When Stress Hurts: Curing Psychogenic Pain

villa-Era-Vigliano-Biella_Current treatments that effectively reduce or eliminate psychogenic pain is the subject of this, the sixth and last post in the series on the close association between psychological stress and psychogenic pain. Encouraging news for psychogenic pain sufferers from the pharmacist: A growing number of patients reports that by taking antidepressants they have experienced a significant reduction in the frequency and intensity of pain. More specifically, relief of psychogenic pain with antidepressants has now been thoroughly documented in the treatment of pain associated with bulimia (Faris et al., 1998), vulvodynia (Stolar & Stewart, 2002), chronic pain of undefined origin (Davis, 1990; Pilowsky & Barrow, 1990), migraine headaches (Kaniecki et al., 2006), chronic pain associated with depression (Bradley, Barkin, Jerome, DeYoung, & Dodge, 2003), functional bowel disorder (Drossman, Toner, & Whitehead, 2003), neuropathic pain (Fishbain, 2000; Saarto & Wiffen, 2005), and post-herpetic neuralgia (Max, 1994).

Non-pharmaceutical Treatments

As we have seen in a previous post, there is a strong emotional and affective component to pain of any origin, whereby pain always has a depressive effect on our mood. There is also ample evidence that pain is often the unwelcome companion of depression, anxiety, psychological trauma, anger and irritability. Even the mere expectation of pain, in the absence of any noxious stimuli, appears sufficient to produce it  and its perception, as has been documented in functional MRI (fMRI) changes to specific brain structures (Fields, 2000; Keltner et al., 2006). Conversely, diverting cognitive attention or causing distraction can mitigate pain, as shown in PET scans of cortical activation (Petrovic, Petersson, Ghatan, Stone-Elander, & Ingvar, 2000).

SH_Rcmds_sm UnlearnPain_BookHoward Schubiner, MD and Michael Betzold are the authors of Unlearn Your Pain, an excellent book that seeks to help reverse chronic pain by promoting a thorough understanding of its principal cause, learned nerve pathways (see Stresshacker’s explanation of the concept in this post). It offers a revolutionary step-by-step process that has been reported to work well by many psychogenic pain sufferers. It is Stresshacker’s recommended book resource.

Psychological Treatments That Can Eliminate Psychogenic Pain

The effectiveness of purely psychological interventions in the relief of chronic or acute pain is supported by the fact that pain and stress share many of the same biochemical processes, neural pathways and CNS structures (see this post for a full explanation).

Decreasing psychological stress through better stress management or counseling has been documented as effective in treating low back pain that is co-occurring with depression (Middleton & Pollard, 2005). There is also evidence that psychosocial interventions are efficacious for pain secondary to arthritis or cancer (Keefe, Abernethy, & Campbell, 2005). Multidisciplinary approaches, including relaxation therapy, biofeedback, behavior modification, hypnosis, desensitization and cognition therapy, have also been proven successful in treating chronic pain of unknown origin (Singh, 2005). Biofeedback therapy can be particularly successful in reducing colorectal pain (Jorge, Habr-Gama, & Wexner, 2003). Hypnotherapy, cognitive therapy, and brief psychodynamic psychotherapy appear to work well in patients suffering from irritable bowel syndrome (Blanchard & Scharff, 2002). Hypnosis has been proven effective in relieving oral pain (Golan, 1997), cognitive behavioral therapy for functional bowel disorder (Drossman et al., 2003), behavioral therapy for the treatment of headaches (Lake, 2001); and family therapy interventions have been associated with successful psychogenic pain treatment (Liebman, Honig, & Berger, 1976; Roy, 1987).

Previously in this series:

When Stress Hurts: The Credibility Gap

StMarksSquare_EN-US761640507How the brain processes and maintains psychogenic pain is the subject of this, the fifth post in the series on the close association between psychological stress and psychogenic pain. Hope is hard to come by for swift and lasting relief of chronic back pain, muscle pain, headaches, migraines, stomach pain, and other stress-related conditions. Medication can help but carries the dangers of addiction or dependency. Non-medical remedies do exist and can work well, but may not be as well known or easy to apply. So the pain continues without relief in sight. And then there is the credibility gap.

Unbelievable Pain That Is Hard To Believe

Even though there is no diagnosable medical condition in the body, and even though
the physical injury that may have originated the pain is now healed, the pain is real. Unexplained. Mysterious. Intense. This is hard to accept by the sufferer, by family and friends, by physicians and pharmacists. There is no “proof” of its existence or intensity that anyone can see. This apparent credibility gap, in itself, creates additional stress to the pain sufferer, which (you guessed it) creates even more pain.

The best illustration, and the best indirect proof that psychogenic pain is real, is offered by “phantom limb” pain, a well-known condition not uncommon among amputees. Significant pain is felt in an arm or a leg that has been amputated. Clearly, there can not be anything wrong with a limb that is no longer there—yet this pain can be excruciatingly intense. What’s going on? What we know about phantom limb pain is that it is created by overly sensitized nerve endings that stop at the point of amputation, but continue to transmit previously learned and now outdated pain information along “stuck” pathways to the brain, as if the arm or the leg was still there. These pathways produce a continuing cycle of pain that can last for months, years, or even decades.

A similar phenomenon of “stuck” pathways takes place in psychogenic pain. Let’s see how it works.

How the Brain Processes Psychogenic Pain

Psychogenic pain is produced when overly sensitized nerve pathways are established between the brain and certain parts of the body, which may be initially provoked and later maintained by a continuing psychological stressor.  The nervous system learns to process psychological distress along these neural pathways (exactly why this happens we aren’t quite sure) and the longer the stress goes unattended, the more sensitized and overactive these peripheral nerves become, producing significant amounts of pain to the muscles, the head and other parts of the body.

The brain interprets these nerve signals and transforms them into the experience of pain. The event that started this learning process in the nerves may have been an injury or a stressful event earlier in life, or the pain may just appear without any directly verifiable reason. Only a careful and detailed look at our current situation and life history can reveal the stressors that may have originated and continue to maintain psychogenic pain.

The Case for Fibromyalgia

Musculoskeletal pain localized in the lower back, shoulders, and arms appears frequently to be unrelated to physiological disease. Fibromyalgia has reportedly become one of the most frequent reasons for patient referrals to rheumatology clinics. It is a disorder that affects many musculoskeletal structures and is characterized by persistent pain, sleep and mood disturbances.

Fibromyalgia origins have been traced to stuck pain pathways in the central nervous system, which cause decreased levels of pain-reducing serotonin and increased levels of substance P in the cerebrospinal fluid. These pathways are further reinforced over time by a stress reaction to the pain. Just about everyone who has chronic fibromyalgia pain reacts to it with fear, anger, anxiety, frustration, and other negative thoughts and emotions. Anger and sadness specifically have been recently linked to an increase in fibromyalgia pain.

Psychological stressors, negative thoughts and emotions, conscious or subconscious,  thus appear to be major causative factors in psychogenic pain and its related syndromes, such as fibromyalgia. The decreased activity, diminished income, difficult relationships that are byproducts of constant fibromyalgia pain do nothing but add to the misery of it all, making the pain-producing nerve pathways even stronger.

In our next and final post on this series we will take a look at the medical and non-medical remedies that have been devised to cure psychogenic pain.

Previously in this series:


  • Medical and Non-Medical Treatments for Psychogenic Pain

When Stress Hurts: The Psychology of Pain

SerraDosOegaos_EN-US952673641Psychological factors that play a role in the onset of physical pain are the subject of this, the fourth post in the series on the close association between psychological stress and psychogenic pain.

Likely Causes of Psychogenic Pain

Negative interaction with one’s spouse has been correlated with the sudden appearance of pain symptoms in otherwise healthy individuals (Campbell, 2002; Hughes, Medley, Turner, & Bond, 1987). Numerous studies show that the appearance of pain is often closely associated with the onset of psychological stress, financial problems, job dissatisfaction (Melin et al., 1997), unemployment, and with other less severe but long-lasting life stressors (Bennett et al., 1998). Covington (2000) speaks of a continuum of suffering of pain and stress and suggests the terms “psychologically augmented pain” (p. 292) to describe physical suffering that appears to be at least partially caused by psychological factors.

Chronic stress in adults, especially over many years and of particular severity, often results in alterations in the allostatic control system, which in the case of gastrointestinal disorders can lead to an exacerbation of symptoms (Bennett et al., 1998). Earlier in life, significant stressors in an infant’s life have been shown to produce a permanent upward modification in the levels of Corticotrophin Release Factor secretion and in the overactivation of the locus ceruleus (Ladd, Huot, Thrivikraman, & al., 2000). Moreover, prolonged abuse or neglect at any stage of life has been linked to a permanent alteration of the HPA axis response to stressors (Heim, Newport, & Heit, 1999).

Certain life stressors have been positively linked with the onset and persistence of gastrointestinal disorders, including inflammatory bowel disease (IBD), irritable bowel syndrome (IBS), functional gastrointestinal disorder (FGD), and gastro-esophageal reflux disease (GERD). Research has also established a correlation between acute stress in adults (such as rape or combat situations) or early life stressors (such as child abuse) and the later onset of these gastrointestinal disorders (Mayer, 2000).

Stress-related Muscle and Bone Pain

Pain in the muscles and joints is often associated with stress. Musculoskeletal pain localized in the lower back, shoulders, and arms appears frequently to be unrelated to any disease and thus bear all indications of having psychological causes (Harkness, Macfarlane, Silman, & McBeth, 2005). Researchers postulate that an increase in this type of pain observed in data collected by the Arthritis Research Campaign over a 40-year span may be due to “an increase in the proportion of the population who are psychologically distressed”  (Harkness et al., 2005, p. 893).

Other research suggests that musculoskeletal pain may be caused by multiple factors such as psychosocial environment, individual personality, specific behaviors, and mental stress. A study by Melin and colleagues (1997) on several hundred factory workers, assembly line workers, and supermarket cashiers suffering from musculoskeletal pain showed that the telltale signs of strong HPA axis activation, i.e. urinary catecholamines and cortisol, salivary cortisol, blood pressure and heart rate, and norepinephrine output all increased due to psychological stress.

Stress, Mental Health and Pain

Physiological pain and psychological disorders such as depression often coexist. Blackburn-Munro & Blackburn-Munro (2001) reported that while approximately 30 percent of individuals who report pain are diagnosed with clinical depression, 75 percent of patients diagnosed with depression also suffer from physical symptoms, including pain. Drossman (1982) provided evidence that individuals who seek medical help for irritable bowel syndrome are significantly more likely to present with psychiatric disorders, abnormal personality patterns and greater life stress.

Katon et al. (2001) in their extensive review of large epidemiological studies found that headache and other variously localized pain are associated with approximately 50% of visits to primary care physicians, and that most of the time, no clear medical explanation of the pain symptom is found. Stressful life events, anxiety and depressive disorders, childhood and adult trauma, and specific personality traits have all been found to be associated with multiple physical symptoms. Kroenke & Mangelsdorff (1989) reviewed over 1,000 patient records and noted 567 new complaints of chest pain, fatigue, dizziness, headache, edema, back pain, dyspnea, insomnia, abdominal pain, numbness, impotence, weight loss, cough, and constipation, and that an organic etiology was demonstrated in only 16% of these cases.

Finally, data from the World Health Organization’s study of psychological problems in general health care was used by Gureje and colleagues (2001) to examine the course of persistent pain syndromes among 3197 randomly selected primary care patients in 14 countries, which evidenced a strong and symmetrical relationship between persistent pain and psychological disorders.

Previously in this series:


  • Fibromyalgia, Severe Headaches and Other Stress-Related Misery
  • Medical and Non-Medical Treatments for Stress and Psychogenic Pain

When Stress Hurts: Neurochemistry Cognates

In this third post in the series on the close association between psychological stress and psychogenic pain, we take a look at neurochemical substances that are involved in the process of psychogenic pain generation and reaction to psychological stress.

The Neurochemistry of Pain: Substance P

aaGiotto_DeposizioneSubstance P, discovered in the 1950s, is the quintessential pain neurochemical, which is activated in response to physiological pain as well as to psychological stress (DeVane, 2001). It is a prototypic neuropeptide of the tachykinin family that has been linked to the production of over 50 neuroactive chemical substances (Brain & Cox, 2006). Its best documented role is as the modulator of signals to nociceptive neurons that communicate the intensity of noxious or adverse stimuli, not only those caused by pain but also those produced by psychological stress (DeVane, 2001; Shaikh, Steinberg, & Siegel, 1993). Substance P receptors are found throughout the CNS but especially in the substantia gelatinosa of the dorsal horn, which is the first point of arrival of afferent pain signals to primary nociceptive fibers.

It is not coincidental that Substance P is also present in the limbic system of the CNS, in the hypothalamus and in the amygdala, all structures that are closely associated with the perception and processing of emotions (Bannon et al., 1983; Culman & Unger, 1995; DeVane, 2001; Stahl, 1999).

Some purely psychological and psychogenic reactions of the organism also see the involvement of substance P, such as the vomiting reflex, anger and defensive behaviors (Krase, Koch, & Schnitzler, 1994), changes in cardiovascular tone (Black & Garbutt, 2002), stimulation of salivary secretions, and other physiological responses that are associated with the general adaptation of the body (Selye & Fortier, 1950) to stressful stimulation.

Kohlmann and colleagues (1997) reported the discovery of substance P in blood pressure regulation in individuals with essential hypertension, a condition that has been related to maladaptive responses to stress (Palomo et al., 2003) and has been shown to respond to psychotherapeutic interventions (Amigo, Buceta, Becona, & Bueno, 1991). Other evidence of the concurrent role of substance P in signaling pain and in the stress reaction comes from animal studies that show an array of defensive behavioral and cardiovascular changes in animals subjected to stressful stimulation (Krase et al., 1994), as well as the detection of substance P in the amygdala of laboratory animals upon neonatal separation (Kramer et al., 1998).

The Neurochemistry of Stress

The neuroendocrine response to a real or perceived stressor consists of the near simultaneous release by the sympathetic nervous system (SNS) of the catecholamines norepinephrine (NE) and epinephrine, the release by the hypothalamus of corticotrophin releasing hormone (CRH), the inhibition by the hypothalamus of gonadotropin releasing hormone (GnRH) and pituitary gonadotropins, the release by the pituitary gland of prolactin (PRL), and the release by the pancreas of glucagon (Sapolsky et al., 2000).

Upon release of NE into the synaptic cleft, approximately 10% of it enters the plasma, thus making plasma NE levels one of the most reliable measures of SNS activity and the magnitude of the body’s response to stressors. Peroutka (2004) has proposed that a migraine attack may be triggered by a significant decrease of NE due to the excessive or prolonged release of adenosine, dopamine and prostaglandin by the over-stimulated SNS. Since sympathetic activation is the primary component of the stress response, stress is thus unequivocally linked to the onset and maintenance of migraine headaches.

The Closest Association: Stress-Induced Analgesia

Livingstone_LionRThe body’s reactivity to real or perceived stressors provokes measurable changes in the autonomic nervous system (ANS) and in the structures controlled by the hypothalamic-pituitary-adrenal (HPA) axis. These changes include blood pressure elevation, pupil dilation, and secretion of cortisol. In the presence of a significant stressor, the stress response also includes a “stress induced analgesia,” or a decreased sensitivity to further pain (as writer-explorer David Livingstone so eloquently reported). This antinociceptive action of the ANS translates into an inverse relationship between blood pressure and pain sensitivity in animals and humans, and is designed to maintain the integrity of the body’s defense systems. Additionally, the release of CRF by the hypothalamus has known analgesic effects (Okifuji & Turk, 2002).

The ANS was recognized by Cannon (1914; Cannon, 1933) as the originator and enabler of the “fight or flight” response to stress. Stress-related releases of adrenaline stimulate the feedback provided by the afferent and efferent vagal fibers. Once again, these same fibers are involved in the activation of endogenous pain modulation centers (Bielefeldt, Christianson, & Davis, 2005). Pain and stress just seem to go together.

Previously in this series:


  • Psychological Stressors and the Sudden Appearance of Psychogenic Pain
  • Fibromyalgia, Severe Headaches and Other Stress-Related Misery
  • Medical and Non-Medical Treatments for Stress and Psychogenic Pain

When Stress Hurts: Central Nervous System

In establishing the connection between the onset of psychogenic pain and stress, it is important to notice that pain and stress share the same central nervous system (CNS) pathways and structures. In this second post in the series on the close association between psychological stress and psychogenic pain, we’ll take a look at these shared structures.

CNS Structures Mobilized by Pain and Stress

PendulumThe body’s response to pain engages a large number of CNS structures that are often the same as the ones activated by the stress reaction. The afferent pathways that carry pain signals connect to the thalamic nuclei and from there to the somatosensory, insular and anterior cingulate (ACC) portions of the brain cortex. A recent functional MRI (fMRI) study (Keltner et al., 2006) on the effects of pain expectation on pain transmission provides the best evidence for the activation of the rostral ACC (rACC), periaqueductal gray (PAG), and medial prefrontal cortex. This and other imaging studies provide evidence of a bidirectional pain pathway receiving input from the limbic system and the amygdala, converging on the PAG, traveling through the pontomedullar nuclei, and controlling spinal pain transmission neurons (Fields, 2000; Fields & Martin, 2001). As the authors of this study point out, “expectation for a higher intensity noxious stimulus increases subjectively experienced pain intensity in part through the action of a descending pathway that facilitates nociceptive transmission at and/or caudal to the region of the contralateral nucleus cuneiformis (nCF)” (p. 4442). The nCF, in humans and other primates, has a composition similar to the PAG and its neurons project directly into the rostroventral medulla, the hypothalamus and the amygdala, all structures directly involved in modulation of the stress reaction.

PMR_muscle-crampsLikewise, the body’s stress response engages a large number of the same CNS structures, specifically certain subregions of the hypothalamus such as the paraventricular nucleus (PVN), the amygdala, and the periaqueductal grey; and certain cortical brain structures, such as the medial prefrontal cortex and subregions of the anterior cingulate and insular cortices (Maier, 2003). These structures provide output to the pituitary and pontomedullar nuclei, which in their turn stimulate the body’s neuroendocrine secretions, as well as to the hypothalamic-pituitary-adrenal (HPA) axis, the endogenous pain modulation system, and the ascending aminergic pathways. The feedback controlling the stress response is provided by the serotonergic (raphe) and noradrenergic (locus ceruleus) structures and by the levels of glucocorticoids in the blood stream, which provide inhibitory impulses to the medial prefrontal cortex and to the hippocampus. Corticotrophin releasing hormone (CRH) is the fundamental chemical substances mediating the stress response, which is secreted by PVN, amygdala, and locus ceruleus neurons. Acute or chronic stress can temporarily or permanently modify the level of responsiveness and output of the CNS to stress (Bennett et al., 1998).

Sharing Pathways, Sharing Outcomes

With this significant convergence of pathways, neurochemical activity and CNS structure activation, it should come as no surprise that acute stress can provoke physical pain, often in the head, the muscles, and the abdominal region. Equally unsurprising is that pain, especially when sharp and unexpected, is in itself a cause of stress that mobilizes the body into immediate action (think of the hand that immediately goes to cover the cut or the burn). Continuous pain, of any origin, is inherently stressful. Continuous stress can be, and often is, manifested by otherwise unexplained (thus psychogenic) physical pain.

Previously in this series: When Stress Hurts: Psychogenic Pain


  • The Neurochemistry of Psychogenic Pain and Stress
  • Psychological Stressors and the Sudden Appearance of Psychogenic Pain
  • Fibromyalgia, Severe Headaches and Other Stress-Related Misery
  • Medical and Non-Medical Treatments for Stress and Psychogenic Pain

When Stress Hurts: Psychogenic Pain

PendulumThis post kicks off a Stresshacker series on the close association between psychological stress and psychogenic pain. Psychogenic pain is by definition a physical pain that can only be associated with psychological stressors. Psychogenic pain is said to occur when all possible organic causes of pain are ruled out and its symptoms cannot be associated with a medically diagnosed condition. There can be a stigma associated with this type of pain as being “all in one’s head,” and the suffering it causes has often been discounted or dismissed as unexplainable and therefore not treatable with conventional medical approaches.

I’m 23, and have had chronic pain since I was in middle school. Doctors always brushed it off, saying it was "growing pains" or "all in my head." About two years ago, I was given the diagnosis of fibromyalgia. I felt like that doctor visit was a waste of time. I certainly do believe that fibromyalgia is a real condition, but that was not what was wrong with me. Doctors are quick to throw some label on patients to placate them… — Mrs. Smith of SC @ Aug 21, 2010 21:20:28 PM

Pain, of any kind, is a complex peripheral and central nervous phenomenon that acts as a signaling mechanism, usually indicating the presence of injury or disease. The International Association for the Study of Pain (IASP) defines pain as, “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” Pain is more than just physical since, like all human experiences, it includes a cognitive and emotional component.

spinozaThe 17th century philosopher Spinoza recognized the emotional and physical valence of pain when he defined it as a “localized form of sorrow.” This definition is particularly appropriate when pain is present in all its debilitating intensity and does not appear to be a sign of injury or a diagnosable illness.

The persistence of unexplained pain to shoulders, upper arms, lower arms, hips, upper legs, lower legs, jaw, chest, neck, or abdomen can lead to a diagnosis of fibromyalgia especially if associated with other symptoms such as irritable bowel syndrome, fatigue, anger and sadness, problems thinking or remembering, muscle weakness, abdominal pain or cramping, numbness or tingling, dizziness, insomnia, depression, constipation, nausea, nervousness, chest pain, fever, dry mouth, itching, frequent or painful urination, or wheezing. Treatment for fibromyalgia can range from powerful prescription pain killers (which can be dangerously addictive) to gentler and often as efficacious non-medical approaches such as psychotherapy and tai chi.

That a reciprocal association exists between psychological stress and unexplained pain symptoms has long been observed in clinical settings. A significant number of patients suffering from psychogenic pain also complain of stress, often made worse by other psychological disturbances such as depression or anxiety disorders.

A review of recent medical literature on pain and stress yields strong evidence for increased sensitivity to stress in patients with psychogenic pain, and vice versa. Studies conducted in the last decade suggest that psychogenic pain and stress are psychological and sensory experiences that require a multidisciplinary, biopsychosocial approach in their treatment.

Next in this series:

  • Psychogenic Pain, Stress and the Central Nervous System
  • The Neurochemistry of Psychogenic Pain and Stress
  • Psychological Stressors and the Sudden Appearance of Psychogenic Pain
  • Fibromyalgia, Severe Headaches and Other Stress-Related Misery
  • Medical and Non-Medical Treatments for Stress and Psychogenic Pain