Definition versus Measurement of Mental Pain: A Reply to Meerwijk and Weiss
Authors: Eliana Tossani
Journal: Psychotherapy and Psychosomatics (2013)

I would like to respond to Dr. Meerwijk and Dr. Weiss [1]. I read with interest their letter outlining their views on the concept of psychological pain.While physical pain is also psychological, psychological pain is not necessarily physical. What is experienced and reported as pain is a psychological phenomenon. Engel [[2], p. 45] defines pain 'as a psychological experience involving the concepts of injury and suffering, but not contingent on actual physical injury. The idea of injury as well as the need to suffer may lead to pain, just as may a real lesion or injury. Similarly, the need not to suffer or not to accept the fact that injury may render a ''painful'' injury painless'.Pain is the somatic perception of tissue damage; it encompasses sensory awareness, negative emotional arousal (threat), and cognition (attention, appraisal, attribution, and more). Pain, inherently psychological, it is not a primitive sensory message of tissue trauma. What we call the mind is consciousness, and consciousness is a relevant feature of brain activity. The brain regulates the physiological arousal of the body in a feedback-dependent manner and emotion is a part of this process [3]. Not all pain causes suffering, and not all suffering, which is expressed as pain or coexists with pain, stems from pain [4].In the past, organic pain was viewed as different from 'psychogenic' pain. The term 'psychogenic' suggested that pain was due to psychological causes only, and that it was not 'real' pain because no specific organic basis could be found [2]. The term mental pain has been chosen in opposition to physical pain. A salient feature of mental pain is that it is not localized and is not due to organic disorders.Mental pain is real and as important as physical pain. The use of the term mental pain, distinct from physical pain, does not imply Cartesian dualism. The fact that two things can be conceptually distinguished (conceptual dualism) does not imply that they have some kind of separate independent existence (ontological or Cartesian dualism) [5].The concept of mental pain is useful to recognize peripheral pain which otherwise is not considered. Moreover, focusing the attention on peripheral pain might be useful to better understand if by tackling pain in the periphery it may be possible to provide symptomatic relief to chronic pain sufferers while avoiding the hazardous side effects of pervasive systemic treatments [6].The tools for assessing mental pain should reflect the internal suffering of the individual, detect when it exceeds the tolerance threshold, and distinguish the different levels (for example demoralization-depression).The ability of a rating or self-rating scale to discriminate between different groups of patients suffering from the same illness (e.g. depressed inpatients and outpatients) and to reflect changes in experiments in therapeutics, such as drug trials, has been defined as sensitivity [7].It is useful to keep in mind that different people, affected by the same disease or trauma, experience vastly different levels of pain, be it physical or mental, which can be provided by clinical specifiers for symptomatology.The definition of mental pain by Meerwijk and Weiss [1] appears to be based on a categorical approach, which appears less suitable to detect the differences in pain severity levels.From a clinimetric point of view, an essential requisite for sensibility of a rating scale is its discrimination properties (responsiveness/sensitivity), which means that it should be able to detect clinically relevant changes in health status over time. Sensibility is an important concept for developing and selecting indexes to monitor changes in several clinical settings [8,9,10].Assessment of mental pain may have important implications in the research on interventions to evaluate the effectiveness of pharmacologic and psychological therapy [7].