Perspectives on psychogenic versus biogenic factors in pain

Abstract

T he focus article has served well to point out the ambiguity and controversy of psychogenic pain. It is far too often that a diagnosis of “psychogenic pain” is made by exclusion rather than the appropriate inclusive criteria. Keeping this in mind, it is understandable that the author has focused on establishing what psychogenic pain refers to (i.e., what is the “concept” and its implications). I address the central positions taken in the focus article separately. Psychogenic pain is a theoretical possibility that can stimulate new ways of thinking about pain. Dworkin theorizes that if the psychological process allowed the body to yield pain that in turn motivated pain behavior, this would allow for research to define which brain process caused the reaction. Fordyce has pointed out that too often a patient’s pain experiences are labeled “psychogenic” when repeated failures using the biomedical model result in persistence of pain.* This and the broad exclusionary criteria often related to treatment failure or the inability to uncover an obvious cause described in the American Psychiatric Association’ and the International Association for the Study of Pain5 classification systems solidifies the conclusion that pain of unknown origin implies our need to reexamine our limited understanding of pain, rather than leaping to the conclusion that such pains must be psychogenic. Table 1 of the focus article further enhances the view that in orofacial pains where the pathophysiologic mechanism is unclear, the suspected psycho-