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Emotional adjustment and chronic pain
Pain, 5 (1978) 173--178 Q Elsevier/North-Holl~nd Biomedical Press
.L73
EMOTIONAL ADJUSTMENT AND CHRONIC PAIN
H, M E R S K E Y *
and D. BOYD
Department of Psychiatry, University of Western On¢.ario and London Psychiatric Hospital, 850 Highbury Avenue, London, Ont. (Canada) (Accepted January 23rd, 1978)
SUMMARY
Previous work has suggested that patients with organic lesions causing pain may show as much emotional disturbance as patients with pain but without lesions. This study examined 141 chronic pain patients for their life experience, both currently and premorbidly, in terms of upbringing, neurotic traits and personality disturbance. Patients with an organic cause for pain reported significantly less family disturbance in childhood, less premorbid personality problems and less neurotic traits than patients who did not have any organic cause for their pain. The data provide support for the view that a significant proportion of the emotional disturbance associated with chronic pain is a secondary effect. Adjectives used to describe pain and factors causing exacerbation and relief of pain, although overlapping, also differed in the two groups.
INTRODUCTION
Substantial evidence exists that anxiety, emotional conflict, stress and personalii,h, play an important par:; in causing or promoting pain [ 2,3,10,13,14, 17]. A few systematic studies have explored the difference in the factors between psychiatric patients who have pain and those who do not [7,8,12]. There are perhaps only two studies which compare the psychiatric ~tate of those patients who have lesions which might cause pain and those who do not. Woodfozde and Merskey [18] using questionnaire techniques, found that on the Maudsley Personality Inventory, patients with lesions were as anxious as patients without lesions. The former group had significantly more signs of phobic anxiety and obsessionality on the Middlesex Hospital qo.e~tionnaire than the latter. These results in the physically ill patients were * Formerly: Physician in Psychological Medicine, The National HospitaIs for Nervous Diseases, London, England.
174
attributed partly to selection and partly to the effects of chronic pain. Pilowsky and Spence [11] using an illness behaviour questionnaire in 100 pain clb,_ic patients failed to show that chronicity as such was related to fi!hess behaviour and this remained true even when the 20 patients with substanti~i organic pathology, in their population, were considered. However, other studies have shown a link between chronicity and personality change with low back pain. [15] or rheumatoid arthritis [4], while surgical intervention to reduce pain has been associated, albeit weakly, with a reduction in personality disturbance [ 16]. It seems reasonable to suppose that patients wi.th pain and physical lesions will have less evidence of premorbid personality disturbance and interpersonal problems titan patients with pain and no physical lesions, even though, as Woodforde and Merskey [ 18] found, the degree of current emotional disturbance in those with lesions may be as much as or more than that of those without !esions. In the present study we report some of the charact~eristics of patients ~4th pain, comparing those with and without lesions. METHODS
A standardized data sheet was filled in on 141 patients with chronic pain seen in consultation (by H.M.) at The Nathmal Hospitals for Nervous Diseases, Queen Square and Maida Vale. The descriptions of pain by 128 of these patients 'were reported on previously [1], and tests on some of them formed the basis for the study by Woodforde and Merskey [ !8]. Data collected on patient characteristics included: sex, age, marital status, inpa~ient or outpatient status, characteristics of patient's father and mother, separations from pm'ent(s) up to age 16, attitudes towards parents, sibs and position in sibline, education and occupation, premorbid personality traits, premorbid neurotic symptomatology, medical and s Jrgical past health, psychiatric and psychosomatic health, menstrual histoEr, marital harmony, current attitudes, antecedent emotional stress, dia~,osis. These variables had responses and sub-categories that were numerically coded and compared with each other giving rh.e to 2348 chi squares. At a significance level of P < 0.05 we expected 117 ~dgn[~icant results by chance. We, in fact, found 312 significant comparisons ~ith P < 0.05. Some of these we excluded because the cause of the significance was obvious; fl)r example, only women have menstrual periods. Probabfli%,.;es of 0.G5 > P > 0.01 have been accepted where they were in accordance with o~;her findings. Data coUecLed and coded +~oshow fea~,ures of ~;he ~ain included: site, ~,~ide, ~evei'ity, co u~'se, duration and frequency cf episodes, overall duration oi pain as a complah~t, precipitants and relieving factors. RESULTS
The 14! patients included 65 men and 76 women. There were 70 outpatient,,~ and 71 iapatients. Seventy-one patients had al~ organic lesion account-
i75
ing for their pain; 70 were thought to have no organic lesion for their pain. The average age was 44.8 (range 14--84), the "non-organic" groul5 being somewhat younger (average 41.0) than the "organic" group (acerage 48.5). One hundred and twenty-seven of the 141 patients had severe pain. The pain wes chronic with an average duration of 70.3 months and a minimum period of 3 months, except that erie patient had had pain for 2 montl~s. Inpatients had pain for longer (average 79.1 months} than outpatients (average 62.7 months). The site of pain is :eported in Table I. Most patients had continuous pain or at least pain that lasted longer than 6 h (131 of 141). As in the earlier report [1], pain lateralized more to the left (P < 0.01), an effect due here to the patients without lesions. Organic disease was found in 71 patients and was evenly divided into male (52.1%} and female (47.9%). However, non-organically based pain occurred more often in women (62.1%) (see Table II). In keeping with this finding, more women had premorbid anxiety symptoms than men (28 : 7, P < 0.001) and more women recognized antecedent emotional stress as a precipitant of pain ( 3 1 : 16, P < 0.05). Of the 89 patients in whom a psychiatric diagnosis was made, 55 (61.8%) were women. The distribution of diagnoses in these 55 women was reactive depression 43.6% (24/55), endogenous depression 10.9% (6/55), hysteria 23.6% (13/ 55), anxiety 20.0% (11[55), and rnanic depressive illness 1.8% (1/55). The principal organic diagnoses were reported by Agnew and Merskey [1] and included causalgia, post-herpetic neuralgia, facial pain, carcinoma, thalamic syndrome, vascular disease, cervical spondylosis, low back (disc) pain and dental pain. The site of pain correlated with the presence of lesions (P < 0.001). Not surprisingly, headache was largely "of no o~cganic basis" (43/49), whereas some areas correlated strongly with having an organic lesion: arms (!!/11}, low back or side (11/12), chest (11/15) and legs (9/12). Other are~ were
TABLE I COMPARISON OF PAIN SITE AND HOSPITALIZATION STATUS Site
Head Face Chest Low back or side Legs Arms Perineum/buttocks/genitaliia Neck Total
Total
Outpatient
(n)
Inpatient (n)
16 15
(n)
(%)
52 27 15 !2 12 11 9 3
(36.9) (19.1)
36 12
(lo.6)
7
8
(8.5) (8.5)
2 4
10 8
(7.1) (7.8)
4 2
7 7
(2.1)
2
1
141
100%
69
72
176 T A B L E II C O M P A R I S O N O F SEX A N D O R G A N I C I T Y OF P A I N X2 equals 2 . 7 9 7 , P < 0.1, N.S. Organic lesion
No organic lesion
Total
Male Female
37 34
25 41
62 75
Total
71
66
137 a
a Full i n f o r m a t i o n was n o t available o n 4 patients o f t h e 141.
found equally in the organic and non-organic groups: face (16/27 organic), neck (2/3 organic) and "genitalia, perineum, buttock" (5/9 organic). None of the patients had abdominal pain, no doubt because such patients were not often referred for combined neurological and psychiatric assessment. As indicated by Agnew and Merskey [1], the desc.',.dption of pain correlated somewhat with physical lesions. "Aching" pain had an organic basis in 26 of 43 cases, "stabbing" pain in 9 of 12 and "aching plus stabbing" in 11 of 14. On the other hand, "throbbing" pain or "throbbing plus aching" were predominantly complaints of patients with no organic lesion to account for their pain (in 22/32 and 9/12 respectively). Nine patients with lesions and 7 without lesions recognized both psychological precipitants and physical ones for their pain. Psychological precipitants alone (wit!bout physical precipitants) were recognized by 28 patients who did not have lesions compared to 2 with lesions and physical precipirants "alone were reported in 48 patients with lesions as compared to 12 withou~.
~n relating origin of pain to parental characteristics it i~ interesting, though admittedly the numbers are small, to see that emotionally based pain occurred in all 6 of 6 patients who reported their fathers as rejecting (P < 0.01), in 9 of the 12 patients with mothers who had psychosomatic illness (P < 0.05), and in all 4 patients reporting their mothers as punishing (P <
0.05). Three-quarters of patients with premorbid conversion symptoms (n = 16) had no organic basis for pain (P < 0.05), and similarly, patients with several of the characteristics "reserved, shy, worrier, nail biter" tended to have pain without a lesion (P < 0.05). A past history of either psychiatric or psychosomatic illness did not correlate with pain being of non-organic cause. Patients who had more than one or two operations tended to have an organic origin for their pain (P < 0.05). Women with no organic basis for their pain were l:aore likely to have severe premenst, rual symptoms and dysmenorrhoea (both P < 0.02). A marriage characterized by upsets, blows, conflicting interests or separaLions was more common in the ~'no lesion" group (P ( 0 . 0 5 ) .
177
As an aside, patients with premorbid obsessive symptoms, or obstinate, critical or combative personality traits, or feelings of g~ilt, tended ~o have fathers who were n o t warm and affectionate (P < 0.001, P < 0 . 0 ! , P < 0.02, respectively). One-quarter of alcoholic fathers was still described as warm and :affectionate. Only 4 patients reported their mothers as punishing but 3 of them also h a d p r e m o r b i d obsessive symptoms. Six patients reported guilty feelings and 5 of them had no organic basis for pain. Patients who were "only children" had a higher incidence of obstinate, critical or combative personality traits. DISCUSSION
Although there were small differenc6s in respect of age and the length of time for which pain was present, the patieats with lesions were not otherwise different in demographic characteristics from those who did not have lesions. More of the second group were outpatients and this probably reflects the understandable reluctance of physicians to admit patients for whom a medical (neurological) admission could be unhelpful. We think it is reasonable, therefore, to compare the characteristics of pain and the personality features of patients in the two groups. Amongst those characteristics of pain which we have noted, the predominance of pain on the left is not a new finding. The significance of the tendency for pain to be lateralized on the left has occasionally been discussed [10] but remains obscure. We still favour the idea that the integration of sensory information from the non d o m i n a n t side of the body is less efficient than that from the dominant side. Other findings such as the sex distribution, site of the pain, continuous nature of the pain, relationship to psychiatric diagnosis and neurological, diagnosis are also not new. It is worth emphasizing, however, that in this ~ e r i e s - perhaps unlike some o t h e r s - - l o w back pain had an organic basis. The occurrence of perir~ea! pain in relationship to organic illness (5 out of 9 patients had lesions) is also interesting in as much as there were clearly 2 patients for whom a psychological explanation was valid, but in addition to the 5 with organic lesions there were also 2 of the remaining 4 in whom organic disturbance we~ strongly suspected and a cause] psychiatric diagnosis was nnt feasible. Another finding of some interest is the recognition by 35 out of 70 (50%) of those without lesions that psychological factors precipitated or exacerbated their pain, whilst this was only evident in 9 patients (13%) of those with organic lesions. The main interest in this report is for the bearing the data have on the question, whether psychological illness causes pain or vice versa, or whether both relationships may be present. If only the former of the two relationships is true, pain should occur in the absence of lesions and the patients with lesions should have as much evidence of predisposition in their personalities, lives before the onset of pain and current interpersonal relationships as those without. Pain certainly occurs in those without lesions and with psychological illness. But when it occurs with le~ions, there is much less evi-
178
dence in our population of predisposing factors in the personality. Although there was clearly some overlap, the patients without lesions have significantly more evidence of an unhappy childhood, premorbid personality problems and current marital maladjustment. The present evidence thus supports the common-sense view that not only does pain follow from psychological illness but that lesions which cause chronic pain tend to produce psychiat~c disturbances. Other evidence for this view has been cited elsewhere [ 9]. Lastly, it is worth noting; that in accordance with the psychodynamics of pain as punishment, which Engel [ 5,6] has emphasized, rejecting fathers and punishing mothers correlated with the occurrence of pain without lesicns. "A remains to be seen whether such parents would be found in excess amongsl psychiatric patien~ with pain compared with psychiatric patients without pain. REFERENCES 1. Agnew, D.C. and Merskey, H., Words of chronic pain, Pain, 2 (1976) 73--81. 2 Barber, T.X., Toward a theory of pain: ~elief of chronic pain by pre-frontal leucotomy, opiates, placebos, and hypnosis, Psychol. Bull., 56 (1959) 430--460. 3 Beecher, H.K., Measurement of Subjective Responses, Quantitative Effects of Drugs, Oxford University Press, New York, 1959. 4 Crown, S. and Crown, J.M., Personality in early rheumatoid disease, J. psychosom. Res., 17 (~.973) 1.89--196. 5 Engel, G.L., Primary atypical facial neuralgia. An hysterical conversion symptom, Psychosom. Med., 13 {1951) 375--396. 6 Engel, G.L., "Psychogenic" pain and the pain prone patient, Amer. J. Med., 26 (1959) 899--918. 7 Merskey, H., The characteristics of persistent pain in psychological illness, J. psychosore. Res., 9 (1965) 291--298. 8 Merskey, H., Psychiatric patients with persistent pain, J. psychosom. Res., 9 (1965) 299--309. 9 Merskey, H., The Status of Pain, Mqdern Trends in Psychosomatic Medicine, Butterworths, London, 1976, pp. 166--186. 10 Merskey, H. and Spear, F.G., Pain: Psychological and Psychiatric Aspects, Bailli~re, Tindall and Cassell, London, 1967. 11 Pilowsky, I. and Spence, N.D., Illness behaviour syndromes associated with intractable pain, Pain, 2 (1976)61--7:1. 12 Spear, F.G., Pain in psychiatric patients, J. psyehosom. Res., 11 (1967) 187--193. 13 Sternbach, R.A., Pain: a Psychophysiological Analysis, Academic Press, New York 1968. 14 Ster~bach, R.A., Pain Patients: Traits and Treatment, Academic Press, New York, 1974. 15 Sternbach, R.A., Murphy, R.W., Akeson, W.H. and Wolf, S.R., Chronic low-back pain: the "~ow-back loser", Postg~'ad. Med., 53 (1973) 135--138. t6 Sternbach, R.A., Murphy, R.W., Timmermans, G., Greenhoot, J.H. and Akeson, W.H., MeasurirLg the severity of clinical pain, Advanc. Neurol., 4 (1974) 281--288. 17 Walters, A., Psychogenic regional pain alias hysterical pain, Brain, 84 (1961) 1--18. 18 Woodforde, J.M. and Merskey, H., Personality trait~ of patients with chronic pain, J. psycb.osom. Res., 16 (1972) 167--172.
.L73
EMOTIONAL ADJUSTMENT AND CHRONIC PAIN
H, M E R S K E Y *
and D. BOYD
Department of Psychiatry, University of Western On¢.ario and London Psychiatric Hospital, 850 Highbury Avenue, London, Ont. (Canada) (Accepted January 23rd, 1978)
SUMMARY
Previous work has suggested that patients with organic lesions causing pain may show as much emotional disturbance as patients with pain but without lesions. This study examined 141 chronic pain patients for their life experience, both currently and premorbidly, in terms of upbringing, neurotic traits and personality disturbance. Patients with an organic cause for pain reported significantly less family disturbance in childhood, less premorbid personality problems and less neurotic traits than patients who did not have any organic cause for their pain. The data provide support for the view that a significant proportion of the emotional disturbance associated with chronic pain is a secondary effect. Adjectives used to describe pain and factors causing exacerbation and relief of pain, although overlapping, also differed in the two groups.
INTRODUCTION
Substantial evidence exists that anxiety, emotional conflict, stress and personalii,h, play an important par:; in causing or promoting pain [ 2,3,10,13,14, 17]. A few systematic studies have explored the difference in the factors between psychiatric patients who have pain and those who do not [7,8,12]. There are perhaps only two studies which compare the psychiatric ~tate of those patients who have lesions which might cause pain and those who do not. Woodfozde and Merskey [18] using questionnaire techniques, found that on the Maudsley Personality Inventory, patients with lesions were as anxious as patients without lesions. The former group had significantly more signs of phobic anxiety and obsessionality on the Middlesex Hospital qo.e~tionnaire than the latter. These results in the physically ill patients were * Formerly: Physician in Psychological Medicine, The National HospitaIs for Nervous Diseases, London, England.
174
attributed partly to selection and partly to the effects of chronic pain. Pilowsky and Spence [11] using an illness behaviour questionnaire in 100 pain clb,_ic patients failed to show that chronicity as such was related to fi!hess behaviour and this remained true even when the 20 patients with substanti~i organic pathology, in their population, were considered. However, other studies have shown a link between chronicity and personality change with low back pain. [15] or rheumatoid arthritis [4], while surgical intervention to reduce pain has been associated, albeit weakly, with a reduction in personality disturbance [ 16]. It seems reasonable to suppose that patients wi.th pain and physical lesions will have less evidence of premorbid personality disturbance and interpersonal problems titan patients with pain and no physical lesions, even though, as Woodforde and Merskey [ 18] found, the degree of current emotional disturbance in those with lesions may be as much as or more than that of those without !esions. In the present study we report some of the charact~eristics of patients ~4th pain, comparing those with and without lesions. METHODS
A standardized data sheet was filled in on 141 patients with chronic pain seen in consultation (by H.M.) at The Nathmal Hospitals for Nervous Diseases, Queen Square and Maida Vale. The descriptions of pain by 128 of these patients 'were reported on previously [1], and tests on some of them formed the basis for the study by Woodforde and Merskey [ !8]. Data collected on patient characteristics included: sex, age, marital status, inpa~ient or outpatient status, characteristics of patient's father and mother, separations from pm'ent(s) up to age 16, attitudes towards parents, sibs and position in sibline, education and occupation, premorbid personality traits, premorbid neurotic symptomatology, medical and s Jrgical past health, psychiatric and psychosomatic health, menstrual histoEr, marital harmony, current attitudes, antecedent emotional stress, dia~,osis. These variables had responses and sub-categories that were numerically coded and compared with each other giving rh.e to 2348 chi squares. At a significance level of P < 0.05 we expected 117 ~dgn[~icant results by chance. We, in fact, found 312 significant comparisons ~ith P < 0.05. Some of these we excluded because the cause of the significance was obvious; fl)r example, only women have menstrual periods. Probabfli%,.;es of 0.G5 > P > 0.01 have been accepted where they were in accordance with o~;her findings. Data coUecLed and coded +~oshow fea~,ures of ~;he ~ain included: site, ~,~ide, ~evei'ity, co u~'se, duration and frequency cf episodes, overall duration oi pain as a complah~t, precipitants and relieving factors. RESULTS
The 14! patients included 65 men and 76 women. There were 70 outpatient,,~ and 71 iapatients. Seventy-one patients had al~ organic lesion account-
i75
ing for their pain; 70 were thought to have no organic lesion for their pain. The average age was 44.8 (range 14--84), the "non-organic" groul5 being somewhat younger (average 41.0) than the "organic" group (acerage 48.5). One hundred and twenty-seven of the 141 patients had severe pain. The pain wes chronic with an average duration of 70.3 months and a minimum period of 3 months, except that erie patient had had pain for 2 montl~s. Inpatients had pain for longer (average 79.1 months} than outpatients (average 62.7 months). The site of pain is :eported in Table I. Most patients had continuous pain or at least pain that lasted longer than 6 h (131 of 141). As in the earlier report [1], pain lateralized more to the left (P < 0.01), an effect due here to the patients without lesions. Organic disease was found in 71 patients and was evenly divided into male (52.1%} and female (47.9%). However, non-organically based pain occurred more often in women (62.1%) (see Table II). In keeping with this finding, more women had premorbid anxiety symptoms than men (28 : 7, P < 0.001) and more women recognized antecedent emotional stress as a precipitant of pain ( 3 1 : 16, P < 0.05). Of the 89 patients in whom a psychiatric diagnosis was made, 55 (61.8%) were women. The distribution of diagnoses in these 55 women was reactive depression 43.6% (24/55), endogenous depression 10.9% (6/55), hysteria 23.6% (13/ 55), anxiety 20.0% (11[55), and rnanic depressive illness 1.8% (1/55). The principal organic diagnoses were reported by Agnew and Merskey [1] and included causalgia, post-herpetic neuralgia, facial pain, carcinoma, thalamic syndrome, vascular disease, cervical spondylosis, low back (disc) pain and dental pain. The site of pain correlated with the presence of lesions (P < 0.001). Not surprisingly, headache was largely "of no o~cganic basis" (43/49), whereas some areas correlated strongly with having an organic lesion: arms (!!/11}, low back or side (11/12), chest (11/15) and legs (9/12). Other are~ were
TABLE I COMPARISON OF PAIN SITE AND HOSPITALIZATION STATUS Site
Head Face Chest Low back or side Legs Arms Perineum/buttocks/genitaliia Neck Total
Total
Outpatient
(n)
Inpatient (n)
16 15
(n)
(%)
52 27 15 !2 12 11 9 3
(36.9) (19.1)
36 12
(lo.6)
7
8
(8.5) (8.5)
2 4
10 8
(7.1) (7.8)
4 2
7 7
(2.1)
2
1
141
100%
69
72
176 T A B L E II C O M P A R I S O N O F SEX A N D O R G A N I C I T Y OF P A I N X2 equals 2 . 7 9 7 , P < 0.1, N.S. Organic lesion
No organic lesion
Total
Male Female
37 34
25 41
62 75
Total
71
66
137 a
a Full i n f o r m a t i o n was n o t available o n 4 patients o f t h e 141.
found equally in the organic and non-organic groups: face (16/27 organic), neck (2/3 organic) and "genitalia, perineum, buttock" (5/9 organic). None of the patients had abdominal pain, no doubt because such patients were not often referred for combined neurological and psychiatric assessment. As indicated by Agnew and Merskey [1], the desc.',.dption of pain correlated somewhat with physical lesions. "Aching" pain had an organic basis in 26 of 43 cases, "stabbing" pain in 9 of 12 and "aching plus stabbing" in 11 of 14. On the other hand, "throbbing" pain or "throbbing plus aching" were predominantly complaints of patients with no organic lesion to account for their pain (in 22/32 and 9/12 respectively). Nine patients with lesions and 7 without lesions recognized both psychological precipitants and physical ones for their pain. Psychological precipitants alone (wit!bout physical precipitants) were recognized by 28 patients who did not have lesions compared to 2 with lesions and physical precipirants "alone were reported in 48 patients with lesions as compared to 12 withou~.
~n relating origin of pain to parental characteristics it i~ interesting, though admittedly the numbers are small, to see that emotionally based pain occurred in all 6 of 6 patients who reported their fathers as rejecting (P < 0.01), in 9 of the 12 patients with mothers who had psychosomatic illness (P < 0.05), and in all 4 patients reporting their mothers as punishing (P <
0.05). Three-quarters of patients with premorbid conversion symptoms (n = 16) had no organic basis for pain (P < 0.05), and similarly, patients with several of the characteristics "reserved, shy, worrier, nail biter" tended to have pain without a lesion (P < 0.05). A past history of either psychiatric or psychosomatic illness did not correlate with pain being of non-organic cause. Patients who had more than one or two operations tended to have an organic origin for their pain (P < 0.05). Women with no organic basis for their pain were l:aore likely to have severe premenst, rual symptoms and dysmenorrhoea (both P < 0.02). A marriage characterized by upsets, blows, conflicting interests or separaLions was more common in the ~'no lesion" group (P ( 0 . 0 5 ) .
177
As an aside, patients with premorbid obsessive symptoms, or obstinate, critical or combative personality traits, or feelings of g~ilt, tended ~o have fathers who were n o t warm and affectionate (P < 0.001, P < 0 . 0 ! , P < 0.02, respectively). One-quarter of alcoholic fathers was still described as warm and :affectionate. Only 4 patients reported their mothers as punishing but 3 of them also h a d p r e m o r b i d obsessive symptoms. Six patients reported guilty feelings and 5 of them had no organic basis for pain. Patients who were "only children" had a higher incidence of obstinate, critical or combative personality traits. DISCUSSION
Although there were small differenc6s in respect of age and the length of time for which pain was present, the patieats with lesions were not otherwise different in demographic characteristics from those who did not have lesions. More of the second group were outpatients and this probably reflects the understandable reluctance of physicians to admit patients for whom a medical (neurological) admission could be unhelpful. We think it is reasonable, therefore, to compare the characteristics of pain and the personality features of patients in the two groups. Amongst those characteristics of pain which we have noted, the predominance of pain on the left is not a new finding. The significance of the tendency for pain to be lateralized on the left has occasionally been discussed [10] but remains obscure. We still favour the idea that the integration of sensory information from the non d o m i n a n t side of the body is less efficient than that from the dominant side. Other findings such as the sex distribution, site of the pain, continuous nature of the pain, relationship to psychiatric diagnosis and neurological, diagnosis are also not new. It is worth emphasizing, however, that in this ~ e r i e s - perhaps unlike some o t h e r s - - l o w back pain had an organic basis. The occurrence of perir~ea! pain in relationship to organic illness (5 out of 9 patients had lesions) is also interesting in as much as there were clearly 2 patients for whom a psychological explanation was valid, but in addition to the 5 with organic lesions there were also 2 of the remaining 4 in whom organic disturbance we~ strongly suspected and a cause] psychiatric diagnosis was nnt feasible. Another finding of some interest is the recognition by 35 out of 70 (50%) of those without lesions that psychological factors precipitated or exacerbated their pain, whilst this was only evident in 9 patients (13%) of those with organic lesions. The main interest in this report is for the bearing the data have on the question, whether psychological illness causes pain or vice versa, or whether both relationships may be present. If only the former of the two relationships is true, pain should occur in the absence of lesions and the patients with lesions should have as much evidence of predisposition in their personalities, lives before the onset of pain and current interpersonal relationships as those without. Pain certainly occurs in those without lesions and with psychological illness. But when it occurs with le~ions, there is much less evi-
178
dence in our population of predisposing factors in the personality. Although there was clearly some overlap, the patients without lesions have significantly more evidence of an unhappy childhood, premorbid personality problems and current marital maladjustment. The present evidence thus supports the common-sense view that not only does pain follow from psychological illness but that lesions which cause chronic pain tend to produce psychiat~c disturbances. Other evidence for this view has been cited elsewhere [ 9]. Lastly, it is worth noting; that in accordance with the psychodynamics of pain as punishment, which Engel [ 5,6] has emphasized, rejecting fathers and punishing mothers correlated with the occurrence of pain without lesicns. "A remains to be seen whether such parents would be found in excess amongsl psychiatric patien~ with pain compared with psychiatric patients without pain. REFERENCES 1. Agnew, D.C. and Merskey, H., Words of chronic pain, Pain, 2 (1976) 73--81. 2 Barber, T.X., Toward a theory of pain: ~elief of chronic pain by pre-frontal leucotomy, opiates, placebos, and hypnosis, Psychol. Bull., 56 (1959) 430--460. 3 Beecher, H.K., Measurement of Subjective Responses, Quantitative Effects of Drugs, Oxford University Press, New York, 1959. 4 Crown, S. and Crown, J.M., Personality in early rheumatoid disease, J. psychosom. Res., 17 (~.973) 1.89--196. 5 Engel, G.L., Primary atypical facial neuralgia. An hysterical conversion symptom, Psychosom. Med., 13 {1951) 375--396. 6 Engel, G.L., "Psychogenic" pain and the pain prone patient, Amer. J. Med., 26 (1959) 899--918. 7 Merskey, H., The characteristics of persistent pain in psychological illness, J. psychosore. Res., 9 (1965) 291--298. 8 Merskey, H., Psychiatric patients with persistent pain, J. psychosom. Res., 9 (1965) 299--309. 9 Merskey, H., The Status of Pain, Mqdern Trends in Psychosomatic Medicine, Butterworths, London, 1976, pp. 166--186. 10 Merskey, H. and Spear, F.G., Pain: Psychological and Psychiatric Aspects, Bailli~re, Tindall and Cassell, London, 1967. 11 Pilowsky, I. and Spence, N.D., Illness behaviour syndromes associated with intractable pain, Pain, 2 (1976)61--7:1. 12 Spear, F.G., Pain in psychiatric patients, J. psyehosom. Res., 11 (1967) 187--193. 13 Sternbach, R.A., Pain: a Psychophysiological Analysis, Academic Press, New York 1968. 14 Ster~bach, R.A., Pain Patients: Traits and Treatment, Academic Press, New York, 1974. 15 Sternbach, R.A., Murphy, R.W., Akeson, W.H. and Wolf, S.R., Chronic low-back pain: the "~ow-back loser", Postg~'ad. Med., 53 (1973) 135--138. t6 Sternbach, R.A., Murphy, R.W., Timmermans, G., Greenhoot, J.H. and Akeson, W.H., MeasurirLg the severity of clinical pain, Advanc. Neurol., 4 (1974) 281--288. 17 Walters, A., Psychogenic regional pain alias hysterical pain, Brain, 84 (1961) 1--18. 18 Woodforde, J.M. and Merskey, H., Personality trait~ of patients with chronic pain, J. psycb.osom. Res., 16 (1972) 167--172.