Psychosomatic reasons for chronic pains.

In this issue of the Southern Medical Journal, the review by J. Rubin on psychosomatic pain quoted a study in which it was found that “college students with chronic pain yielded a history of abuse (physical and/or sexual) in 43.5% of the females (275 subjects) and 23.8% of the males (151 subjects).” We suggest that as many victims of sexual abuse repress their memory of the incident(s), the actual number of those with chronic pain who have been abused may in fact be even higher. The most likely reason for this connection between abuse and chronic pain is the notion that strong negative emotions are repressed by the person in the emotionally painful moment of abuse. In holistic therapy, where the focus is on integrating body, feelings, and mind, we often find such feelings “hidden in the tissues and organs of the body,” causing not only pain but also actual disease. In a multidisciplinary treatment of a patient with chronic pain, it is therefore necessary to remain open to the possibility that the root cause may not be visibile initially and that it may indeed be quite ugly. One important conclusion reached in the review is that “clinicians should routinely ask chronic pain patients about any history of past or present abuse.” This inquiry is correct and very important, regardless of the presence of chronic pain. As severe cases will often be buried in shame, however, the physician is not likely to obtain this knowledge without first attaining a mutual level of trust and confidence. Personal development, improvement of the quality of life, awareness of deep existential dimensions, and purpose of life are all concepts that need to be addressed in the empowerment of the patient and that will subsequently help him or her deal with the pain. There is also the need for a new language for pain. The often-used expression “nonanatomic pain,” for example, is impractical, as most pains are diffused throughout the patient’s internal body image, even when the cause is indeed somatic. When physically exploring the cause of the pain, the physician needs to help the patient understand the location, quality, and nature of the pain. Such an understanding often transforms a diffuse, chronic, “nonanatomic” pain into one that is well defined and localized. When presented to the patient, the pain may even change in quality and location as the psychologic significance and meaning are addressed. This process of “confronting the pain in the body” is an important aspect of healing chronic pain in a holistic/multidisciplinary clinic. Indeed, it is therapeutic in its own right because a local, focused, and “understandable” pain is much more manageable for the patient than a diffuse pain. Because it is possible that a psychosomatic, emotional element is present in many diseases, we would therefore like to propose a new distinction in the linguistics of pain; pain that cannot be localized and attributed to an organic origin should be termed “primary,” whereas those pains that can be identified and associated with an organic source should be labeled “secondary.” The issue is complicated, for an organic pain, such as a chronic infection, may well be caused by trauma, which thus “blocks” the region of the patient’s body and duly disturbs immune system regulation. Processing the patient’s complicated and repressed feelings of guilt, fear, and shame is often very helpful in alleviating chronic pains in the clinic. What are urgently needed are tools that will help general practitioners and other physicians address this suppression; this processing is especially important in the treatment of adolescents and young adults. We believe that a holistic approach to both existence and sexuality will help us, as physicians, heal many pains and problems of psychosomatic origin in the future.