Overview

Psychogenic pain refers to pain caused, increased, or prolonged by underlying psychological factors such as mental or emotional problems. Despite lacking a direct physical source, this condition is real and often causes significant distress. In the past, “psychogenic pain” was believed to be imaginary.

Nowadays, healthcare professionals and researchers know that various processes and factors can cause pain – not just physical causes. Hence, the term “psychogenic pain” is no longer used to prevent misunderstandings and invalidating a person’s feelings. Appropriate diagnosis and treatment of pain is crucial for maintaining overall physical and mental well-being.^1,2

How does pain work?

To comprehend psychogenic pain, it's essential to grasp how our bodies process pain. Your body detects pain through the nervous system. The process of detecting and reacting to pain begins with noxious stimuli, which damage cells and trigger the release of special chemicals into the surrounding tissue. 

Nociceptors – specialised receptors in your nervous system – act like alarms, detecting these chemicals and sending urgent signals to your brain. These signals are translated into the sensation of pain, helping you pinpoint the problem area. Pain triggers protective reactions in your brain and body, such as reflex muscle movements to move away from stimuli and immune responses to protect wounds from infections. 

However, nociceptor signals aren't always necessary to experience pain, and sometimes these receptors can activate on their own, creating a sensation of pain without physical stimuli. Additionally, since physical and mental health are closely linked, mental health conditions may influence how the body perceives pain.

Understanding psychogenic pain

Pain is typically categorised into three main types:

• Nociceptive pain
• Neuropathic pain
• Psychogenic pain (also classified as "other pain" or nociplastic pain)

Nociceptive pain resulting from damage to internal or external tissue (e.g., skin), and neuropathic pain (arising from damage to the nervous system) have identifiable physical sources. Whereas, psychogenic pain manifests without any discernible illness or injury but is linked to emotional conflict or mental health conditions, such as:

• Stress
• Depression
• Anxiety
• Post-traumatic stress disorder (PTSD)

This condition has also been referred to as pain disorder, pain behaviour, somatoform pain disorder, and more recently, nociplastic pain. Psychogenic pain differs from nociceptive and neuropathic pain as the pain doesn't correlate with physical symptoms.^1,3,4

Psychogenic pain can manifest as either acute (characterised by sharp but brief episodes), or chronic (persistent and long-lasting pain). It most commonly presents with the following symptoms:

• Headaches
• Muscle pains
• Stomach aches
• Back pain

Anxiety is often associated with acute pain, whereas depression is associated with chronic pain. Psychological factors that may worsen this condition include:²

• Physical abuse
• Sexual abuse
• Substance abuse
• Counter-dependent personal relationships
• A history of attachment issues
• Presence of the aforementioned mental health conditions

What is the link between mental health and pain?

The precise mechanism which links psychological factors and mental health conditions with pain remains unclear. Various theories propose that this pain may stem from the nervous system's response to muscle tension during emotional stress or the misinterpretation of mental distress as physical pain. However, despite ongoing research, there remains uncertainty surrounding this condition.

As a result, there is a lack of established guidelines for diagnosing and treating psychogenic pain. Moreover, due to stigma, this term is often avoided altogether. Consequently, there is insufficient data on its prevalence.¹

Diagnosis of psychogenic pain

Diagnosing psychogenic pain often involves a process of exclusion, ruling out other potential causes until psychogenic factors remain the likely explanation. When presenting with pain to a healthcare provider, physical examinations are conducted to identify any physical or neurological origins of the pain.

In cases of psychogenic pain, no physical findings will account for the symptoms. A psychological assessment may be performed to explore factors, such as onset, severity, or exacerbation of the pain. Due to the nature of psychogenic pain, diagnosis may be prolonged, but certain diagnostic criteria can aid in confirming the diagnosis, including:¹

• Unclear onset of pain
• Poorly localised pain (i.e., difficult to pinpoint to one specific area)
• Pain intensity that correlates with mood fluctuations
• Limited responsiveness to painkillers but potential responsiveness to antidepressants and sedatives
• Presence of pain alongside other mental health conditions

Treatment approaches for psychogenic pain

Psychogenic pain presents challenges in treatment, with approaches tailored to the type of pain and any underlying mental health conditions. However, it is treatable, often through a multidisciplinary approach encompassing psychotherapy and medical interventions. Treatment plans may include:

Psychotherapy

As a first-line treatment, psychotherapy aims to identify and address the underlying mental causes. Cognitive behavioural therapy (CBT) and group therapy offer avenues for sharing struggles and experiences and provide support and resources.

Medication

In cases where psychogenic pain coexists with conditions like depression and anxiety, antidepressants may be prescribed, addressing both mental health and pain symptoms. Non-narcotic painkillers such as ibuprofen can alleviate severe pain.

Opioids are generally avoided for psychogenic pain due to their limited efficacy in addressing underlying causes and the risk of substance abuse and dependence.

Alternative treatments

Other interventions include physical therapy to manage muscle pain or tension, and aerobic exercise to alleviate physical discomfort. Acceptance and commitment therapy is another psychotherapeutic approach. Additionally, alternative modalities like meditation, acupuncture, and yoga offer complementary avenues for symptom management and overall well-being.^1,4

Summary

Psychogenic pain, a condition driven by psychological factors, can be profoundly distressing, impacting both physical and emotional well-being. While historically referred to as "psychogenic," this term is now outdated and no longer used by healthcare providers due to misunderstandings and the potential for people to feel invalidated or offended.

However, it's important to note that psychogenic pain is indeed a real condition, albeit one that is now approached more holistically by looking at factors beyond mental health, such as social, or environmental factors.

Just as our bodies have a natural mechanism for detecting and responding to harm, our minds play a crucial role in shaping our experience of pain through nociceptor signalling. Yet, psychogenic pain isn't always accompanied by these signals. Instead, it often arises from emotional conflict or mental health issues like stress and depression. Diagnosing psychogenic pain can be complex, requiring careful consideration and exclusion of other causes.

Once identified, treatment approaches focus on addressing the underlying mental causes with compassion and empathy. Treatments (e.g., psychotherapy, medication, and alternative therapies) aim to provide support by acknowledging the connection of the body and mind in healing. Validation and social support are vital components of this journey, offering comfort and understanding to those navigating the challenges of psychogenic pain.