“Psychogenic” pain and the pain-prone patient

Abstract The general principles formulated in this paper may be summarized as follows: 1.1. What is experienced and reported as pain is a psychological phenomenon. Pain does not come into being without the operation of the psychic mechanisms which give rise to its indentifiable qualities and which permit its perception. In neurophysiological terms this also means there is no pain without the participation of higher nervous centers. 2.2. Developmentally, however, pain evolves from patterns of impulses arising from peripheral receptors which are part of the basic biologic nocioceptive system for the protection of the organism from injury. The psychic experience, pain, develops phylogenetically and ontogenetically from what was originally only a reflex organization. This may be compared to the necessity for functioning eyes and ears to receive light and sound waves before the complex psychic experiences of seeing and hearing can evolve. 3.3. Once the psychic organization necessary for pain has evolved, the experience, pain, no longer requires peripheral stimulation to be provoked, just as visual and auditory sensations (hallucinations) may occur without sense organ input. When such are projected outside the mind (in contrast to a painful thought or a painful frame of mind) they are felt as being in some part of the body and are to the patient indistinguishable from pain arising in the periphery. 4.4. Since the experience, pain, and the sensory experiences from which it evolves are part of the biologic equipment whereby the individual learns about the environment and about his body, and since this has a special function as a warning or indicator of damage to body parts, pain plays an important role in the total psychologic development of the individual. Indeed, pain, along with other affects, comes to occupy a key position in the regulation of the total psychic economy. We discover that in the course of the child's development, pain and relief of pain enter into the formation of interpersonal (object) relations and into the concepts of good and bad, reward and punishment, success and failure. Pain becomes par excellence a means of assuaging guilt and thereby influences object relationships. 5.5. From the clinical viewpoint we discover that disordered neural patterns originating in the periphery confer certain qualities on the pain experience that permit the physician to recognize their presence and hence make a presumptive diagnosis of an organic lesion. 6.6. Clinical psychological studies of all varieties of patients with pain reveal that some individuals are more prone than others to use pain as a psychic regulator, whether the pain includes a peripheral source of stimulation or not. These pain-prone individuals usually show some or all of the following features: 6.1.(1) A prominance of conscious and unconscious guilt, with pain serving as a relatively satisfactory means of atonement. 6.2.(2) A background that tends to predispose to the use of pain for such purposes. 6.3.(3) A history of suffering and defeat and intolerance of success (masochistic character structure). A propensity to solicit pain, as evidenced by the large number of painful injuries, operations and treatments. 6.4.(4) A strong aggressive drive which is not fulfilled, pain being experienced instead. 6.5.(5) Development of pain as a replacement for a loss at times when a relationship is threatened or lost. 6.6.(6) A tendency toward a sado-masochistic type of sexual development, with some episodes of pain occurring in settings of conflict over sexual impulses. 6.7.(7) A location of pain determined by unconscious identification with a love object, the pain being either one suffered by the patient himself when in some conflict with the object or a pain suffered by the object in fact or in the patient's fantasy. 6.8.(8) Psychiatric diagnoses include conversion hysteria, depression, hypochondriasis and paranoid schizophrenia, or mixtures of these. Some patients with pain do not fit into any distinct nosologie category.