OUP user menu

The Chronic Pain Syndrome: Don't Forget the Unconscious Mechanisms!

Benjamin L. Crue Jr. MD, Jack Pinsky MD
DOI: http://dx.doi.org/10.1111/j.1526-4637.2008.00536.x 6-7 First published online: 1 January 2009

“Pain is always subjective.” “Many people report pain in the absence of tissue damage or any likely pathophysiological cause. Usually this happens for psychological reasons. If we take the subjective report, there is often no way to distinguish their experience from that of pain due to tissue damage. If they regard their experience as pain and it is reported in the same ways as pain caused by tissue damage, it should be accepted as pain”[1,2].

There is no disagreement about their being “many people” who suffer with and report pain in the absence of any demonstrable current pathophysiological cause. And, pain is a subjective complaint. This has been validated repeatedly by extensive diagnostic evaluations done by clinicians who work with patients who suffer chronic pain. A chronic intractable benign pain syndrome (CIBPS) has been defined and reported [3–7]. The suffering with this chronic pain is also congruent with the above quoted description of pain that is accepted by the International Association for the Study of Pain, and it is medically appropriate to refer to it as a “syndrome.”

This syndrome develops for psychological reasons. The fact that the psychological substrates for this syndrome are not uniform and are mostly a dynamic mix in nature makes many permutations and combinations possible. This is in accord with our knowledge of the way our brains deal with psychological matters; and these also are highly subjective, as is the experience of pain. Regardless of the school of psychological thought, there is general and wide agreement that many of the components of most psychological events remain unavailable to consciousness.

How and if these events do become consciously available occurs through a maze of different mental mechanisms that involve unconscious determinants such as need systems, emotional conflict, and defense mechanisms. As a result of this inherent complexity, it is not surprising that definitive diagnostic psychiatric disorders may not be able to be designated when a CIBPS has developed. Because these kinds of complex events cannot be discreetly measured or usually described, as can pieces of behavior, there is no reason in the serious study of pain to ignore their central importance, and certainly not their existence. If we cannot actively encompass and use this in our thinking about these medical problems, how can we expect humans who intractably suffer with this kind of chronic pain to begin to understand some of the sources of their pain and suffering in order to help them foster the development of a healthier adaptive shift away from the hold of this syndrome? What may seem like minor adaptive shifts can make large changes in a suffering process.

Recent publications tracking and/or commentary on interventional treatments (generically, nerve block procedures) for chronic noncancer pain have reported a paucity of positive lasting outcomes for this approach to treatment, as well as poorly designed clinical research protocols [8,9]. Other published commentary has also questioned the appropriateness of the use of these procedures for many of the problems of chronic pain for which they are widely used [7,10].

When a CIBPS is established, by definition, there is no known associated nociceptive input from the periphery. However, its presence continues to be commonly assumed, and it is the stated or tacitly used reason given for interventional treatment attempts. Patients with CIBPS commonly have histories of multiple failed intervention attempts. Why is it that there rarely has been concomitant questioning of the interventional rationale for the persistent focus on nociception from the periphery?

No doubt, issues of medical philosophy, economics, placebo response, as well as the Zeitgeist of the public's expectations from Medicine are also involved. These are salient parts of this state of affairs, and each requires its own careful examination and interpretation.

There have been enormous advances in our knowledge of neuroanatomy, neurophysiology, neurochemistry, and neuropharmacology associated mainly with acute pain mechanisms. These must and will be pursued through scientific research. This ought not be considered incompatible with the exploration of matters of the mind that clearly play such major roles in chronic pain problems. We have just left the proclaimed “decade of the brain” and are completing the proclaimed “decade of pain control and research.” We must not ignore the need to continue to explore unconscious brain processes that largely form our consciousness through which the suffering with chronic pain syndromes emerge. This exploration needs to continue even if it is true that we are at this time far from being able to specify the routes and mechanisms which these omnipresent and wholly human events occur. In these regards, recognition and clinical use of psychodynamic constructs are required that include needs, defense mechanisms, and emotional conflicts. As a working example, this syndrome can be regarded as an attempt to adapt to unconscious threats to the self of sustained, dysphoric affects of conflicts. As maladaptive as it may appear to suffer chronic pain as a defense from other threats, it must be remembered that this process is unconsciously determined. As such, there is no allegiance to our usual understanding of logic. These kinds of human events frequently require more nonlinear considerations in their assessment and understanding.

A sign on the wall of Albert Einstein's office at Princeton appeared to support this approach to gain a sapient understanding of chronic pain syndromes. It reads:

“Not everything counts that can be counted, and not everything that can be counted counts.”


View Abstract