By Stephen M. Raffle, M.D.

The clinical aspects of psychogenic pain have occupied my attention for many years. As Assistant Clinical Professor of Orthopedics at University of California San Francisco Medical School, for 15 years I focused my work in that Department as a psychiatrist on the assessment and treatment of chronic pain and psychopathology. The mind-body dichotomy has occupied physicians for hundreds of years because of the long appreciation about the ways in which the mind may affect the expression of clinical symptoms as well as how physical symptoms may affect the appearance and continuation of mental disorders. It is widely recognized and accepted that pain may have psychological origins as well as physical origins and that the expression of pain may be a symbolic expression of emotional disturbance, i.e., emotional pain. A related problem is a Conversion Disorder, where anxiety is converted into a physical symptom other than pain.

Pain is difficult to measure at best, although attempts have been made to do so. The Tourniquet Test is a measure of pain threshold perception, which generally is used in a laboratory setting, but may be used in a clinical setting. The Cold Water Immersion test is another means of measuring an individual’s perception of pain and pain threshold when compared to a normalized population. A relatively easy and standardized test for pain measurement is the McGill Pain Inventory, which assists the clinician in identifying various components of pain. Sternbach first published the McGill Pain Inventory data in 1976 and since then many investigators and clinicians, myself included, have found it a useful adjunct in assessing the quantity and quality of a person’s complaint of pain.

In my clinical experience, the best assessment of pain complaints is the diagnostic psychiatric interview. Here, I assess the interaction between emotional conflict and complaint of physical pain.

Ultimately, pain, be it psychogenic, physical or an admixture of the two, is a symptom and not a disease. I must identify the underlying cause of the pain and explain it. Treatment should be directed at the source of the pain, although symptomatic reduction of pain perception often is necessary while other measures are taken.

Some of the causes of pain with a psychiatric component include but are not limited to pain as a depressive equivalent, pain as a conversion type disorder, delusional pain, sexual pain disorders such as pain with intercourse or pain due to chronic spasm of the vagina, pain associated with drug withdrawal and pain associated with a wide variety of medical conditions such as diabetic neuropathy, migraines, or chronic back pain. Pain may arise from physical injury from which a psychological injury results. The psychological injury may be experienced as a heightened perception of pain, in excess of what is expected only from the seriousness of the physical injury. Chronic pain conditions often benefit from psychiatric intervention in order to help limit the use of habituating drugs.

The augmentation of pain by psychological factors in the presence of bona fide physical pain commonly occurs if, for example, an individual has been in a motor vehicle accident, or suffered a Post-Traumatic Stress Disorder, with depression and also suffers from a physical injury. The psychiatric conditions may magnify the perception of pain because the individual’s coping skills to deal with the pain are diminished due to the presence of emotional difficulties and the debilitating effects of the physical injury. This, then, would constitute a pain disorder with both psychological factors and a general medical condition.

In the Back Clinic at UCSF when I was teaching there, it was not unusual to see patients who were suffering both from physical injuries and psychological injuries, which taken together incapacitated the person more than either circumstance would have by itself. As such, there existed a synergism between the emotional and physical problems, which may be as a whole greater than the sum of the parts. Aggressive treatment of both aspects of the pain was necessary for relief.

Particularly in litigated situations, I, as the forensic evaluator, must also be aware that some individuals intentionally embellish existing pain symptoms or create complaints when none actually exist. This is malingering, lying for a profit.

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