symptoms of depression may be neces­ Patients with Psychogenic Pain sary. These often include feeling “down” or “blue,” unprovoked crying spells, easy fatigability, inability to R. A. De Vaul, M D, Sidney Zisook, M D, and H. James Stuart, MD concentrate, loss of efficiency, a lack Houston, Texas of interest and satisfaction in work, withdrawal from family and friends, sleep disturbance (particularly early morning awakening), loss of appetite, weight loss, loss of interest in sex, constipation, and suicidal ideation. This article describes characteristics of groups of patients with a Periodicity is also a characteristic of high probability of having pain complaints on an emotional basis. depressive pain.7 In addition, a past history of depression, alcoholism, acci­ An approach to patients with psychogenic pain, including manage­ dent proneness, or manic episodes, as ment suggestions, is emphasized, with particular reference to the use well as a family history of either of extensive history for their identification and the importance of depression, alcoholism, or sociopathy minimizing unnecessary medical and surgical procedures. helps to corroborate the diagnosis.8 Once identified, depression (and accompanying pain) can often be re­ Evaluating pain complaints is a conversion symptom of hysterical lieved by a three-week trial of tricyclic large part of medical and surgical neurosis; (4) pain as a symptom of an antidepressants in the 100 and 200 mg practice.1 While pain is generally con­ unresolved grief reaction; and (5) pain per day range. It makes little differ­ sidered an indication of physical illness as a symptom of a “need to suffer.” ence which tricyclic antidepressant is or distress by both the patient and The following are brief case illustra­ used, so long as adequate doses are physician, it is often emotional in tions and discussions of each of the given over a long enough period of origin and not due to organic pa­ subgroups of psychogenic pain pa­ time. Should this fail to produce thology.2'4 Pain of emotional origin tients with emphasis on identifying significant improvement, electrocon­ or “psychogenic pain” is a real percep­ characteristics and management vulsive therapy might well be tion and is usually accompanied by all strategies. considered.9 the physiologic concomitants of or­ Case Presentations ganic pain. In addition, neurologic Psychosis findings such as paresthesias and func­ Depression tional motor weakness are common.2 Mr. L. is a 21-year-old, white, single Mr. F. is a 56-year-old, white, mar­ This similarity of organic and psycho­ machinist, admitted to the psychiatric ried accountant, father of two, genic pain frequently leads to unneces­ service complaining of persistent burn­ sary and inappropriate medical proce­ admitted to the surgery service with a ing pain in his right shoulder from dures or surgery to rule out any chief complaint of severe, continuous, “cosmic rays being broadcast by the possibility of organic etiology. Pain left upper quadrant abdominal pain of local radio station.” The patient’s medication or tranquilizers are fre­ three weeks’ duration. Medical evalua­ presentation and history were consis­ quently prescribed in lieu of manage­ tion, including complete laboratory tent with the diagnosis of schizo­ ment strategies appropriate to the and x-ray survey, was negative. Fur­ phrenic psychosis. He had received an emotional nature of the pain. Neither ther history revealed three months of electrical burn in his right shoulder at placebo trial nor psychological tests increasing depression. Symptoms the age of six, working in his father’s are reliable in differentiating the origin included early morning awakening, workshop. The patient’s acute psycho­ of pain.5 However, a productive loss of appetite, a 20 lb weight loss, sis and his pain resolved with anti­ approach is the use of extensive loss of interest in sex, unprovoked psychotic doses of phenothiazines. medical history and the clinical presen­ crying spells, and occasional suicidal Delusional pain may be seen in tation to identify patients with a high ideation. During the initial history, the many types of psychiatric illness other probability of psychogenic pain. These patient had presented only his pain than schizophrenia, including hysteri­ symptom. However, the symptoms of patients usually have characteristics of cal psychosis, mania, depression, toxic depression were obtained from the one or more relatively well-defined delirium, and other organic brain patient and his family upon direct subgroups: (1) pain as a symptom of syndromes. Like other delusions, the questioning. The patient responded to depression; (2) pain as a delusional pain is a fixed symptom, resistant to tricyclic antidepressants with complete symptom of psychosis; (3) pain as a all reassurance or medical evidence to relief of his pain. the contrary. The pain description is Pain is a well-documented symptom usually bizarre and is frequently of depression.6 Typically, a careful presented in a very atypical, symbolic history will reveal the onset of depres­ way. From the Department of Psychiatry, The University of Texas Medical School, sion preceding the pain complaint. The frankly psychotic patient is not Houston, Texas. Requests for reprints However, the patient sometimes com­ should be addressed to Dr. R. A. DeVaul, difficult to recognize. However, a brief Assistant Professor, Department of Psychi­ plains only of pain, and direct and structured interview may not atry, Health Science Center at Houston, The University of Texas, P.O. Box 20708, questioning of the patient and his reveal the extent to which a less Houston, Tex 77025. family regarding other signs and disturbed patient has lost contact with t h e JOURNAL OF FAMILY PRACTICE, VOL. 4, NO. 1, 1977 53 reality. A more extensive and non­ relationship, and occurs as a significant illness.12 When questioned, these pa­ directive history will usually demon­ part of any medical intervention. How­ tients report an inability to cry suffi- strate the patient’s chaotic state and ever, it is not useful in the differential ciently for the dead person, a need to reality impairment. These patients are diagnosis as it significantly relieves cry in order to feel relieved, a lack of best referred for psychiatric treatment. organic pain.11 In addition “fooling” conviction that they have been able to Appropriate antipsychotic treatment the patient jeopardizes the trust grieve, and often a history that they generally leads to resolution of the essential for a constructive medical have not attended the funeral. delusional pain and other symptoms of intervention. One striking form of unresolved psychosis. Effective management of this group grief reaction is illustrated by the case of patients frequently requires a two- example. The patient presented to the Hysterical Neurosis stage strategy. First, the physician medical service with symptoms of her Miss D. is a 14-year-old, white, high should reassure the patient that there deceased mother’s illness. Identifica­ school student, admitted to the sur­ is no evidence of serious medical or tion with the person who has died is a gery service with a chief complaint of surgical illness and suggest that he will normal part of grief; in unresolved crampy, lower abdominal pain. Medi­ feel better shortly. A minor analgesic grief, it may take the pathologic form cal evaluation was negative, including may be prescribed with the strong of enduring symptoms and signs of an laboratory and x-ray evaluation. The suggestion of relief. This will be illness of the person who died. The patient seemed relatively unconcerned especially useful for acute symptoms patient’s description of the pain about the pain and was noted to be that tend to begin and end suddenly. complaint is usually in the same terms seductive and manipulative. The pa­ For patients who fail to respond to as his description of a similar symptom tient described her pain as “like being reassurance and suggestion, the next of the deceased. in labor.” History revealed the patient step is confrontation. The patient is Patients with pain as a symptom of wanted to have a baby, and was unable told that there is no doubt about the an unresolved grief reaction are to deal with her sexual feelings. validity of the pain and suffering but important to identify to initiate Despite a diagnosis of conversion pain, in all likelihood it is a manifestation of proper treatment. Weekly counseling the patient was operated on with emotional stress. Following the usual with the family physician, minister, negative findings at laparotomy. mixed response of perplexity, anger, priest, or social worker often mobilizes Pain as a conversion symptom is a and disappointment, the patient may a grief reaction with complete relief of neurotic solution to a personal con­ be willing to discuss personal problems the symptoms. Counseling involves en­ flict. Its characteristics often include: and agree to appropriate counseling or couraging the patient to talk about the (1) a pain description that relates to social intervention. A genuine concern person who died and express the the underlying personal conflict (this and willingness to continue to follow intense attendant emotions. Since patient’s pain was described as similar the patient medically is crucial to this grieving is painful, the patient needs to''someone in labor and prevented her approach. support to proceed and frequently from acting on her desire to become feels worse before beginning to pregnant), (2) inappropriate indiffer­ Unresolved Grief Reaction recover.13 ence to the pain despite its continued Mrs. L. is a 24-year-old, white, presence, (3) sudden onset in an married mother of two, admitted to " 4 Need to Suffer" emotionally charged situation, (4) a the medical service, with intermittent Mrs. K. is a 45-year-old, white, pain description that defies neuro- substernal chest pain of two months’ married mother of two, admitted to anatomical boundaries, (5) an associ­ duration.