Dr Simon Clarke ~ All in the mind? The Dynamics of Chronic Pain

As a clinical psychologist working in chronic pain (CP), the question I get asked most by lay people (apart from whether I am reading their mind) is why bother? The thinking is usually this: pain is a physical experience that results from an injury of some sort, which surely requires a physical (usually medical) remedy. The implication from this, of course, is that I’m a psychologist and so I deal with ‘mental’, and not physical, experience. And as pain is clearly a physical experience, what am I doing in pain?

This form of thinking, which the philosopher John Searle called ‘residual dualism’ (Searle, 1984), is perhaps understandable in non-professional people, especially since such dualisms permeate many aspects of Western culture. However, such ontological faux pas are less forgivable with experienced medical professionals who perhaps should know better. The amount of times I have been asked by medics whether this patient’s pain is “all in their head”, or if I can please tell them whether their pain is “psychological” or “physical”. As if these things are mutually exclusive! Sometimes archaic, cod-Freudian gems are wheeled out for effect: a patient is described as having “psychogenic” pain or being a “somatizer”.

Unfortunately, these statements quoted above betray a fundamental misunderstanding about the nature of body/brain perception. Pain is a complex experience that involves a dynamic interplay between physiological, emotional and psychological (cognitive) elements. Theories based on experimental neuroscience see CP as a failure of the brain and nervous system to regulate pain signals from previously damaged pain areas. Pain can thus be likened to a faulty alarm system that has not been switched off, even though the initial emergency has passed (see Weich & Tracy, 2009). Psychological factors such as heightened pain expectation, experiential avoidance, trauma, mood disorders and stress are crucial factors maintaining this alarm system (Gatchel et al., 2007). As the International Association for the Study of Pain have pointed out, “[pain] is unquestionably a sensation in a part or parts of the body but it is also always unpleasant and therefore also an emotional experience [emphasis added]” (Merskey, 1986, p. 1, as cited in Gatchel et al., 2007). The pain experience is integrative: you simply cannot separate the “physical” from the “psychological”. It is phenomenological nonsense.

Suffering with a pain condition can be a horrible experience. CP disrupts vocational/educational functioning, relationships, sexual functioning, interests/hobbies and overall quality of life. It is very common for people to have repeat hospital appointments with different departments, have to undergo multiple scans/investigations/medication etc. which usually leads to inclusive diagnosis and/or treatment. Often they have to battle with stigma from family, friends, wider society and even within the medical professions. They are often accused of making it up, exaggerating their symptoms or malingering. Not surprisingly given all of this, mood problems in people with CP are common (Gatchel et al., 2007).

Medical systems perpetuate this process with the notion of a catch-all diagnosis and binary, either/or dichotomous evaluations. A careful balance has to be struck with patients between gently pointing out the importance of psychological factors, without reinforcing earlier messages that they are making it up or it is all “in the mind”. This can be a liberating message for patients that can help people finally move on with their life. Isn’t it time for our medical systems to do the same thing?

Posted by:
Dr Simon Clarke
Clinical Research Psychologist (Physical Health Speciality)
University Of Nottingham and Nottinghamshire Healthcare NHS Trust

Gatchel et al. (2007). The biopsychosocial approach to chronic pain: Scientific advances and future directions. Psychological Bulletin, 133, 581-624.

Merskey, H. (1986). International association for the study of pain: Classification of chronic pain. Descriptions of chronic pain syndromes and definitions of pain terms. Pain, 3(Suppl.), 1–226.

Searle, John. (1984). Minds, Brains and Science: The 1984 Reith Lectures. Harvard University Press.

Wiech, Katja, and Irene Tracey. (2009). “The Influence of Negative Emotions on Pain: Behavioral Effects and Neural Mechanisms.” NeuroImage 47, no. 3,  987–994.



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