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The role of psychological factors in chronic pain. II. A critical appraisal

Summa~ This paper. the second of two. concerning the study of psychological factors in chronic pain,
presents a critical appraisal of the literature. Questionable assumptions, flawed methodology, and conceptual
problems in earlier work are discussed, as are gradual improvements in methodological rigour and conceptual
clarity. Methodological weaknesses in studies, including lack of control groups, selection biases, overinterpretation
of corr~lati~~n~~l data, and use of inappropriate testing instruments are examined. Questions are raised about
persisting tendencies to split mind from body by attributing pain to either organic or psychological causes. Despite
advances in research and thinking in recent years, several issues remain unresolved in both the research enterprise
and the clinical setting. These are discussed in relation to the respective needs of the researcher. the clinician, and
the patient. Limitations on research conducted in clinical settings are considered and targets for improved
methodology in studies are identified.

Key words: Psychological: Criticism: Methodol(~gy: Chronic pain; Personality profile; Multic~~us~liity

introduction challenged. During the same time, research has been

criticized for weak methodology. inconsistent findings,
While psychology research has made important con- biased interpretations of data. and questionable con-
tributions to thought about chronic pain during the ceptualizations. The following critical appraisal exam-
past half century, meth~~dol~~gical and conceptual prob- ines these concerns using representative examples of
lems have given rise to questions and criticisms. The research, and discusses improvements in the body of
psychological study of pain was founded on the belief work in recent years.
that pain which could not be explained by physical
causes was psychological in origin. Studies based on
psychological theories attempted to show that patients Methodology
with intractable pain shared certain personality charac-
teristics which predisposed them to pain. Underlying The following methodological problems have been
this body of work were the following ~~ssunlptions: (a) the subject of criticism: (a) absence of. or inadequ~~te,
pain is caused by either organic or psychological fac- control groups; (b) selection biases; tc) overinterpreta-
tors; (b) pain which does not correspond to known tion of correlational datal; and (d) use of inappropriate
physical pathology is psychological in origin: and (c) testing instruments for patients with pain.
patients with undiagnosed intractable pain are a psy-
chologically homogenous group. In the past IO-15
years, the dualistic conceptions and linear causal views The frequent absence of adequate control groups in
which huttrcsscd these assumptions have been cogently studies of chronic pain patients has been noted by
many authors (Roy et al. 1984; Turk and Salovey 1984;
Roman0 and Turner lY85; Gupta 1986; Payne and
Norfleet 1986; Malone and Strube 1YXX: Flor et al.
* Corrcspondlng author: Ann Ciamsa. Ph.D., Room 7846, McGill-
Montreal General Hospital Pain Centre. 1650 Calar Avenue.
1902; Kohler and Kosanic lYY2). For example, in a
Montreal. Ouehec H3G lA4. Cnnxk. Tel.: (514) 934-8222: FAX: report of a study without a control group, Violon
(514) ‘)34-x227. (1982) concluded that pain in the adults she observed
IS
resulted from early emotional trauma associated with
parent absence, abandonment, lack of physical aff‘ec-
tion, open rejection and physical abuse. However, with-
out an appropriate comparison group, it is difficult to
assess the etiological significance of psychological
events such as childhood difficulties, pain in a family
member, or marital maladjustment which are relatively
~onlrnoI1 in the general popuIation, This fact is sup-
ported by Crook et al. (1984) who found that most of
the subjects they studied had had some experience of
persistent pain with a close family member, and Frank
et al. (1978) who found a high level of sexual dysfunc-
tion in couples, with neither partner suffering from a
pain problem. Such findings underscore the need for
appropriate comparison groups before pain is cx-
plained as an operant response to marital difficulties,
or a somatic means of resolving underlying emotional
conflict.
In a review of research on the “arthritic personaiity”,
Anderson et al. (198.5) found that studies which lacked
a control group consistently reported the expected
personality traits in patients with rheumatoid arthritis,
while results from studies which used a control group
were mixed. In recent studies, control groups are more
often included; when they are not, their absence is
acknowledged as a Iimitation of the research design.
Single case methodology which can identify causal rela-
tionships on a case by case basis offers a useful option
for some clinical studies (Hilliard 1993: Jones 1993).
Concern has been expressed about studies which
extend findings from pain clinic samples to the general
population of pain sufferers (Chapman et al. 1979;
Crook and Tunks 1985; Roman0 and Turner 1985;
Sherman et al. 1987; Atkinson et al. 1991). Because a
bias towards neuroticism is likely to be present in any
specialized clinic population (Merskey et al. 198%
studies need to use comparison groups of subjects with
chronic pain recruited outside of pain clinic settings, if
conclusions are to be drawn about chronic pain pa-
tients in general. Studies which compared pain patients
treated in general practice with those seeking treat-
ment in a pain clinic found substantial differences on
psychological variables between the two groups (Chap-
man et al. 1979; Crook and Tunks 1985; Gamsa 1990).
There is also some indication that over-representation
of low so&o-economic status (and thus, the covariables
associated with being poor and working class) may
reflect a selection bias related to the clinic setting
(Crook et al. 1984; Merskey 1984).
Merskey (1989) has discussed the effect of bias in
hospital populations as demonstrated by early research
on the concept of migraine personali~. An abundant
literature from the 1940s and 1950s reported that pa-
tients with migraine showed characteristic traits. in-
cluding perfectionism, above-average lnlclligencc, dii’li-
culty expressing aggression, repress& ho5tiliQ. an4
tendencies to be dependent. resentful, ;rnd h~~~o~h~)~~~
driacal. However, when Hemyk-Gutt and Kces (lYt7.11
compared migraine patients in ;I clinic with postal
workers who suffered from migraine but who did not
attend a clinic, they found much less evidence of the
“migraine personality” in the postal workers. A rt’cent
study (Kohler et al. 1991) failed to find differences cm
personality measures between migraine sufferers rc-
cruited in a non-clinic setting and headache-free con-
trol subjects. Crook and Tunks ( 198.5) showed that
patients who are treated in a pain clinic are 1ikeIy to be
a select group of pain sufferers who have more cmo-
tional disturbance and complain more of pain. Also,
differential referral is likely to create bias in pain clinic
populations, because general practitioners and other
specialists are more likely to refer a difficult, emotion-
ally disturbed patient to a pain clinic (Merskey 19791.
Cherinterpretation of correiationai datu
Because chronic pain is, by definition, a clinical
entity, the use of experimental design to assess the role
of causal factors is rarely feasible. Correlational de-
signs, typically used in the clinic setting, can provide
the investigator with useful information concerning
variables associated with a disorder, and may even
suggest causal relationships, if appropriate research
designs and statistical analyses are used. However.
correlational studies rarely permit direct causal conclu-
sions to be drawn. Nevertheless, (as discussed by Roy
1985), numerous authors have overinterpreted results
of pain studies by drawing causal conclusions from
correlational data (Liebman et al. 1976; Gross et al.
1980-81; Violon 1980, 1982; Blnmer and Heilbronn
1982).
Correlation is also misused in studies by Perry et al.
(1988, 19911, who concluded that Iow correlations on
different measures of pain were indicators of “func-
tional” pain. Slater et al. (1992) point out that this
misapplication of correlation data led to a wrongful
conclusion about distinctions between “functional” and
“organic” pain. The error is not trivial because health-
care providers and others are more likely to react
negatively to patients whose pain is labelled as func-
tional (Lennon et al. 1989; Nepomuceno et al. 1982;
Beyerman 1982; Faucett and Levine 1991). In recent
years published reports of correlational studies tend to
make the point that causal connections are only specu-
Iations (e.g., Sternbach 1986; Spinhoven and Linssen
1991).
Inappropriate use of tests
Because tests to assess neurotic disturbance often
include somatic items, their use may not be appropri-
ate for patients with chronic pain. The Minnesota
Multiphasic Personality Inventory (MMPI) is one such Violon 1982; Catchlove et al. 1985; Adler et al. 1980).
test which has frequently shown elevated scores on the However, as discussed in Part 1 (Gamsa 1994) of this
scales of Hypochondria+ Depression, and Hysteria in 2-part review). many studies did not find pain patients
pain patients. On the basis of such findings, pain has to be different from the general population on these
been attributed to premorbid neuroticism (Freeman et variables (Apley 1975; Singer 1977: Koy 1982, 1985:
al. 1976). In the last decade, the use of the MMPi Salter et af. 1983; Larson and Marccr 1984; Bouckoms
neurotic triad scales with pain patients, has been seri- et al. 1985; Merskey et al. 1985; Gamsa 1990; Gamsa
ously questioned (Naliboff et al. 1982; Watson 1982; and Vikis-Freibergs 1991). This lack of consistent find-
Roy et al. 1984; Smythe 1984; Love and Peck 1987; ings persists across different pain problems and a broad
Wade et al. 1992). Watson (1982) showed that most range of psychosocial variables. including for example,
chronic pain patients have elevated scores on only personality traits of patients with rheumatoid arthritis
those items in the neurotic triad scales which reflect (Anderson et al. IYSS), major life events in patients
specific reactions to pain and illness, and not on those with headache (De Benedittis and Lorenzetti 1992).
which measure diffuse neurotic responses. In a recent affective disturbances in patients with fibromyalgia syn-
study using the NEO-personality inventory and the drome (Boissevain and McCain 199lb), and support
MMPI, Wade et al. (1992) showed that most pain from spouses in patients with spinal cord injury
patients had a normal personality structure, and con- ~Summers et al. 19911.
cluded that elevations typically found in the MMPI Variability of findings across studies is well illus-
reflect somatic symptoms related to pain, not neuroti- trated by research into the relationship between pur-
cism. Moore et al. (1988) found that pain patients tend suit of compensation and psychopathology in pain pa-
to score high on the schizophrenia scale because they tients. Several studies found that compensation pa-
endorse items concerning somatic complaint and diffi- tients showed evidence of psychological disturbance
culties of Iiving with a pain problem. They make the when compared with patients who were not on com-
important point that inaccurate application of a psychi- pensation after injury (Beals and Hickman 1972; Stern-
atric diagnosis can only add to the patient’s suffering. bath et al. 1973; Weighill 1983). This finding was
Other assessment instruments have not been the supported by Waddell et al. (1984) who concluded that
subject of such criticism, although some questions have in one-third of patients, the cause for remaining on
been raised about tests with a large somatic compo- disability after a work accident was psychoi~~gical, rather
nent. Zaphiropoulos and Burry (1974) ehminated the than physical, impairment. By contrast. other studies
somatic items from the Beck Depression Inventory in showed that patients who were on compensation or
assessing depression in patients with rheumatoid dis- awaiting litigation were not more psychologically dis-
ease, and others have noted that overlapping symptoms turbed than those not on compensation (Pelz and
in pain and depression may result in inaccurate diagno- Merskey 1983; Melzack et al. 1985; Mendelson 1986).
sis when DSMIII diagnostic criteria are used (Katon et Leavitt et al. (19821 concluded that psych~~logic~ll dis-
al. 1985; Sullivan et al. 1992). Also, the General Health turbance was neither exacerbated by compensation is-
Questionnaire, which was designed to identify cases of sues nor predisposed patients to seek compensation.
probable psychiatric illness, tends to show high scores Dworkin et al. (1985) found no relationship between
for patients with physical disorders who are not found compensation and emotional disturbance when groups
to be emotionally disturbed in standard clinical assess- were equated for unemployment levels. In a rcccnt
ment (Benjamin et al. 1991). These concerns under- weli~controlled Australian study. Guest and Drum-
score the need for cautious interpretation of tests mond (1992) found that the compensation claimants
which include somatic discomfort or distress as indica- they examined showed emotional distress both before
tors of psychological disturbance in pain patients. and after settlement of their claims. They suggest that
emotional disturbance is influenced by a complex intcr-
action of factors, including continued lack of employ-
inconsistent endings ment, financial insecurity, and the psychos~)cial consc-
quences of pain, including isolation. activity limitations
Although numerous studies report relationships be- and lowered self-esteem.
tween a variety of psychological factors and pain, over-
all, the body of published literature shows a remark-
able lack of consistent findings across studies. At one Biased interpretation of data
time or another, pain disorders have been related to
psychological variables such as family size, birth order, While it is often necessary to USC limited logical
socio-economic status, deprivation in childhood, and leaps to draw meaningful conclusions from data, dis-
numerous personality disorders (Engel 19.59; Parkes torted logic, found in some published studies, dots not
1973; Swanson et al. 1978; Blumer and Heilbronn 1982; shed light on questions under study. Two types of
distortions are found in the psychological literature on MMPI in patients both with acute and with chi.onic
pain. First. the patient’s emotional state, measured pain. Although patients with chronic pain (more than TV
after years of pain, is said to reflect psychological months) had higher scorch than patients with acute
disturbance preceding pain onset. Second. data arc pain. life histories showed that most t)f the chronic
interpreted selectively to fit with the study’s hypothesis. pain patients had functioned adequately prior to the
painful injury. Sternbach ( 1974) concluded that IICU-
hferences about antecedent disturbance roticism in most pain patients is a consequence, not a
The unwarranted conclusion that current measures cause, of prolonged suffering.
provide information about disturbance preceding pain Numerous authors have argued that distress is a
onset is particularly misleading when emotional prob- reasonable response to persistent pain and its associ-
lems are then alleged to be the cause of pain (e.g.. ated limitations, especially when there IS neither diag-
Tinting and Klein 1966; Parkes 1973: Blazer 1980-81; nosis nor effective treatment to legitimize the somatic
Bouckoms et al. 1985; Catchlove et al. 1985; Violon symptom (Marbach et al. 1978; Beetham 1979: Mar-
1989). Such errors of inference are exemplified by bath and Lund 1981; Pelz and Merskcy 1983: Turk and
reports which suggest that sexual or marital dissatisfac- Salovey 1984; Grushka et al. 1987).
tion plays an etiological role in pain, although causal
relationships have not been investigated (see review: Select&2 interpretation
Payne and Norfleet 1986). Explanations based on fam- Reports may be said to be based on selective inter-
ily systems theory suggest that pain in a member of a pretation when conclusions are derived from question-
dysfunctional family is perpetuated, and sometimes able logic, when supporting data are discussed while
precipitated, in order to maintain family equilibrium refuting data are neglected, or when interpretations to
(Roy 1985; Payne and Norfleet 1986; Turk et al. 1987). support the hypothesis arc presented while alternate
That pain. in some cases,. is exacerbated by family plausible interpretations are disregarded.
problems is not in question. However, conclusions need For example, Violon (1982) concluded that pain in
to be based on well-documented evidence to support a the subjects she studied was an expression of psycho-
causal relationship between pain and family dynamics logical distress resulting from early physical abuse and
and must not be only theory driven. emotional deprivation, but she disregarded the possi-
Studies by Maruta and Osborne (1978) and Maruta bility that severe abuse and neglect may have directly
et al. ( 1981) which addressed the question of temporal caused painful injuries or illnesses. Based on findings
relationship, showed increased marital maladjustment in their subjects of early work onset, infrequent vaca-
following the onset of pain. In a retrospective survey tions, and frequent overtime work, Blumer and Heil-
conducted by Bradley (1963). 46% of depressed sub- bronn (1982) concluded that the patients they studied
jccts with pain reported that pain preceded their de- suffered from a personality disorder, “ergomania”.
pression, while 54% reported a simultaneous onset of which expressed itself in both excessive work and de-
the two. No subjects remembered feeling depressed velopment of a pain problem. It is difficult to know on
before the onset of pain. These findings are, however, what grounds Blumer and Heilbronn determined that
open to question since they relied on subjects’ memo- the work history of these subjects was evidence of
ries and verbal reports. In medical charts of family psychopathology, especially since they were predomi-
medicine patients treated for depression, Widmer and nantly “blue-collar workers”, and may have had little
Cadoret (1978) found evidence of increasing pain 7 choice but to work hard at physical labour from an
months prior to records of depression. Evidence of early age. More consistent with the data is the conclu-
depression reactive to pain is also provided in a recent sion that unremitting, strenuous labour may lead to
well-controlled study by Atkinson et al. (19911, using physical injuries which increase the likelihood of pain
DSMIII criteria to assess emotional disturbance in in later life. It is also possible that psychological conse-
men with chronic back pain. quences of working hard from an early age, together
In a comparison of patients who had chronic pain with other stresses accompanying a low socio-economic
with a group who had no pain but suffered from a life-style contribute to a complex biopsychosocial pro-
disorder resulting in similar limitations in functioning, cess, which results in increased risk for development of
Naliboff et al. (1982) showed that all aberrations in the a pain disorder. Although Blumer and Heilbronn’s
personality profiles of pain patients could be attributed study has been criticized by several authors (Merskey
to the effects of limitations in daily functioning. They 1982; Turk and Salovey 1984). its findings continue to
concluded that functional limitations associated with be cited as evidence for pain of psychological origin
pain were the prime cause for emotional disturbance. (Bouckoms et al. 1985; Pilowsky 1988; Brown 1990).
In a study using the cross-sectional approach, Stern- Psychoanalytic formulations allow for inferences
bath et al. (1973) found elevated scores on the Hypo- about neurotic disturbances which are repressed, and
chondriasis, Depression and Hysteria scales of the therefore not evident. For example, in an early study
by Wittkower et al. (1941) on the etiology of chest pain, nosed organic disease and patients suffering from pain
hostility was considered to be present both when it was alleged to have a psychological basis. Woodforde and
evident and when it could not be detected. Parkes Merskey (1972) found that scores on neurotic traits
(197.3) found that many of the amputees he studied such as anxiety, phobia. obsessionality and somatic
who had moderate to severe phantom pain, made a preoccupation were higher for both groups than is
good adjustment to their amputation and were func- considered normal and were comparable to scores of
tioning well a year later. However, because he consid- psychiatric outpatients. but there were no significant
cred these amputees to be individuals with a “stiff differences between the “organic” and “non-organic”
upper lip” and “compulsively self-reliant” pcrsonali- pain patient groups. Reports which have failed to find
ties. he concluded that “the painful phantom may be personality differences between patients with an or-
the tip of an iceberg of discontent”. and proposed that ganic and a psychological diagnosis include studies on
the “good outcome” was perhaps “more apparent than low back pain (Sternbach et al. 107.3; Joukamaa IYYI).
real”. This conclusion is tautological since no evidence myofascial disorders (Faucett and Levine IYYI ). mi-
was presented to support the presence of emotional graine in children (Cooper et al. lYX7). recurrent ab-
disturbance in these well-adapted patients, other than dominal pain in children (Garber et al. IYYO). hcadachc
the pain itself. In some studies, masked depression is or migraine in adults (Merskey ct al. 19x5: Kohlcr and
said to precipitate pain, even when depression. as such, Kosanic 1992). and temporomandibular pain (Salter et
has not been diagnosed (Lesse 1974; Violon lY80; al. lYP1: Schnurr et al. IYYO). Studies which do show
Blumer and Heilbronn 1982). Such explanations shed more psychological disturbance in undiagnosed pain
little light on questions under investigation since any patients than in those with a medical diagnosis (Mc-
findings can be interpreted to support the study’s hy- Crcary et al. 1977; Almay lY87; Van Houdenhovc et al.
pothesis. 19X7) need to account for the impact on the patient’s
In both behavioural and psychoanalytic theories. emotional state of the lack of a diagnosis to lcgitimizc
pain in a family member is considered to be an impor- the pain.
tant psychological event which may have predisposed
the patient to pain. While there is compelling evidence
to support this idea, gcnctic influences may also ex- A psychological diagnosis is often made when there
plain some pain conditions, common to members of a are inadequate physical findings to account for the
family (Apley 1975; Edwards et al. 1985). For example, pain. For example. even when there is no positive
in a review of studies on migraine, Selby (1983) con- evidence for psychopathology other than a discrepancy
cluded that evidence for a genetic predisposition is between physical findings and the patient’s reactions to
convincing. pain, requests for medical attention may be labelled
“Abnormal Illness Behaviour” (Pilowsky IYXY). Nu-
merous authors have criticized the practice of attribut-
Dualistic conceptions ing pain to psychological causes only bccausc physical
findings arc lacking (Merskey 19X4; Grushka et al.
Psychological research into pain has been based in 1987; Sherman et al. 1087; Benjamin et al. 1988:
large part on dualistic conceptions, with mind sepa- Merskcy 1989). Grushka et al. (1987). in their investiga-
rated from body in attempts to understand the causes tion of the personality profiles of patients with burning
of pain. A critical analysis of the published literature mouth syndrome. cited many studies in which absence
shows that attempts to distinguish pain of psychological of physical findings was the only evidence used to
origin from pain due to physical causes have not been establish a diagnosis of psychologically caused pain.
successful (Perry et al. 1988. 1991; Egle and Hoffman Similarly, Sherman et al. (1987) reported that health-
1990: Joukamaa I9Yl). cart providers working with patients who had phantom
limb pain often attributed the pain to personality fac-
tors because physiological mechanisms were not avail-
able to explain the pain.
Overall, studies have failed to show that patients Absence of medical findings does not constitute an
with a diagnosis of functional pain are different from observation of psychologically caused pain. Except
those with an organic diagnosis on psychological mea- when there is positive evidence for pain of psychologi-
sures (Woodforde and Merskey 1972; Sternbach et al. cal origin. it is more parsimonious and clinically sound
1973; Sternbach 1974; Rosen et al. 1980; Marbach and to describe the problem as “pain of unknown origin”.
Lund 198 1: Armentrout et al. 1982; Ahles et al. 1987;
Magni et al. 1989; Faucett and Levine 1991; Kohlcr Votyitzg diagnostic. criteria
and Kosanic 1992). For example, in a comparison of Widely varying diagnostic criteria are used to cstab-
patients who had chronic pain associated with diag- lish physical findings in some chronic pain disorders
tsec Boissevain and McCain’s (1991a) review of fi- the basis of personality constellations ( Dunbar I ~5-4:
bromyalgia syndrome). For example, in the view of Alexander 19.50). Second, Engel’s ( I%(4 1 l’ormulat ion oi
some authors, musculoskeletal pain arises from psycho- the “pain-prone” patient generated ;I considerable
logical causes (Egle et al. 1987; Landro and Winnem body of research to identify a personality profile to
19871, while others believe it originates in peripheral explain cases of undiagnosed intractable pain. ‘l’hird.
nociceptors (Fishbain et al. 19X6; Henriksson et al. the common presentation of reactive disturbances such
1987; Rosomoff 1987; Simons 1988). Also, concern has as depression, anxiety, and anger (Merskey 1989) led
been expressed that physical diagnoses in myofascial some to conclude that patients with chronic pain had
pain are often overlooked (Clarke et al. 19851. similar personalities (Timing and Klein 1966: Freeman
et al. 1976; Blumer and Heilbronn 19X2; Catchlove et
AdLlances in knowledge and diagnostic tools al. 1985). Finally, the search for laws (consistently
Advances in knowledge and diagnostic tools have observed relationships) to provide coherent and sya-
revealed organic causes for disorders which were previ- tematic explanations motivated researchers in the dis-
ously diagnostic enigmas and believed to have no phys- cipline of psychology to seek consistent relationships
ical basis. Diagnostic procedures and knowledge about between personality variables and pain.
pathophysiology are continually advancing, but some In the last decade, the validity and usefulness of the
painful conditions are still not well understood, “uniformity myth” (Spangfort 1987) has been disputed
Merskey (1989) discussed the many syndromes classi- by numerous authors (Armentrout et al. 1982: Roy et
fied as hysterical disorders in the past which, now, are al. 1984; Turk and Flor 19X4; Turk and Salovey 19X4;
understood to have an organic basis. In attempts to Roman0 and Turner 1985; Roy 1985: Fishbain et al.
assess whether pain is of organic origin, the patient’s 1986; Gupta 1986; Love and Peck 1987: Merskey et al.
physical reactions are often tested to determine 1987; Almay et al. 198X; Anderson ct al. 1988; Arner
whether they correspond wit,h known pathology. Gould and Meyerson 1988; Bradley 19X8; Kohler and Kozanic
et al. (1986) were able to demonstrate the presence of 1992). Accumulated evidence from recent work casts
“non-physical” findings (that is, findings that were doubts on the idea of a “typical” pain patient. with
incongruent with an accepted physical diagnosis) in a predictable personal history and personality character-
sensory examination of patients with diagnosed acute istics. Overall, the literature has not found a consistent
central nervous system damage. On the basis of these psychological pattern to distinguish patients with
results, they concluded that hysteria could easily be chronic pain from the general population.
misdiagnosed. Faulty interpretation of statistical tests may have
In the past, phantom limb pain was believed to be lent support to the belief that chronic pain patients
generated by psychological factors (Kolb 1954; Stern- belong to a psychologically homogenous group. In con-
bath 1968; Parkes 19731, since noxious input to the ventional usage, a statistically significant difference
painful area was not possible. Although the etiology of between patients with chronic pain and a pain-free
phantom pain is still not well understood, recent work control group on, for example, early childhood prob-
suggests that physiological changes underlie the pain lems, translates into the statement that subjects with
(Sherman et al., 1989; Melzack 1989; Katz 1992), with pain had more problems in childhood than subjects with-
some indication that different mechanisms may explain out pain. However, as pointed out by Favreau (1993).
pain of different descriptions (Sherman et al. 19891. In tests of statistical significance, on their own, provide no
summary, there is a paucity of convincing evidence to information about the proportion of subjects in one
support dualistic conceptions which separate pain of group who are different from another group. There
psychological origin from physically generated pain in may in fact be a substantial overlap between the distri-
the general population of patients with chronic pain. butions of two groups, such that, in this example, only
a small proportion of patients with pain have had more
problems in childhood than a pain-free control group,
Uniformity myth and linear causal explanations while the majority of patients with pain are not differ-
ent from the control group. The tneaning of “dif-
For about 30 years a prolific literature sustained the ference” becomes increasingly distorted with large
notion of a “typical” pain patient with characteristic sample size because the proportion of subjects who
personality traits. The search for a personality profile must be different to yield statistical significance be-
received impetus from beliefs that a common cause comes smaller as sample size increases. Thus. a statisti-
could be found to explain the general problem of cally significant difference on a given characteristic
puzzling intractable pain. In the light of historical between subjects with and without chronic pain does
perspective, several confluent factors appear to have not, in and of itself, provide information about the
contributed to this belief. First, ideas in psychosomatic general population of patients with chronic pain. It
medicine fostered theories that explained disorders on may instead represent a small subgroup which is differ-
ent from both the general population and from other (Merskey lY89). In clinical practice (and to a lesser
patients with chronic pain. A descriptive statistic, such degree in published research), pain continues to be
as the proportion of patients who arc different, pre- attributed to psychological causes when physical find-
sents more meaningful information (Jacobson and Fol- ings are lacking and pain persists despite medical inter-
lette lYK4). vention (Kupers et al. 1991; see discussions in: Schnurr
In the last decade, the search for a common pain et al. IYYO; Boissevain and McCain 199la; Kryspin and
patient profile has been largely abandoned, although Phillips 1901: Lynch 1992). In such cases, it is reason-
there are some exceptions (Blumer and ~eilbronn 1082; able to entertain a psych~~logical hypothesis to explain
Bouckoms ct al. 1985: Violon 198’)). Instead, studies the pain and to provide a direction for trcatl~cnt.
aim to identify subgroups with different psychological However, unless there is clear evidence for a causal
profiles (Long 1981; Armentrout et al. 1982; Ahles et connection between pain and pre-existing emotional
al. IY87: Jensen et al. IYYI; Wade et al. 1992), an effort problems, a psychological explanation is no more than
which is likely to have greater clinical utility and to a hypothesis and must be acknowledged as such. Evi-
more accurately describe the variety of patients who dence of its presence should be established in the same
suffer from chronic pain. way as physical cause.
In summary, the body of psychoiogy research into A number of factors may explain the continued
pain has failed to yield compelling evidence for a direct tendency to split psyche from soma. First, health-cart
causal relationship between psychological factors and providers become frustrated when their best attempts
pain in the general population of pain patients. In to use the medical armamc~ltarium fail to hc helpful.
recent years conceptu~~lizations and methods of ohser- These feelings of frustrati~)n, and perhaps personal
vation have hecomc much more rigorous, and carefully failure, arc exacerbated when patients display distress
designed control procedures are now more often used. or hostility. Such feelings of defeat can be allayed by
Control in clinical settings is often difficult to attain, re-assigning the diagnosis to the psychological domain.
but limitations of method arc usually acknowledged, A number of needs may thus bc fulfilled for the
and conclusions drawn accordingly. With increased un- health-care provider: (a) failure to help tht: patient is
derstanding of the complex interaction of psychosocial no longer personal failure. but due to an error in the
and physiological factors in pain, multicausal explana- “shop” selected; (h) the hostile and unpleasant patient
tions have supplanted notions of simple linear causality is effectively “punished” when the “blame” is shifted
(Lipowski IYYO; Gamsa and Vikis-Freibergs 1991; Katz to the patient’s psyche (most patients take personal
lYY2). rcsponsihility for the psyche): (cl a f’cciing of ctmpc-
tence is m~iintained when an altcrnatc positive diagno-
sis is offered (as opposed to saying “1 don’t know”):
Unresolved issues and (d) “‘dumping” the difficult patient can be justified
since the pathology, which is no longer considered to
Questions and answers about pain reflect three sets be organic, is outside the practitioner’s expertise. While
of needs which are not always convergent: (a) the the practitioner obtains relief by attributing the pain to
scientist seeks to explain data and to accurately predict psychological causes, the patient, who is attached to
future observations; (b) the health-care provider needs the medical model and the hclief that a professional
a working scheme and tools to promote effective treat- should bc able to fix the pain in the body. becomes
ment; (cl the patient seeks pain relief and improved more distressed. It is also true that a small numhcr of
quality of lift. Thus, the scientist’s vision is both driven patients whose pain is legitimately attributed to psy-
and ohscured by a pet theory. the clinician defends chological causes will become distrcsscd when ;t psy-
against frustration and feelings of personal failure by chological diagnosis is made.
“blaming” patients who do not respond to treatment, Second. researchers and clinicians arc both guided
and the suffering patient remains attached to the mcdi- by a scientific hcritagc which dichotomizes human
cal model and the belief that a doctor will be found to functioning into categories of body and mind. Reports
effect a cure. These divergent needs, in part. explain of pain which correspond to physical findings provide
the pcrsistencc of important unresolved issues, both in data about the body and thus readily fit the rcquirc-
the research enterprise and in the clinical setting. ments of science. When experiences of pain fait to
I’cwisting dualistic C%WT correspond with physical findings. they may be consid-
The recognition that psyche and soma do not func- ercd science-worthy data, but only if they can bc ex-
tion as isolated entities, i.c., that neither plays an plained by a psychological theory. Thus, ;I diagnosis
unimpeded role in the ctioiogy of pain, has been one of based on psychological theory may oft’er the researcher
the inlportant advances in thought about pain. Still, or clinician the security of scientific tll~~~~rings even
beliefs from earlier decades tend to perpetuate the when conceptualizations are vague, methods of obser-
view that pain is either in the body or in the mind vation questionable. and the data have hcen shaped to
fit. While researchers and clinicians riced to recognize tomy at h and 24 months. and Dworkln L‘I al. ( IVY? 1
the blend of personal frustration and epistemological showed that psychological measures assessed early II!
error which perpetuates the splitting of body and mind. the acute phase of herpes roster predicted pcrsiatcni
to completely discard dualistic divisions is unlikely to postherpetic neuralgia. It is important to note that
be productive. Thoughtful separation of mind and body although it may be possible to identity a group at
remains a legitimate conceptual convenience, facilitat- increased risk for chronic pain on the basis of psycho-
ing the continued search for the multiple causes of logical features, it does not follow that the majority of
pain. patients whose pain becomes chronic are members 01
this group.
Studies to assess differences between patients who
Subgroups with psychologically maintained pain “fail” and those who “succeed” in multidisciplinary
While emotional disturbance has not been found to programs could shed light on psychosocial variable5
be etiologically significant in most pain patients, in a associated with poor outcome. Such study is limited,
small subgroup there is reason to attribute persistent however, by the screening out in some programs ot
pain and associated problems to underlying psychologi- patients who are considered unlikely to benefit (Kn-
cal pathology (Katon et al. 1985; Adler et al. lY89: berts and Reinhardt 1980) or who have no insurance
Wade et al. 1992). Early identification of such ‘at risk’ and cannot pay (Guck ct al. 1985), as well as by
patients could expedite the use of appropriate psycho- inconsistent criteria for successful outcome. Finally. it
logical interventions while limiting repeated useless. may be instructive to compare the antecedent histories
frustrating, expensive, and potentially harmful medical of severely disturbed and moderately disturbed pain
treatments. In carefully conducted studies, antecedent patients.
psychological features (singly or in combination) have Information derived from the use of these strategies
been identified in subgroups of patients with chronic would facilitate the planning of appropriate early treat-
pain. These include a past history of major depression ment, including psychotherapy and psychotropic mcdi-
(Katon et al. 1985; Atkinson et al. 19911, childhood cation. A very small percentage of highly disturbed
abuse (Adler et al. 1989), alcohol abuse (Katon et al. patients with chronic pain and long-standing psychoso-
1985; Wurtele et al. 1990; Atkinson et al. 1991). family cial problems are unlikely to respond to any treatment.
psychiatric history (Katon et al. 1985), and sexual abuse For such patients, no intervention will be successful in
in childhood (Wurtele et al. 1990). These features may attenuating pain or improving quality of life. Szasz
be important prognostic indicators. (1974) refers to these as ‘-painful persons”: patients
Certain research strategies may help to clarify the who appear to have attained their best psychic balance
psychological variables which increase a patient’s risk by maintaining the sick role, and who have little to gain
for developing a chronic pain problem. Prospective from becoming “well”. After careful medical and psy-
studies designed to assess psychosocial status soon chological evaluation, such individuals arc best scrvcd
after injury or early in the presentation of a pain by a doctor who is prepared to accept that pain relief is
complaint, and to follow patients over time would not a realistic goal, and to offer ongoing support. At
permit comparisons between those whose pain resolves the same time, of course, it is essential that a patient
and those whose pain persists. Such studies could thus identified is not deprived of necessary medical
provide useful information for separating antecedent treatments.
from reactive disturbances, for guiding treatment in
early stages of a pain disorder, and for predicting
outcome of interventions, including surgery. Linton Behavioural approaches
(1993) has discussed the economic value of preventing There is reason to be concerned that behavioural
musculoskeletal injuries from becoming chronic and interventions, commonly used in pain clinics, may be
described some promising treatments aimed at such aimed less at achieving patient well-being than at at-
prevention. taining “positive outcome”. Patients are sometimes
Long-term follow-up studies using single subject de- admitted selectively into pain treatment programs (Ro-
signs would contribute data concerning the course of berts and Reinhardt 1980), a practice which creates
treatments and responses in patients whose pain per- biases in the outcome of studies, and deprives some
sists for many years (Jensen et al. 1991; Hersen and who are in need of treatment the opportunity to bene-
Barlow 1976). To date, only a few prospective studies fit (Sternbach 1989). Of particular concern is the possi-
have been conducted although their use has been rec- ble conflict of interest arising from the need to satis&
ommended (Anderson et al. 1985; Brown 1990; Main insurance companies by enhancing a programme’s
and Waddell 1991; Katz 1992). For example, Sorensen record of success (see: Nepomuceno et al. 1982; Dear-
and Mors (1988) found that specific items on the dorff et al. 1991). The risk that the patient’s needs may
MMPI predicted poor outcome after lumbar diskec- be neglected is particularly great when insurance com-
panics, whose primary goal is to return the patient to simultaneously in pain clinic programmes (Sternbach
work, are relied upon for funding (Merskey 1992). 1989). it is difficult to sort out the effectiveness of
In operant programmes, reinforcers are eliminated specific interventions. While in theory it is possible to
in attempts to reduce “pain behaviours” and produce isolate and control individual treatment variables, such
“well bchaviours” such as return to work and de- control is extremely difficult. and prohably not appro-
creased use of medication. Such strategies may be priate in the clinic setting.
effective in reducing overt signs of pain. However. it is To promote further advances. rcscarch tools need
not at all clear whether patients arc suffering less or continued sharpening in several arcas: (a) C’w~ttd
whether they have simply learned a new operant rc- gr-wps. Whenever possible. groups should hc compara-
sponse - that of stoicism. Fordyce et al. (1985) have ble on all baseline measures except for the one under
argued that this objection is irrelevant because he- study. Kcsearch designs using subjects as their own
haviour programmcs arc not designed to reduce or controls are useful alternatives when true control
eliminate pain, but to “treat cxccss disability and ex- groups are unavailable. (h) Srl~riotr 1~iu.w. Be~auae
pressions of suffering”. This goal favours the question- thr: setting in which subjects are recruited may gcncr-
able assumption that trained observers can better judge ate a selection bias. cart should be taken to limit
the patient’s needs than the patient is able to do (see conclusions to the population represented by the sam-
C&nest i985). These caveats are not intended to dc- ple studied. (cl Or.cl-irltc,r~~t-~,ttrtiottqf‘ i.~~~~~,ll~ti(~t~~llhrtr.
tract from the benefits many patients cxpericnce with Causal statements based on correlation data arc onI1
increases in function, even when pain is not reduced. speculations, and must be identified as such. (d) Ina/~
nor to question strategies using early activation and propriarc~ ML of rc~rs. Psychological tests should bc
limited bed rest to prevent chronic disability (Linton interpreted with caution hccausc somatic or situational
1993). items are more likely to mcasurc normal reactions to
From both a diagnostic and an epistemologic~l1 point pain and physical linljtati~~ns than to I-cftcct psy-
of view. an error of logic is made when diminished pain chopathology. fc) ftIt~r~)~~,tuti~~~lc~f’ mrtlts. Results
hehaviour after operant treatment is given as “proof” should convey clinical meaning ~thow and beyond the
that operant factors arc of ctiological significance results of a statistical test. Statistics such 2s effcot siLc.
(Schmidt 1987). While cffcctivencss of a treatment may proportion of subjects who arc different. or proportion
help to explain a disorder, it does not necessarily who have improved with trc~~tn~cIlt should hc prc-
provide inf~)rrn~~ti~~Il about etiology. sentcd to clarify tho nlcaniI~g of findings.
The lack of consistent findings across studies ctmtin-
ucs to be :I recurrent lament. ~OGIUSC the psychologi-
cal variables under study arc complcs. the problem i\
difficult to solvtt. It may hc neccasary to accept limits in
a field of study defined by multiple iiltcr~icting sari-
ahics (WC cannot isolate and cttntrttl the variables: they
can’t bc separated and they won‘t stand still). At the
Despite methodoiogical and conceptual difficulties, same time. the pain research community needs tcr work
psychology research has contributed significantly to towards increased use of statidardi~ed definitions.
advances in the study and treatment of pain. In re- common tests. and consistent mcthodoiogy.
sponse to criticisms, research methods have improved
over the last half century and entrenched ideas have
changed. Psychologists have introduced research de- Acknowledgements
signs which permit more meaningful (if rarely. uncquiv-
ocal) conclusions to br: drawn from data. Although 1 wish to thank Dr. Michael Cousins for providing
there is still much work to bc dono, research has begun sabbatical lcavc facilities, and Drs. Harold Mcrskcy,
to shed light on ~sychoIogical factors which exacerbate Janet Grccly. Milton Cohen. and Olga Favrcau for
and pcrpetuutc pain. Systematic study shows that anxi- helk>ful comments on carlicr versions of this paper.
ety and depression contribute to pain. that certain
personality disorders and cognitive styles are associ-
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