Psychological mislabelling in chronic pain: reducing the risk

FREUD’S LEGACY

The overemphasis on psychological explanation is a legacy of a deep-seated psychogenic bias that ran through medicine for much of the last century. Freud developed the psychogenic model in the 1880s.⁶ At the centre stood a psychological gatekeeper whose job was to regulate the entry of anxiety-provoking thoughts into consciousness. Freud believed such thoughts, frequently sexual, exerted continual pressure for conscious expression.

Occasionally, through a process of psychic transmutation — Freud’s ‘mysterious leap’ — these thoughts would break into consciousness not as thoughts, but as physical symptoms. This was conversion. And for the next 100 years the idea that highly charged emotions could metamorphose into physical signs and symptoms mesmerised both medicine and popular thought.

CHRONIC PAIN IS BIOLOGICALLY BASED

Advances in pathophysiology, pharmaceuticals, and medical behavioural therapies started to erode the concept of psychogenesis in the middle of the 20th century. Gradually, behavioural therapy became an integral component in a new approach to chronic pain.

In the hospital-based pain centres that blossomed in the 1980s, for example, multidisciplinary teams helped patients replace opioids with non-addictive medications and behavioural self-management techniques. Importantly, the assumptions of the biobehavioural approach offer a buffer against psychological mislabelling.

Foundational assumptions of biobehavioural treatment are that: chronic pain is biologically based; a nonresponse to medical or physical therapy is not an indication of psychological involvement; and biobehavioural pain management is not psychotherapy — it typically focuses on acquiring coping skills to pace activities, increase productivity, avoid flares and triggers, and optimise medication use, rather than on emotional concerns. This is not to suggest that biobehavioural therapy is indifferent to anger, depression, personality disorders, and the like; only that when psychopathology is present it is treated as comorbid to the patient’s pain condition.

Reassurance on these fundamental points can be therapeutic for patients who have been demoralised by the suggestion, implicitly or explicitly, of an underlying psychological problem. It can also set the stage for behavioural counselling by the primary care provider, or referral to a multidisciplinary pain centre or behaviourally oriented pain specialist.

Alignment of patient and practitioner perspectives around a biobehavioural model reduces the risk of psychological mislabelling while strengthening the therapeutic alliance. It is a pain management asset that should not be underestimated.