- Email: [email protected]
PAIN AND THE PSYCHIATRIST
1166
mechanisms of identification. A striking example was the psychogenic abdominal pain experienced by some expectant husbands during their wife’s pregnancy, but less dramatic examples could often be demonstrated in the ordinary clinical interview. This sort of excessive selective sensitivity to others’ feelings was often regarded as a hysterical trait, but it might be found in other personality types. Aggressive feelings and emotional to be given antibiotics or if he is left with an uncomfortably distress were sometimes projected as pain felt in a parnarrow anal canal, may not too high a price have been paid ticular site, and Professor Stengel mentioned a patient for convenience ? whose agonising post-amputation " phantom limb " pain recurred whenever he watched a disturbing programme on television. In his studies of the pain-prone patient, PAIN AND THE PSYCHIATRIST Engel 6 had provided the " only consistent theory of IN the thirty-ninth Maudsley lecture, before the Royal psychogenic pain ". This hypothesis depended upon Medico-Psychological Association on Nov. 20, Prof. E. analytical interpretations and might not be acceptable to Stengel recalled the interest that had been shown in the some psychiatrists, but it fitted several of the facts and subject of pain by earlier psychiatrists, including Henry was worthy of further study. Maudsley 1; but he contrasted the enormous amount of Analysts, psychiatrists, and neurologists were generally recent physiological research on pain with the modern agreed in their reluctance to regard every symptom without psychiatrists’ curious neglect of it. This attitude was organic cause as hysterical-particularly pain, which certainly not justified by the place which pain occupied in served additional functions as a protective signal and psychiatric symptomatology: Professor Stengel found that possible source of masochistic gratification. pain was a main complaint in nearly half his own patients. Only a few of the many patients who experienced Although clinicians often attempted to distinguish psychogenic pain were seen by a psychiatrist. This between organic and psychogenic pain, they largely circumstance was mainly determined by the nature of the ignored the psychogenic kind; and it was a neurologist2 complaint, but the attitudes of patients and doctors must who had made a " gallant attempt at classification". also play an important part. Few people (even among Conversion symptoms could arise without accompanying the medical students Professor Stengel had questioned) hysterical stigmata, and pain was sometimes an emotional expected psychiatrists to be concerned with alleviating expression of a thought or fear (chest pain due to anxiety pain; but in neglecting " one of the doctor’s noblest about heart-disease) or a somatic hallucination in a tasks", psychiatrists had probably forfeited much of depressive or schizophrenic psychosis. Work in Professor the prestige awarded to other branches of medicine. Stengel’s department indicated that psychogenic pain was associated with psychiatric illness in its onset and somePAROXYSMAL MYOGLOBINURIA times in its fluctuations; it tended to be continuous and EXTENSIVE crush injury to the voluntary musclesmay capricious in its response to treatment, although antidepressant drugs were often very effective. Many of those give rise to myoglobinuria; and myoglobin also appears who suffered from it were anxious about their health and in the urine when degeneration affects large muscle masses, fitness, came from lower socioeconomic classes, and gave as in occlusive arterial diseaseand the anterior tibial a history of surgical operations. syndrome.Other causes of myoglobinuria include acute The description and definition of pain presents con- polymyositis 10 11 and epidemic Haff disease .12 In addition, siderable semantic difficulties; and in discussing its there is a well-recognised syndrome, usually referred to as physiological characteristics, it is customary to distinguish idiopathic paroxysmal myoglobinuria, in which episodes between the perception of pain and overall reaction to it. of severe and generalised muscular pain and weakness are Professor Stengel’s earlier work3 concerned the dis- accompanied by profuse myoglobinuria.13 Korein et al.14 in 1959 showed that this disorder first began, as a rule, crepancy between normal sensory perception and blunted reaction to noxious stimuli, which he called pain asymboly. between 15 and 20 years of age and that it persisted for This condition was seen in a congenital form associated many years with frequent exacerabtions. Some patients with mental deficiency and in certain patients with were symptom-free during remissions, while others were parietal-lobe lesions. In some respects the condition disabled by recurrent muscle pain after exercise. In some resembled the abnormal pain responses of schizophrenics such cases calf enlargement has been observed,15-17and in and the masochistic reactions of abnormal personalities; addition a number of them have been shown to have but studies of pain responses and thresholds by different atrophy and weakness of certain muscle groups, so that the methods 45 in heterogeneous groups showed no con- suggestion has been made that these were cases of muscular nection with the psychiatric diagnosis, mental sub- dystrophy associated with myoglobinuria. Recently, too, normality, or the tendency to suffer psychogenic pain. Schmid and Mahler 18 described a patient with McArdle’s The subjective character of pain imposed inevitable 6. Engel, G. L. Amer. J. Med. 1959, 26, 899. 7. Bywaters, E. G. L. J. Amer. med. Ass. 1944, 124, 1103. limitations on physiological methods of experiment; and 8. Bywaters, E. G. L., Stead, J. K. Clin. Sci. 1945, 5, 195. 9. Adams, R. D., Denny-Brown, D., Pearson, C. M. Diseases of Muscle. because of its psychic nature pain had played an important New York, 1962. 10. Günther, H. Virchows Arch. path. Anat. 1924, 251, 141. part in the evolution of psychoanalytic theory and the
pylephlebitis as a complication of septic (unoperated) piles, but others have been less fortunate. Suppurative cholecystitis and gangrenous appendicitis, like infected piles, drain their toxins into the portal circulation, it is true. But they differ from piles in that a protective omentum and peritoneal lining wall off the disease. Immediate operation for acutely prolapsed piles may serve convenience, but it is never lifesaving. If the patient has
of conversion mechanisms. Precipitation and localisation of pain were sometimes determined by
study 1. 2. 3. 4. 5.
Maudsley, H. Pathology of Mind. London, 1895. Walters, A. Brain, 1961, 84, 1. Schilder, P., Stengel, E. Z. ges. Neurol. Psychiat. 1928, 113, 143. Stengel, E., Oldham, A. P., Ehrenberg, A. S. C. J. ment. Sci. 1955, 101, 52; ibid. 1958, 104, 434. Hall, K. R. L., Stride, E. Brit. J. med. Psychol. 1954, 27, 48.
Paul, F. Wien. Arch. inn. Med. 1924, 7, 531. Berlin, R. Acta med. scand. 1948, 129, 560. Reiner, L., Konikoff, W., Altschule, M. D., Dammin, G. J., Merrill, J. P. Arch. intern. Med. 1956, 97, 537. 14. Korein, J., Coddon, D. R., Mowrey, F. H. Neurology, Minneap. 1959, 9, 767. 15. Meyer-Betz, F. Dtsch. Arch. klin. Med. 1910, 101, 85. 16. Louw, A., Nielsen, H. E. Acta med. scand. 1944, 117, 424. 17. Acheson, D., McAlpine, D. Lancet, 1953, ii, 372. 18. Schmid, R., Mahler, R. J. clin. Invest. 1959, 38, 2044.
11. 12. 13.
mechanisms of identification. A striking example was the psychogenic abdominal pain experienced by some expectant husbands during their wife’s pregnancy, but less dramatic examples could often be demonstrated in the ordinary clinical interview. This sort of excessive selective sensitivity to others’ feelings was often regarded as a hysterical trait, but it might be found in other personality types. Aggressive feelings and emotional to be given antibiotics or if he is left with an uncomfortably distress were sometimes projected as pain felt in a parnarrow anal canal, may not too high a price have been paid ticular site, and Professor Stengel mentioned a patient for convenience ? whose agonising post-amputation " phantom limb " pain recurred whenever he watched a disturbing programme on television. In his studies of the pain-prone patient, PAIN AND THE PSYCHIATRIST Engel 6 had provided the " only consistent theory of IN the thirty-ninth Maudsley lecture, before the Royal psychogenic pain ". This hypothesis depended upon Medico-Psychological Association on Nov. 20, Prof. E. analytical interpretations and might not be acceptable to Stengel recalled the interest that had been shown in the some psychiatrists, but it fitted several of the facts and subject of pain by earlier psychiatrists, including Henry was worthy of further study. Maudsley 1; but he contrasted the enormous amount of Analysts, psychiatrists, and neurologists were generally recent physiological research on pain with the modern agreed in their reluctance to regard every symptom without psychiatrists’ curious neglect of it. This attitude was organic cause as hysterical-particularly pain, which certainly not justified by the place which pain occupied in served additional functions as a protective signal and psychiatric symptomatology: Professor Stengel found that possible source of masochistic gratification. pain was a main complaint in nearly half his own patients. Only a few of the many patients who experienced Although clinicians often attempted to distinguish psychogenic pain were seen by a psychiatrist. This between organic and psychogenic pain, they largely circumstance was mainly determined by the nature of the ignored the psychogenic kind; and it was a neurologist2 complaint, but the attitudes of patients and doctors must who had made a " gallant attempt at classification". also play an important part. Few people (even among Conversion symptoms could arise without accompanying the medical students Professor Stengel had questioned) hysterical stigmata, and pain was sometimes an emotional expected psychiatrists to be concerned with alleviating expression of a thought or fear (chest pain due to anxiety pain; but in neglecting " one of the doctor’s noblest about heart-disease) or a somatic hallucination in a tasks", psychiatrists had probably forfeited much of depressive or schizophrenic psychosis. Work in Professor the prestige awarded to other branches of medicine. Stengel’s department indicated that psychogenic pain was associated with psychiatric illness in its onset and somePAROXYSMAL MYOGLOBINURIA times in its fluctuations; it tended to be continuous and EXTENSIVE crush injury to the voluntary musclesmay capricious in its response to treatment, although antidepressant drugs were often very effective. Many of those give rise to myoglobinuria; and myoglobin also appears who suffered from it were anxious about their health and in the urine when degeneration affects large muscle masses, fitness, came from lower socioeconomic classes, and gave as in occlusive arterial diseaseand the anterior tibial a history of surgical operations. syndrome.Other causes of myoglobinuria include acute The description and definition of pain presents con- polymyositis 10 11 and epidemic Haff disease .12 In addition, siderable semantic difficulties; and in discussing its there is a well-recognised syndrome, usually referred to as physiological characteristics, it is customary to distinguish idiopathic paroxysmal myoglobinuria, in which episodes between the perception of pain and overall reaction to it. of severe and generalised muscular pain and weakness are Professor Stengel’s earlier work3 concerned the dis- accompanied by profuse myoglobinuria.13 Korein et al.14 in 1959 showed that this disorder first began, as a rule, crepancy between normal sensory perception and blunted reaction to noxious stimuli, which he called pain asymboly. between 15 and 20 years of age and that it persisted for This condition was seen in a congenital form associated many years with frequent exacerabtions. Some patients with mental deficiency and in certain patients with were symptom-free during remissions, while others were parietal-lobe lesions. In some respects the condition disabled by recurrent muscle pain after exercise. In some resembled the abnormal pain responses of schizophrenics such cases calf enlargement has been observed,15-17and in and the masochistic reactions of abnormal personalities; addition a number of them have been shown to have but studies of pain responses and thresholds by different atrophy and weakness of certain muscle groups, so that the methods 45 in heterogeneous groups showed no con- suggestion has been made that these were cases of muscular nection with the psychiatric diagnosis, mental sub- dystrophy associated with myoglobinuria. Recently, too, normality, or the tendency to suffer psychogenic pain. Schmid and Mahler 18 described a patient with McArdle’s The subjective character of pain imposed inevitable 6. Engel, G. L. Amer. J. Med. 1959, 26, 899. 7. Bywaters, E. G. L. J. Amer. med. Ass. 1944, 124, 1103. limitations on physiological methods of experiment; and 8. Bywaters, E. G. L., Stead, J. K. Clin. Sci. 1945, 5, 195. 9. Adams, R. D., Denny-Brown, D., Pearson, C. M. Diseases of Muscle. because of its psychic nature pain had played an important New York, 1962. 10. Günther, H. Virchows Arch. path. Anat. 1924, 251, 141. part in the evolution of psychoanalytic theory and the
pylephlebitis as a complication of septic (unoperated) piles, but others have been less fortunate. Suppurative cholecystitis and gangrenous appendicitis, like infected piles, drain their toxins into the portal circulation, it is true. But they differ from piles in that a protective omentum and peritoneal lining wall off the disease. Immediate operation for acutely prolapsed piles may serve convenience, but it is never lifesaving. If the patient has
of conversion mechanisms. Precipitation and localisation of pain were sometimes determined by
study 1. 2. 3. 4. 5.
Maudsley, H. Pathology of Mind. London, 1895. Walters, A. Brain, 1961, 84, 1. Schilder, P., Stengel, E. Z. ges. Neurol. Psychiat. 1928, 113, 143. Stengel, E., Oldham, A. P., Ehrenberg, A. S. C. J. ment. Sci. 1955, 101, 52; ibid. 1958, 104, 434. Hall, K. R. L., Stride, E. Brit. J. med. Psychol. 1954, 27, 48.
Paul, F. Wien. Arch. inn. Med. 1924, 7, 531. Berlin, R. Acta med. scand. 1948, 129, 560. Reiner, L., Konikoff, W., Altschule, M. D., Dammin, G. J., Merrill, J. P. Arch. intern. Med. 1956, 97, 537. 14. Korein, J., Coddon, D. R., Mowrey, F. H. Neurology, Minneap. 1959, 9, 767. 15. Meyer-Betz, F. Dtsch. Arch. klin. Med. 1910, 101, 85. 16. Louw, A., Nielsen, H. E. Acta med. scand. 1944, 117, 424. 17. Acheson, D., McAlpine, D. Lancet, 1953, ii, 372. 18. Schmid, R., Mahler, R. J. clin. Invest. 1959, 38, 2044.
11. 12. 13.