There is a “pain” that effects a person so deeply that its origin cannot be found in simple diagnostic testing for a physical malady. All people who present to physicians with chronic bodily pain are not necessarily experiencing a physical ailment.
This posting will be an attempt to generally describe this group of psychiatric disorders that has been reclassified in the Diagnostic and Statistical Manual of Mental Disorders V (DSM-V) published by the American Psychiatric Association. I have entitled this posting “The Mystery of Psychological Pain.”
As a retired Pain Management physician I am reminded that, in addition to the challenge of correctly identifying the physical cause for a patient’s chronic pain, that there is a subset of patients that actually do not have a physical reason for their “pain”. This does not necessarily mean that the patient is being willfully dishonest.
The first well described pattern of this type of patient was published by Dr. Richard Asher in 1951. He described a pattern of self-harm where a patient would fabricate their history, symptoms, and physical findings. The person had often travelled widely and was a dramatic story teller. Upon attempted verification of their dramatic stories they were often found to have been lying or distorting the truth.
Dr. Asher affectionately called the disorder “Munchausen’s Syndrome” named after Baron von Munchhausen, a well-known story teller from the 1700s. The Baron used to entertain guests at his home and tell colorful stories about his exploits.
He became famous when a contemporary writer published a book anonymously about him using fantastic and impossible stories (fictionalized by the writer). Perhaps he intended to embarrass the Baron, but instead, made his name famous.
In Dr. Asher’s rendition of “Munchausen’s Syndrome” the affected person exaggerates or creates symptoms of illnesses in themselves to gain the attention and treatment of medical personnel. There is a peculiar and elusive type of psychopathology that underlies this type of behavior.
The patient often succeeds in their efforts, therefore having unnecessary surgical procedures and often succumbing to the complications related to multiple abdominal surgeries. It is essential that medical doctors are aware of the risk that these patients pose to themselves and the medical licenses of those who treat them.
The Most Current Diagnostic Definition
The DSM-V calls these disorders, such as Munchausen’s Syndrome, Somatic Symptom Disorders (SSD). These are a group of psychiatric disorders that have no organic or physical (somatic) cause for the bodily symptoms that the patient complains about. I want to emphasize to you that simple dishonesty is not the only mechanism at work (though it could be in certain cases).
Unlike the classical dishonest person, many of these patients offer their symptoms at quite a physical cost to themselves or others without much practical gain. They often end up disabled and unproductive. This category of disorders is not rare.
It is estimated that they are the third leading cause of psychiatric illness (after Anxiety and Depression). Females seem to be at a much higher risk for this type of mental illness (almost a 10:1 female to male ratio). The overall incidence in the American population is estimated to be 12%.
The clues to an underlying SSD would be as follows:
- Historical evidence of visiting multiple different medical practitioners. Usually they will not have one primary doctor that is coordinating their care.
- There will be an anthology of medical diagnostic studies that will have been performed. The studies will be universally without any abnormalities that explain their pain.
- The history is usually dramatically explained by the SSD person. There may be inferences that the other doctors simply “did not understand them” (despite having performed an extensive work-up).
- Any reference for need to consider a psychiatric cause for their pain is usually met with disdain and dramatic refusal for psychiatric consultation.
- There may be physical evidence of multiple surgical scars on physical examination. Investigation of the previous surgical findings will show no evidence of abnormalities.
- All objective findings for a physical cause for their pain will be negative.
As you can see, convincing a person that there is no physical explanation for their “pain” can be very challenging. Physicians rely upon the accurate and honest medical history of a patient in order to arrive at a proper diagnosis. There is no diagnostic study that can replace the accurate medical history on a patient.
The Neuro-Physiology Of Ssd
There have been several recent reports in the neuroscience literature that seem to indicate that brain function in a person with a SSD is perturbed. It seems that the neural connections between the front of the brain (frontal cortex) and the amygdala (an almond sized portion of the brain located deep in the temporal lobe) are poorly developed.
The amygdala is integral for processing emotional information. The frontal cortex is essential for processing information regarding impulse control and decision making. Under development in these areas would lead to inaccurate processing of emotional information, impulsivity, and immaturity.
The Psychology Of Ssd
Why would a person feign chronic abdominal pain?
What is to be gained? In some cases there may be a motivation to obtain narcotic pain medicine. Most doctors would be loath to prescribe chronic pain medications without any objective findings on physical examination or diagnostic testing.
The psychology of the SSD person is thought to be more complex than simple deception. This type of patient often has little in the way of a family support system. The SSD patient may be seeking emotional support and uses the physical presentation for the “secondary gain” of the emotional support of medical personnel.
The actual psychological mechanism has not really been worked out. Much more scientific study is necessary for this very challenging group of psychiatric illnesses.
The mystery of psychological pain has yet to be understood. As you can imagine, well controlled studies will be difficult to arrange given the nature of this type of psychiatric illness. What you cannot accurately study you will not be able to understand.
Somatic Symptom Disorders (which includes psychological pain) will need to be a priority for future study given the large number of people that are likely to develop this disorder in the near future.
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