Addressing Patients’ Psychic Pain
Case 1: Protracted Grief
“Ms. A,” age 36, had been in agony since the death of her 18-year-old daughter, “Laurel,” from acute leukemia 2 years earlier, and was referred by her primary care physician. Her anguish seemed boundless, and she grieved at her daughter’s grave virtually daily, still crying inconsolably from time to time. Her husband described Ms. A as “irreparably devastated.”
Ms. A had been raised in a poor and emotionally unsupportive household, and at age 16 she became pregnant by her “wild” boyfriend and gave birth to Laurel. Two years later, she gave birth to a second daughter, “Holly,” fathered by the same boyfriend, who, shortly thereafter, was incarcerated for drug dealing.
As the girls grew up, differences in their personalities became more pronounced. Laurel was a “perfect child” who Ms. A hoped would achieve the kind of life that she could only dream about for herself. Laurel was “the light of my life,” “my best friend,” “the source of my joy in the world,” and the “one good thing I ever did.” Holly, on the other hand, “took after her father”—tough, angry, and oppositional, a frequent runaway, drinking and experimenting with street drugs.
At age 16, Laurel was diagnosed with acute leukemia. She subsequently suffered through multiple medical hospitalizations, enduring a great deal of pain, but rarely complaining, because she didn’t want to upset her family. After 2 years she died, her last few weeks a drawn-out misery for all concerned.
Ms. A’s anguished, convulsive crying lasted for weeks. She described experiencing “unbearable pain,” feeling as if her life had been simply “torn to pieces.” For months, she visited the grave site daily, lamenting, often wishing that she might die to join her daughter in an afterlife.
My ongoing therapeutic work with Ms. A consisted of listening, facilitating her grief-filled explorations of both painful and loving reminiscences, attempting to offer consoling perspectives, and being with her, validating her own efforts to achieve some degree of ultimate acceptance. Even with psychiatric treatment, intermittent psychic pains persisted for years.
Case 2: Mood Disorder, Eating Disorder, and Personality Disorder
“Ms. B,” a 40-year-old married professional, sought care for her “chronic nuttiness.” Over the years, she had been variously diagnosed with anorexia nervosa, binge-eating/purging type; obsessive-compulsive disorder; major depressive disorder with psychotic features; bipolar disorder; and borderline personality disorder. She made it clear that despite these problems, she remained funny, fiercely smart, and surprisingly resilient.
Other players in Ms. B’s “privileged, strict Catholic” upbringing were a narcissistic, always critical mother, an avoidant father, and a bullying, teasing older brother. Restrictive eating, binge eating, and purging, together with significant depression, started at age 12. Dreadful moods, often associated with intensely painful sensitivity to disappointments, resulted in concentrated episodes of cutting, primarily during adolescence. “My nerves and my guts resonate with my mood.” She saw many of her compulsive behaviors as attempts to fend off these excruciating agonies.
Ms. B and I worked together for 5 years, combining psychotherapy and medication management. Some medications helped, at least for a while, but most did little. In therapy she described how intensely she felt things and often wished that she were less sensitive to life’s situations—“I really need a much better shit screen. Can you get me a better shit screen?”
During our therapy, three crises precipitated waves of increased agony: the death of a beloved grandmother who had been Ms. B’s primary protector as a child provoked deep grief and feelings of painful aloneness; being abruptly fired from her desirable job because of inconsistent performance provoked considerable shame and rage; and her husband’s infidelity, leading to divorce and to strong suicidal impulses, provoked “unbearable” mental pain resulting from feeling betrayed, humiliated, invalidated, and “destroyed as a person.”
Despite a strong belief that suicide is sinful, she thought the only way to achieve release might be to kill herself. Calmly and matter-of-factly, she mused, “If I decide to suicide, you have to understand that it won’t be impulsive or due to depression; it will be a clear-headed rational decision on my part. I know you’ve done everything possible—everyone’s done everything possible—but I’m still excruciatingly tormented by my emotional sensitivities. I don’t see any other escape....”
Case 3: Melancholia
“Mr. C,” a 60-year-old esteemed scientifically trained business executive and a successful husband, father, and community member, sought consultation for his second episode of major depression with melancholic features, 6 years after his first. In the context of a company downturn that was in no way his fault but for which he felt responsible, Mr. C’s initial episode occurred at age 54. “It was as if I hit a wall.” His mood slid downward and he developed classic vegetative symptoms, including agitated ruminations, sleep disturbance with early morning wakening, diurnal mood variation, and loss of appetite and weight. After combinations of antidepressant and antipsychotic medications failed to bring relief, he reluctantly agreed to a course of ECT. His condition fully remitted after 10 treatments, and a month later he returned to work.
I saw Mr. C for the first time during his second bout of depression, about 2 weeks after he started to decline. His wife and children were very concerned for his safety, reporting that for prolonged periods he had started to sit alone in his darkened home office, staring silently into the distance, and could barely be coaxed out for meals.
During our interviews he described his inner experiences in slowly articulated, ponderous sentences. “It’s hopeless. I’m suffering tremendously. I can’t tell you what set this off, but my thoughts are very, very dark … a plague. I think I’ve been a very bad person. I’ve hurt a lot of people in business, and I was a fraud as a scientist. I must deserve what I’m going through.… I wish someone would just kill me and get it over with….” Mr. C agreed to another course of ECT, which again successfully produced remission. Following these treatments, reflecting on his ordeal, he mused, “Thank God it’s over. Although I’m having a hard time now recalling exactly what it felt like, I can tell you it was the worst thing I’ve ever been through, and I can’t imagine going back there again and surviving.”
Whether associated with physical or psychological causes, patients seek relief for pain and suffering. Although physical pains are usually well attended to, clinicians sometimes overlook and neglect intensely experienced psychic pains. While physicians in general medicine might often start by asking patients, “What hurts?” and “How bad is the pain?”, clinicians rarely ask such questions directly or routinely about pains generated by psychological events and psychiatric disorders. In this article, I focus on psychic pains, consider how these experiences might be related to pain stemming from physical injuries and central pain syndromes, advocate for clinicians to direct clinical attention to psychic pain in our patients, and reflect on treatment implications.
As a ubiquitous human experience, pain has long been subject to philosophical discussion. Ways of experiencing and transcending pain and suffering were principal concerns of the Buddha. In Timaeus, Plato reasoned that pain is not a unique sensory modality but an emotional state produced by stronger than normal stimuli. His view set up still ongoing debates in philosophical circles regarding the extent to which pain is sensation or emotion. Descartes, in distinguishing body from mind, laid the groundwork for the classic “specificity” theory of pain, noting that peripheral sensory events are piped into the brain by nerves. From an existential perspective, Kierkegaard saw the inescapable universality of psychic pain’s manifestations as despair and suffering, and he focused on what we now call cognitive appraisal and cognitive restructurings through understanding, acceptance, and faith, as remedies (1).
Psychic Pain as a Distinct Symptom and Pain Phenotype
Defining Psychic Pain
Given its inherent subjectivity and lack of biomarkers, psychic pain is difficult to define, and numerous authors have grappled with defining its linguistic variants (2–4). Shneidman (5) likened it to an “ache in the mind,” equivalent to “headache” or “stomachache.” Psychic pain is also characterized by words infrequently seen in routine narratives describing mental status examinations: agony, anguish, angst, despondency, entrapment, humiliation, misery, remorse, suffering, and torment, among others. In reviewing published models of psychological pain, Meerwijk and Weiss (3) distilled three essential characteristics: an unpleasant feeling (which might include suffering), appraisal of an inability or discrepancy (e.g., between what is desired and what is achievable), and unsustainability (an unbearable, destructive situation that demands resolution). Others stress the nonlocalization of psychic pain, lack of an organic cause, and distinction of psychic pain from the more complex concepts of suffering, focusing on the necessity of being able to sensitively discriminate how individuals experience differences in their pain (3). To further clarify how these terms are used, semantic and lexical studies—for example, using semantic differential methods employed in developing Melzack’s original McGill Pain Questionnaire (6)—could better delineate how different populations use psychic pain-related words and distinguish them from words denoting other qualities of noxious experiences.
Is Psychic Pain Distinct?
Somatic pain, psychic pain, and clinical depression frequently co-occur. In the population at large, individuals with severe somatic pain show increased rates of numerous psychiatric disorders, especially major depressive disorder and bipolar depression (7). Individuals with somatic pain are also at increased risk of having psychic pain (however, the converse does not hold—that is, individuals with high psychic pain ratings do not necessarily have high somatic pain ratings) (8). In turn, intense psychic pain (e.g., resulting from grief) carries the risk of clinical depression.
Nevertheless, these phenomena have been plainly distinguished. In available studies comparing somatic and psychic pain, most patients rate psychic pain as much more severe and less bearable than severe somatic pain (9). Similarly, psychic pain has been clearly differentiated from clinical depression (10). As a higher-order construct, “clinical depression” can be deconstructed to an array of cognitive and emotional components (broadly, cognitive and emotional negativity and accompanying somatic/vegetative signs and symptoms). Although in states of severe depression the experience of psychic pain may well be present, the diagnosis of clinical depression does not include the presence of psychic pain as a criterion, nor does psychic pain occur exclusively in states of depression.
Psychic pain is also distinguishable from other psychiatric symptoms. Although many clinical features commonly associated with depression, anxiety, and psychosis may coexist with and contribute to the experience of “pain in the mind,” none of them exactly coincides with “pain.” Many of these emotions and moods can be experienced at prepain levels, and of these terms all are too limited to convey precisely the broader noxious “qualia” (subjective experience) encompassed by “pain.” Psychic pain’s subjective quality appears to be distinct and more elemental than any of these higher-order experiences. Almost a somatic sensation, psychic pain might be experienced as gut-wrenching, teeth-gnashing anguish that often seems embedded in noxious somatic sensations, which, one might speculate, result from the fact that the neural networks serving these pain functions highly overlap.
Even in the presence of significant depression and anxiety, the co-occurrence of psychic pain yields additional predictive power regarding the likelihood of suicidality and completed suicide. Shneidman (5) suggested that when it reaches “intolerable intensity,” psychic pain is a particularly important consideration for patients who die by suicide. In his view, although many individuals who suffer from what he characterized as “psychache” are not suicidal, every suicide is touched by intolerable psychological pain. Psychic pain is a common theme in suicide notes (11).
Furthermore, psychic pain is seen across a wide array of defined psychopathological disorders, noted not only in patients who are suicidal but also in nonsuicidal patients with melancholia and mixed mood states, borderline personality disorder (12), guilt-related psychic pain in obsessive-compulsive disorder (13), acute psychotic disintegrations and schizophrenia (14), posttraumatic stress disorder related to domestic violence (15), and acute adjustment states marked by loss, grief, and failure (16, 17), among others.
Neurobiological Underpinnings of Psychic Pain as a Distinct Phenotype
Several observations suggest strong convergence in the neurophysiological underpinnings of somatic and psychic pain. Such convergences carry broad implications for the delineation, assessment, monitoring, and treatment of psychic pain specifically and possibly for psychopathology in general.
First, brain networks activated during experiences of severe psychic pain as manifested in grief (18), social isolation and exclusion, romantic rejection, and empathically experienced pain (19, 20) and in patients with major depression and suicidal behavior (21, 22) and borderline personality disorder (12) substantially overlap those subserving chronic pain of somatic origins (“the pain neuromatrix”), although they are not precisely coincident. These networks largely involve several areas of the anterior cingulate gyrus, inferior frontal gyrus, insula, thalamus, cerebellum, and periaqueductal gray matter of the brainstem (23–26). Other affected areas are those associated with reward and motivation areas, including the nucleus accumbens and ventral tegmental gray (27). In response to negative emotions, activation of neural networks has even been imaged as far down as the midthoracic spinal cord (28). In response to viewing photographs of limbs in painful situations or of faces grimacing in pain, even those rare individuals with genetic variant sodium channelopathies resulting in congenital insensitivity to somatic pain show activation of the central midline areas of these networks involved in the emotional processing of pain (29).
Second, somatic and psychic pain show other close associations. Just as psychic pain and depression are distinct but closely associated, chronic somatic pain, even sustained pain for 24 hours, also places sufferers at much greater risk of clinical depression, and a direct statistical correlation exists between pain intensity and the severity of depression (30). Furthermore, first-line medications for the treatment of central sensitization syndromes associated with somatic pain, including those associated with rheumatoid arthritis, fibromyalgia, complex regional pain syndromes, and others, virtually all benefit mood and anxiety states—e.g., duloxetine and calcium channel alpha-2/delta ligands (gabapentin and pregabalin). Similarly, neuropathic pain is currently treated primarily via centrally acting agents such as serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants, gabapentin, and pregabalin (31). These findings also suggest considerable overlap in networks mediating somatic and psychic pain experiences. Furthermore, several antidepressants have been shown to have mu and delta opioid receptor agonist properties (32, 33).
Finally, individuals contending with somatic pain and psychic pain often seek relief from similar chemicals: opioids, cannabinoids, and alcohol, which users might say they take to numb or anesthetize both classes of pain.
Measuring Psychic Pain
Using the Mee-Bunney Psychological Pain Assessment Scale, Mee et al. (10) demonstrated in patients with major depressive disorder that psychic pain can be reliably rated and correlates positively with higher ratings of suicidality (assessed with the Suicide Behavior Questionnaire) and reported number of previous suicide attempts. Over and above maximal contributions of depression and hopelessness ratings (assessed with the Beck Depression Inventory and the Beck Hopelessness Scale), psychic pain scores added to variance in suicidality ratings. Similarly, using a seven-item 10-point Likert scale to assess psychic pain, Olié et al. (8) compared three groups of patients diagnosed with major depressive disorder. Although no differences in somatic pain ratings were reported by never-suicidal depressed patients compared with depressed patients who had made either remote or recent attempts, psychic pain ratings were significantly higher in both groups of patients who had ever attempted suicide. Furthermore, these ratings correlated significantly with the frequency and intensity of suicidal ideation.
Similar findings have emerged from studies using the Orbach and Mikulincer Mental Pain Scale (22, 34, 35) and using Holden’s 2001 revision (36) of Shneidman’s Psychache Scale (37). Using this same scale in a population of depressed patients, some of whom reported suicidal ideation and some of whom had made an attempt, Cáceda et al. (38) also found that psychic pain predicted suicidal ideation in the overall sample and differentiated the suicide attempters from the suicidal ideation group.
Clinical Implications
It is emotionally exhausting to stay focused while listening patients’ expressions of anguish without reflexively disengaging empathic attunement or allowing the mind to wander. Staying with another person’s pain is not only difficult, it is actually painful itself; patients’ pains evoke sympathetic psychic pains—contagions similar to those occurring during interpersonal transmissions of anxiety.
The first patient in the vignettes, a woman with severe bereavement whose entire purpose in life and sense of meaning were wrapped up in her daughter and destroyed when her daughter died, primarily required a sympathetic presence, gentle exploration, and facilitation of the grief process. The second patient, who had complex features of significant mood disturbances, eating disorder, and borderline personality disorder, experienced lifelong, frequent bouts of psychic pain, which she tried to keep at bay through numerous but largely ineffective coping strategies. Ultimately, because of several developmental deficits, she lacked adequate psychological buffers and barriers to protect her from her anguish, and intermittently gave vent to accompanying rages at fate, other people, and me. She required psychotherapeutic management and understandings of complex, primitive processes as well as medication management. The third patient, a man with a discrete, almost “pure culture” melancholic syndrome who suffered equal torment and largely chose to bear his pain in silence, required biological treatment.
In all cases, the pain experiences were sufficiently severe to drive these individuals to wish for death, and sometimes to the brink of suicide as a way of attempting to put an end to their suffering. Words they used to describe these moments included “awful pain,” “anguish,” “agony,” “torment,” “torture,” “afflicted,” and “cursed.” During these instances, often the best that I could do at the moment was to sit silently with them for a while—trying to soothe their pain through empathic witnessing and acknowledgment, which sometimes seemed to help. Using pain medicine as a model, a clinical approach needs to encourage patients to access their inner resources through a variety of psychological, social, physical, and integrative approaches in combination with evidence-based medications and somatic interventions.
Clinicians can straightforwardly acknowledge patients’ psychic pain experiences. They can certainly help patients better clarify and understand these pains. From an existential perspective, even if together they are unable to reframe the underlying problems, clinicians can help patients attempt to find meaning in their experiences and, if possible, discover capacities to transcend these dark periods. Akin to the stance of “welcoming” and “compassionate listening” advocated for general pain medicine (39), as is noble in all medical practice, clinicians should do what they can to help patients better face and bear their pain and suffering, if only by letting them know that another person is with them and that they are not alone as they go through their hellish experiences.
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