at the clinic had been fairly normal. When not dismissed as malingering, chronic pain in the absence of obvious organic causes is still often attributed to psychological factors. At times, this attribution seems almost instinctive, made without adequate clinical investigation and without evidence of psychological problems.
While anybody’s pain could be psychologized, stereotypes and biases almost certainly play a role in the likelihood of this happening. Women, for one, are at a higher risk. There is evidence of a tendency to give women psychiatric referrals for the same symptoms for which men are prescribed diagnostic tests, and women’s pain reports are less likely to be taken at face value—not only by clinicians but by lay people as well. The observation that women have more chronic pain, especially medically unexplained chronic pain, is also sometimes explained by psychological factors, such as the higher prevalence of depression and anxiety among women. Although there is growing recognition that centuries of bias have hindered research into conditions that disproportionately affect women, leading to significant knowledge gaps, the stereotype of the overly emotional, “somatizing” woman has been difficult to dislodge. Similarly, stereotypes of racialized minorities as having lower pain thresholds or lower pain tolerance, often attributed to pathological effects of culture, can be deeply rooted.
When clinical attributions of psychological causation are made, patients often have a hard time challenging them. Admitting to a history of mental illness—or psychological trauma of any kind—can be taken as corroborating evidence, denial of such a history can be explained away by a lack of self-awareness or outright lying, and pleas or protests can be seen as evidence of psychological disturbances. Patients who insist that their pain has an organic cause are at risk for receiving a psychiatric diagnosis, such as that of somatic symptom disorder, given on the basis of “excessive thoughts, feelings, or behaviors” related to persistent and distressing physical symptoms. The vagueness of these diagnostic criteria should worry us all. For how does one decide when thoughts, feelings, or behaviors related to chronic pain become excessive and pathological, especially when pain demands attention and severe pain is virtually impossible to ignore? As the essayist and chronic migraine sufferer Lisa Olstein writes, “All pain is simple and all pain is complex. You’re in it and you want to get out.”
Clinicians might be particularly tempted to deem thoughts, feelings, and behaviors related to one’s pain excessive in cases where the pain itself seems excessive or “disproportionate” (recall that “overreaction” was one of the Waddell signs for psychological causation of low-back pain). But medically unexplained pain is, by definition, disproportionate to the level of observed damage. A diagnosis of somatic symptom disorder then risks misclassifying a normal reaction to severe, difficult-to-explain chronic pain as a psychiatric issue.
Psychiatric ailments warrant treatment, and medical and healthcare providers should take psychosocial factors into account when encountering individuals with persistent pain. An important lesson to take from Freud, Alexander, and Engel is that human beings are complex mind–body systems with histories that shape both our physical and psychological states and dispositions. Psychosocial factors have been shown to correlate with symptom severity and treatment outcomes across a range of medical conditions, and the practice of screening chronic pain patients for depression and anxiety is justified by evidence indicating that these conditions often co-occur. The stress associated with gender, racial, and other forms of marginalization might contribute to pain and, more generally, social context can make pain better or worse. But all this can be acknowledged and incorporated into clinical practice without endorsing the idea that certain kinds of pain are primarily psychological in origin.
In fact, the idea of psychogenic pain is difficult to reconcile with the contemporary scientific understanding of pain. The picture that has emerged in recent decades is that pain, especially persistent pain, results from a dynamic integration of inputs from multiple bodily systems. These include the endocrine and immune systems, and preliminary evidence suggests that sex-based differences in their function might explain why women in general have more pain. In addition, since immune system factors have also been implicated in the development of stress-linked psychiatric illness, these differences might partially explain why women are more prone to both chronic pain and certain psychiatric disorders. Attempts to explain women’s greater prevalence of chronic pain in terms of higher rates of depression and anxiety might then rely on a common reasoning error, in which a correlation between two variables is taken to be causal when both are caused by a third variable.
In recent years, many pain experts have been advocating for caution in the clinical diagnosis of chronic pain conditions. The latest version of the International Classification of Diseases (ICD-11) no longer includes diagnostic codes for psychogenic pain. Chronic pain, now a disease in its own right, is explicitly described as multifactorial and etiologically complex, and a subtype labeled “chronic primary pain” provides a diagnostic code for persistent pains that cannot be straightforwardly linked to an underlying organic disease or treatment. The new diagnostic categories therefore reflect the emerging understanding that clinical explanation of chronic pain is complicated by both known limitations and unknown unknowns.
The ICD-11 is yet to be officially adopted by most countries, and the removal of the option to code for psychogenic pain does not prevent clinicians from informally psychologizing persistent pain. Still, the changes should make it easier to embrace complexity and uncertainty in clinical contexts. This kind of taxonomic scaffolding is important because humans do not have the best track record when it comes to dealing with complexity and uncertainty. We prefer simpler explanations over more complicated ones. We rely on shortcuts and heuristics, and we are more likely to do so when cognitively or emotionally strained. We also tend to have a low tolerance for uncertainty. We want answers, we want things to make sense, and we want a good story. And the more we rely on a story, the more entrenched it gets and the more obvious it starts to seem, no longer in need of justification or evidential support.
Many different stories have been told about pain. Pain has been understood as an omen sent by deities (Mesopotamia), a demonic infiltration (Egypt), an imbalance of humors (Greece), an imbalance of doshas (Ayurveda), and a disturbance of qi (Traditional Chinese Medicine). In Europe, in the wake of the Scientific Revolution, a mechanistic account of pain emerged: pain was conceptualized as a response to injury or tissue damage and as a matter of linear nerve transmission. It was this story that Freud, Alexander, and Engel sought to complicate, because they recognized that many pains did not fit this picture. But the stories they gave us were also oversimplified. It is not the case that we can infer psychological causation from the mysteriousness of physical symptoms or even from co-occurrent psychosocial problems. It is not even clear that the idea of psychogenic pain has any meaningful role to play in clinical practice at all; most chronic pains are likely too complex to fit into the simple dichotomy of primarily organic vs. primarily psychogenic.
Still, our stories about psychogenic pain and the kinds of people who are prone to it have become so entrenched that the practice of psychologizing difficult-to-explain pain lives on. These stories leave many persistent pain sufferers without appropriate treatment while also impeding the investigation of many poorly understood medical conditions. To fix this situation, another simple story won’t do. What is needed are practices that don’t come naturally to us: learning from our past mistakes, cultivating a tolerance for uncertainty, recognizing the limits of our current understanding, and making space for complexity.
Tiina Rosenqvist
Tiina Carita Rosenqvist is an assistant professor of philosophy at Rowan University. Her research focuses on philosophy of perception and philosophy of medicine. Recent work includes “Engineering the concept of pain for clinical practice” (forthcoming) and “Women’s pain and psychogenic diagnoses” (with Sara Purinton, 2026).
