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  • Writer's pictureDerrick Schull

When they tell you the pain is all in your head...

Psychogenic Pain Disorder (PPD)

PPD refers to a person experiencing pain with no medical explanations for the pain. It has other names such as “Pain somatization disorder.” These terms essentially mean, we can’t find a reason for the pain so it is likely all in your head. To many, this diagnosis can be quite off putting and offensive. No one wants to be told they are crazy and the pain is all in their head. Often, the referral of pain patients to psychological practitioners is taken as an assault or lack of validation, as if the doctor isn’t really listening. It turns out, there is quite the debate in the scientific community on whether PPD is real or not. Can pain really be all in your head, or are we missing the true cause of pain in these patients? Let’s explore this concept more closely.

Psychological response to pain is normal

Often when someone is experiencing pain, it is accompanied by psychological complaints such as depression, anxiety, demoralization, or irritability. We don’t have to look far to see there is a connection between the two. One logical explanation is that pain is so uncomfortable it makes us psychologically miserable. In this case, once the pain is removed, the psychological aspects should vanish as well. Therefore, this is not what we are talking about with PPD. In PPD, patients have pain and psychological complaints and there has not been any way to eliminate the pain, so the psych complaints persist.

Can pain be caused or altered by our emotions or other factors?

Scientific studies have shown that people getting sham/placebo pain treatments often feel the pain getting worse. Normally, pain would be experienced as the same or improved in accordance with standard placebo effects. This indicates that there is an expectation or psychological cause behind the experience of pain. Other experiments have used dense sensory-motor blocks to stop extremity pain, to no effect. In these cases, the nerve is completely blockaded against sending a pain signal, yet the patient still experiences pain. In interesting primate studies researchers conditioned monkeys to expect a painful stimulus and saw their brains (with imaging techniques) creating a pain response before any pain stimulus was applied. Meaning they felt pain without any cause aside from they expected to feel pain.

We also have research that shows when experimental subjects watch something that induces fear, excitement, or other intense emotions, the parts of their brain that process pain will become active. Furthermore, it is well understood that people who undergo extreme traumas will present with many symptoms, including pain,that have no physical explanation.

We can compare PPD to a similar disorder called “phantom pain.” This is where amputees still feel pain in the part of their body that was removed. In these incidences, pain is being generated in the nervous system and has nothing to do with pain from the perceived source. Similarly, there is a theory called “pain memory” where the nervous system retains a pain single long after the source has been healed. These both suggest that pain is legitimate, had an original source, but persists for some unknown reason. Could it be that PPD similarly had an original source, but the brain/nervous system has gotten stuck in a pain signal loop?

It would also seem there is a big confounding factor when it comes to studying pain. A study on more than 2000 lower back pain patients found that all of those working at the time of initial pain consultations returned to work, with the exception of those in litigation, of whom not one returned to work. These patients have been shown to improve the same amount in pain programs, but still claimed no improvements in quality of life and higher rates of disability. In other words, if there is an incentive to be in pain, then pain is experienced worse. It is not clear if this is unintentional, or if there is in fact malingering/faking the pain to maximize re-imbursement. Studies on malingering show that between 1.25% and 10.4% of compensation claims have confirmed misrepresentations of symptoms. That means we cannot ignore that there are in fact people that are faking it, but this does not account for the majority of chronic pain patients.

As you can see, there is quite a web of factors contributing to pain syndromes. From research, it seems reasonable to conclude that pain could in fact be caused by (or exacerbated by) psychological changes. There is clearly evidence supporting PPD as a diagnosis, but figuring out if a patient is misdiagnosed, malingering, exaggerating their pain for sympathy and attention, or has a true psychogenic pain disorder can be a tall order. What’s important is that many people find resolution by exploring alternative methods.

How to approach PPD

I personally can speak to having great success with all types of pain when utilizing alternative therapies. In my experience, many patients are being labeled inappropriately with PPD, likely because their other practitioners did not have further tools to evaluate and heal pain. I always start by assuming that the pain is real and has a source (even if the brain is the source). If you have this disorder, review your detailed history, including: all injuries, psychological events/traumas, and all past tests. Finding the cause is always number 1. The best treatment is always going to be a holistic, individualized approach.

Here are the key interventions for anyone suffering with pain (including PPD):

Reduce inflammation - Both pain and psychological disorders are often related to inflammation in the body. It may be that pain and psychological changes occur together and are both a sign of one big underlying issue, and thus both have to be treated together for complete resolution. Correcting the microbiome, gut permeability, and removing food intolerances are essential to any protocol as this will reduce inflammation.

Use holistic healing systems - homeopathy and acupuncture are excellent at addressing the mind and body together. Make sure to have these types of practitioners on your healing team.

Low Energy Neurofeedback – this is one of my preferred treatments for difficult to treat pain symptoms. This technology is capable of retraining nerve signals and brain processing of pain signals. I have had many patients where this is what finally got their pain to go away.

Balance the musculoskeletal system – this usually requires one or more professionals in the fields of physical therapy, chiropractic, naturopathic, craniosacral therapy, massage therapy, or others that can help recondition muscles and bones. Work to strengthen and stretch appropriate muscles can do wonders for reducing mysterious pain.

Photonic stimulation – low level laser therapies are well researched for reducing pain and inflammation of muscles and joints. Certain devices are capable of calming down nerve conduction to reduce pain. They also stimulate mitochondrial activity which hastens healing of the treated tissues.

Seek out a psychologist who specializes in pain disorders - this will, at the very least, help you cope with having chronic pain (which will reduce your experience of it). Best psychological therapies for pain/PPD: operant-behavioral therapy, cognitive-behavioral therapy, mindfulness-based therapy, and acceptance and commitment therapy.

Stay engaged - Pain is down regulated by being distracted. Simply keeping yourself busy will alleviate pain.

Exercise - well proven to alleviate pain, as long as you are not making it worse.

Hypnosis – this works entirely on re-writing subconscious beliefs and are great for modulating and reducing pain.

Build your pain healing team!

Be well,

~Dr. Schull

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