Have you gone to the doctor because you are sick only to be reassured that all your tests are normal? You could be suffering from a psychogenic disease. No, this is NOT all in your head; however, the problem could have started there. Nonetheless, what you are experiencing is real. And it is estimated that 30% of outpatient doctors visits are due to psychogenic symptoms, with women being affected more than men. So how do you know if your symptoms are psychogenic? I will provide you with the 7 signs your pain is psychogenic based on my experience as a doctor and published expert opinions.
Table of the 7 Signs of Psychosomatic Pain
| 1. Symptoms do not correspond with physical exam |
| 2. Symptoms are atypical AND inexplicable |
| 3. Symptoms are constant in nature |
| 4. Symptoms do not have specific alleviators or triggers |
| 5. Symptoms do not progress as expected |
| 6. Symptoms are not improved with pain-relievers |
| 7. Symptoms improve during sleep or rest |
What is a psychogenic disease?
Think of psychogenic disease as a mental or physical disturbance whose cause typically cannot be explained by an organic process (measurable biological changes in the body).
Psychogenic diseases is divided into two categories: dissociation and somatization. Dissociation refers to problems with the mind (i.e. memory, consciousness, and self-identity impairments) where as somatization refers to problems in the body. For this article, we will focus more on somatization.
Somatization is divided into two categories: voluntary and involuntary. Voluntary somatization involves a desire to be sick, so this includes factitious disorder and malingering. Involuntary somatization (somatoform disorders) occurs at the unconscious level. These involuntary disorders include somatic symptom disorder, functional neurologic disorder, illness anxiety disorder, and body dysmorphic disorder.
How to tell if your pain is psychogenic
As a doctor, whenever a patient comes to me for an evaluation, I always develop a list of differential diagnoses. Basically, I create a list of all the common and rare causes of their symptoms, which helps guide my questioning, examination, and testing. On this list was always the possibility of a psychological condition.
I provided a table above of the 7 signs you are suffering from psychogenic pain. Read below to further understand each sign.
1. Symptoms do not correspond with physical exam
The first step in determining whether or not your symptoms are psychogenic or organic is to undergo a proper medical evaluation. A doctor will review your family history and medical history to look for any risk factors.
Then, a physical exam will help pinpoint what is causing your symptoms. If there is a discrepancy between your history and physical exam, then it is possible you are suffering from a psychogenic disease.
For example, let us say you are dealing with excruciating abdominal pain, but you have no history of trauma, surgeries, or inflammatory processes. A work-up including labs and imaging is normal, but your pain is out of proportion to the exam and is causing significant impairment to your activities of daily living. This resembles a psychogenic process.
2. Symptoms are atypical AND inexplicable
If your symptoms are atypical and perplexing to a physician, you may be dealing with a psychogenic illness. Kozuke et al describes a great example of this. A hole in the urinary and intestinal tracts causes air in the urine called pneumoturia. This would be an alarming symptoms of course; however, it is easily explained by the likely presence of the hole between tracts. If your symptoms are atypical AND cannot be readily explained by some biological process, then it could be psychogenic.
3. Symptoms are constant in nature
As aforementioned, medical diseases typically worsen over time if left untreated. They will also occur intermittently. Think of someone with lupus who is doing well until they have a flare up of symptoms, such as arthritic pain. Well, psychogenic diseases stand out in terms of symptom frequency in that often times patients complain of constant symptoms.
4. Symptoms do not have specific alleviators or triggers
Over the course of an illness, patients typically become well-versed regarding what makes their symptoms better or worse. However, if you are suffering from a psychogenic process, your symptoms are likely constant in nature making it difficult to pinpoint alleviators or triggers. Therefore, if you cannot pinpoint your alleviators or triggers consider a psychogenic cause because it suggests the influential factors are not arising from an organic process.
5. Symptoms do not progress as expected
Symptom progression is expected for any untreated organic disease process. In other words, doctors will expect you to get worse over time. In psychogenic processes, this progression may be atypical in that the symptoms may persist, but not worsen.
6. Symptoms are not improved with pain-relievers
In medicine, we are able to manage pain with over-the-counter pain-relievers aka analgesics like acetaminophen and ibuprofen and prescription analgesics like Norco and Percocet. These medications work by interfering with a physiological process, but can also work by interfering with a psychological one. This is known as the placebo effect. When a person believes a drug can cure them, it can. This means the inverse must also be true. If a person has an unconscious desire to remain ill, analgesics will not work. This suggests a psychogenic process may be at play.
As an aside, there are other medical scenarios where a pain medication, may not work. For example, if you are experiencing nerve pain, then acetaminophen is unlikely to help with this type of pain. Or if you are a chronic opioid user, you may develop a tolerance that renders your normal doses ineffective over time.
7. Symptoms improve during sleep or rest
As discussed previously, we would expect organic diseases to progress over time if left untreated. Similarly, we would expect said diseases to eventually worsen even when the body is at rest. Psychogenic illness may do the opposite. The reduction in stress load may actually lead to symptom relief when you are at sleep or rest. So if you feel better at rest, consider a psychogenic illness.
List of Psychogenic Illnesses
- Dissociation (with memory, consciousness and self-identity impairment),
- Illness Anxiety Disorder (formerly Hypochondriasis)
- Somatic Symptom Disorder (formerly Psychosomatic Illness)
- Functional Neurologic Disorder (formerly Conversion Disorder)
- Psychogenic Movement Disorders
- Psychogenic Seizures
- Body Dismorphic Disorder
- Other Specified Somatic Symptom and Related Disorder
- Brief illness anxiety
- Illness anxiety without excessive health-related behaviors
- Brief SSD
- Pseudocyesis, or false belief of pregnancy
Defining Somatic Symptom Disorder (formerly Psychosomatic Illness)
“Somatic Symptom Disorder (SSD) involves one or more physical symptoms accompanied by an excessive amount of time, energy, emotion, and/or behavior related to the symptom that results in significant distress and/or dysfunction” (D’Souza & Hooten). The most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) has now included within the definition that one can suffer from SSD with or without a medical explanation for their physical symptoms.
DSM-V Criteria for Somatic Symptom Disorder
A. One or more somatic symptoms that are distressing or result in significant disruption
of daily life.
B. Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns as manifested by at least one of the following:
- Disproportionate and persistent thoughts about the seriousness of one’s symptoms.
- Persistently high level of anxiety about health or symptoms.
- Excessive time and energy devoted to these symptoms or health concerns.
C. Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months).
List of Common Illnesses Associated with Psychogenic Processes
- Asthma
- Back Pain
- Essential Hypertension
- Migraines/Tension Headaches
- TMJ
- IBS
- Pelvic Pain
- Ulcers
How to Treat Psychogenic Pain
As psychogenic pain is simply pain that comes from the mind, psychological treatment is the standard of care. Cognitive behavioral therapy (CBT) is a main stay for most psychological illnesses.
Studies have shown that cognitive-behavioral therapy is associated with significant improvement in patient-reported functioning and somatic symptoms, a decrease in health care costs,[11] and a reduction in depressive symptoms.
D’Souza RS, Hooten WM.
As a wellness coach, I am biased towards a wellness approach to behavioral therapy. I think CBT can focus too much on prior negative events in one’s life, which can make going to therapy an emotionally exhausting experience. So I have developed my own wellness coaching practice with a goal of producing the same results without my clients feeling terrible in the process.
Other treatment modalities are physical therapy and pharmaceuticals. Physical therapy can be very beneficial, but if at all I believe pharmacologic approaches should be limited due to possible adverse reactions. Those suffering from anxiety or depression may benefit from an SSRI or SNRI. And of course mindfulness practices and exercise have been shown to help.
But Wait There is More to Consider
It is worth pointing out that psychogenic diseases are akin to a diagnosis of exclusion. If the doctor cannot find a cause for your sickness, he/she will likely consider psychogenic disease.
However, a diagnosis of a psychogenic disease is making a rather large assumption that a psychological cause is responsible for the initiation or maintenance of your current condition. If we adhere to Occam’s Razor, then the simplest solution is likely right. Basically, there is a problem with your mind; and therefore, the solution should be CBT and other psychological treatments.
But we all know life can be more complicated than this at times. It is possible that there are many causes for what you are experiencing, and perhaps medicine just hasn’t caught up yet. And we do not have enough evidence to support any current causal theories.
What we do know is that there are several likely risk factors that have been investigated and may prove contributory, such as childhood neglect, personality disorders, sexual abuse, psychosocial stressors like unemployment, chaotic lifestyle, and history of alcohol and substance abuse.
In Summary
In this article, I discussed the ways you can tell if your are experiencing psychogenic pain. As mentioned above, the best way to go about this is through a proper medical examination as you do not know what you do not know. And I will say again that psychogenic pain is very real, and chronic pain can change the way your body functions, so do seek treatment for this by a medical professional.
Finally, I know that if you are experiencing a health crisis like this, your mood has undoubtedly been negatively impacted. It is common to experience anxiety or depression when in poor health.
Conversely, sometimes your mental health can cause unexpected symptoms in your body. For those of you who are suffering from anxiety, check out my article on how anxiety manifests in the body. There will soon be an article covering depression symptoms as well.
