It’s NOT all in Your Head

Richard Lawhern, PhD
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The life journey which led to writing this began in 1996, when my spouse went through an excruciating series of root canals. She was in pain for weeks. Two years later, the pain came back to stay. Anti-inflammatory medication didn’t touch the agony she experienced on the side of her face opposite the root canal work (and later at different times on both sides). Not even opioid medications did much for her.

Over a period of a year, she was seen by a dentist, a maxillo-facial surgeon, an ear nose and throat specialist, a general practitioner and two neurologists. The last of these physicians heard her medical history and said “I think you have Trigeminal Neuralgia, but I don’t often see it or treat it. I’m going to prescribe an anti-seizure medicine for you which often helps. For more information, you need to contact the US Trigeminal Neuralgia Association.”

That was it: take these pills and talk to other patients who have your kind of pain.

I have since discovered that this sort of response is not uncommon for patients who have relatively rare or subtle medical disorders. There are over 3,000 such disorders, and others seem to be emerging all the time. Many medical doctors hate chronic medical problems which soak up their time and resources but which don’t get better. This may be particularly true of chronic pain conditions, and is even more broadly true of the medical issues of women.

Over 100 million people in the US suffer from chronic pain – defined as pain lasting longer than 12 weeks. Up to 80% of those sufferers are women, many of whom report having been repeatedly brushed off or referred out by medical doctors who could find no discrete medical cause for the symptoms they reported. Some patients report an even harsher finding by their doctors: “To the best of my ability to determine, your pain is not medical in origin. I believe you need to be evaluated by a psychiatrist or psychologist who is qualified in psychosomatic issues.”

[The quote is exact, from a patient who understandably wishes to remain anonymous]

My response to my wife’s pain was to make myself a layman expert on the subject. As an operations research analyst, I had taught market research and open source intelligence methods to professionals and librarians in those fields. Thus it was natural for me to turn to the Internet. In 1996, there were fewer than 4,000 “hits” on the term “Trigeminal Neuralgia” in Internet search engines. I read quite a few of them. In the Fall of 2013, there are 1.4 million hits. I’d like to think I’ve contributed to that growth of visibility, though it is surprising how often I continue to encounter pain patients who first hear the term from a neighbor, friend, or nurse, rather than from a doctor.

In the volunteer work that I do with pain patients these days, I’ve taken time to ask them about their experiences with medical doctors who referred them for mental health evaluation for symptoms that the doctor couldn’t put a disease name to. In an alarming number of cases, females among this population are written off as “hysterical” — a common rejection or shunning that is quite well established as an issue in both lay and professional literature. The same kinds of referral also occur with men, but significantly less often. For many patients, a better course of treatment emerges later with a different doctor who finally recognizes what is going on after several others have missed the diagnosis. For some, the light never appears at the end of the tunnel. Suicide is a real risk among those who have been told “it’s all in your head.”

The term “hysteria” casts a long shadow over issues of chronic pain. The contemporary roots of the term go back to a French neurologist named Charcot and to one of his students, Sigmund Freud. In my studied opinion, Freud’s theory of “female hysteria” is one of the most widely accepted mythologies ever invented out of thin air and academic surmise. Professionals who regard themselves as learned have invented an entire field of psychological practice around the term. We call that field psychosomatic medicine, and politely ignore the reality that its practitioners are rarely able to help their patients get better in any consistent way.

I am not one of those who claims that there is no relationship between our emotions and our physical health. There is ample evidence in medical and lay literature to the contrary. What I do claim, however, is that the preponderance of evidence shows that physical sickness or prolonged pain cause us to be depressed and anxious, particularly when no cause or effective treatment can be found for medical problems. Depression can wear us down physically by depleting our energy reserves. But in my view, depression does not cause our pain, even if it plays into or amplifies pain of medical origins.

There is no such thing as “psychogenic” pain. PERIOD!

I also agree that sensitivity to pain can sometimes be managed or moderated by resort to methods from the mental health toolbox: rational cognitive therapy, creative visualization techniques, stress control, meditation, the Yogas, moderate physical exercise to promote endorphins, and (perhaps) dietary changes. At least one class of psychoactive medications can also play a positive role in some forms of pain. The Tri-Cyclic Antidepressant (TCA) drugs are known to have a cross-over effect against pain of neuropathic origin, even at doses below those believed to be therapeutic for depression itself.

My message to medical and mental health clients is “It’s not all in your head.”

Footnote: My spouse has proven to be one of the lucky ones who respond positively to anti-seizure medications with minimal side effects. She has managed her pain and lived a full professional, social and family life for the past 16 years. Many chronic pain patients are not as fortunate.

36 COMMENTS

  1. “There is no such thing as “psychogenic” pain. PERIOD!”

    Thanks for discussing these things. I absolutely agree. Our whole society needs to be more respectful of pain that we cannot see. Even if we do not have medical solutions, respect would go a long way towards not making things worse.

  2. I had been in a terrible auto accident and when my source of pain was ongoing I was referred to a psychiatrist (soft tissue damage and severe whiplash weren’t “believed” back then). The downhill drugging began.

    The original problem was pain and I ended up being told I was permanently mentally ill and later told I’d never been mentally ill?? Makes no sense.

    Later when I was suffering from a progressive neuro-muscular disease I was told (the aha moment) this too was not real and the disease progressed till a neurologist diagnosed me. This makes no sense either?

    There has been quite a lot of research and study into pain and its consequences but with females being repeatedly told what they are suffering is not real what are we to do? Many of us are not well enough to keep fighting.I do believe the majority of doctors are frightened by chronic pain and without proper training do an auto pilot referral to psychiatrists.

  3. Amazing article, and not one I expected to read here. This was the source of my second bout with pharmaceutical damage. I suffered a dental injury that led to excruciating pain, and after several months of not ever being diagnosed with anything (and getting lots of weird looks from doctors) I finally got the “trigeminal neuralgia” DX. The neurosurgeon who gave it, however, did consider the possibility that it was injury induced and at least atypical TN. I do NOT handle pharmaceuticals well, and suffered an interaction that almost killed me. However, I survived and the injury (or whatever it was!) healed, never to return. Which is great, because half my face was paralyzed and the muscles were visibly drooping. I was obviously a mess, and found it shocking, while being unable to even smile, that many (even doctors) acted as if I was being simply trouble (until I got to my neurosurgeon).

    I’m just shocked to see such a familiar story here! Whenever I discuss damage I’ve suffered from medications, I’m always asked why I was ever on them, and this was the reason. It was facial pain following another chronic pain condition that is, at this point, barely background noise to me. But few people even know about TN, and those who do assume it’s never to do with injury and cannot ever heal.

    I’m very glad your spouse’s is being managed well.

  4. Thank You for sharing. I am only 39 years old, and broke my jaw in 1999 and didn’t have any major pain until the year 2011. Found out I had TMJD (Temporomandibular Joint Disease) and Fibromyalgia. I finally found a good family Doctor and Specialist that work together to help manage pain without addictive drugs. I take Neurontin, and Cymbalta. I have to work VERY hard to manage my pain. Eating right, getting enough sleep, staying stress free, and exercise all help me. I thought of suicide when I had a Doctor tell me there was NOTHING wrong. Finally, I had an MRI and CAT Scan done when my new Doctor actually was listening to me. They found out, I have ZERO Meniscus in my Jaw Joints, rubbing bone on bone, and major bone loss in both jaw joints. Doctors need to listen to their patients. I was begging to not be on Muscle Relaxers or Pain Killers just FIND THE PROBLEM and let’s work on relieving symptoms. I love my Doctor of now 2 years. He cares about me as a PERSON. Pain is real, and even if you look okay on the outside, you may not be okay. I have a Handicap Permit, I don’t use it unless I have to, and the stares I get are awful. People shouldn’t judge.

  5. I’m glad I remembered this article. I have finally found a doctor who listened to me with my latest hip/pelvic injury after 3 months of being referred out and not treated while slowly becoming completely disabled. All the doctor I found could say was, “Why did they let this get this far?” My (former) trainer asked the same thing. I was in the hospital over Christmas, and for all the scans they did, I couldn’t get a single doctor to examine the fact that the right side of my pelvis has dropped by an entire inch following a pelvic joint injury. They scanned my brain for something neurological. They scanned my spine. They scanned for inflammation (after I’d received a huge steroid shot that tamped down inflammation) and then told me there was no “anatomical cause for” my pain and dysfunction. Now my new team is hoping it’s not too late, and it wouldn’t have been when I first sought treatment.

    All I could tell either my new doctor and my trainer when they keep asking how I was ignored for so long is that I’m a woman who was having referred pain and spasm from a joint in my pelvis, and that tends (apparently) to make doctors and PTs, especially male ones, to pass you along instead of bothering to diagnose. I’m beyond frustrated now and completely disabled. Thanks for letting me rant. I just hope they can do something at this point, but am less and less hopeful as the days go on.

  6. Dr. Lawhern, thank you so much for your messages of support. I pursued this relentlessly and finally found a doctor who would listen that this was not some chronic pain syndrome and checked me into a hospital to do tests until the issue was resolved. A new MRI (they missed this somehow the first time) showed a labral tear to the hip and a tear of the hamstring tendon. Unfortunately, in the 4 months since injury it has caused significant damage to the muscles in the area as well, but I’m now being gotten to the best surgeon possible within 3 days to be evaluated for surgery.

    I can’t even explain how traumatic it is to not be taken seriously for 4 months as some malingering female pain patient when I repeatedly told them how active I had been and that this happened suddenly. I had doctors who refused to even examine me “diagnose’ pelvic floor dysfunction, only to be told I don’t have this problem (which I knew I didn’t) from the specialists they sent me to. I swear, when this is over I”m writing a book. Hopefully they’ll start having me fixed up within the next few weeks.

    I just wanted to thank you. This has been hellish. I went from injured to disabled in 4 months of being ignored while having quite obvious injuries to the very area I went in saying were injured. Your article is absolutely required reading. Please keep on trucking yourself, and keep raising awareness.

  7. I thought I had successfully navigated unfriendly, uninformed waters to avoid the sort of physician who doesn’t believe in things such as fibromyalgia pain, who are audacious enough to state it’s psychosomatic, or who are just so jaded that they are apt to find any way to dismiss a patient they don’t know how to treat. I haven’t even turned 40 years old yet, but I’ve been dealing with chronic illness and doing the doctor dance for the past 15 years. And I just ran into my second physician with an abhorrent attitude towards me and my illness. A physican’s assistant stated to me, “It’s all in your head” and even tapped her head for emphasis, and refused to manage my pain. I was so shocked that I inadvertently stated in a flat tone, “That’s f-ing ridiculous.” However, I said the actual curse word.

    She refused to address my pain issue despite no history of drug dependency. And my regular doctor, who unfortunately wasn’t available, had normally and recently prescribed adequate pain relief for me. We had just decided to try an alternate medication which was not working and I wanted to go back to my original medication which did work, it was just only effective for 24 hours vs the 48-72 hours the manufacturer indicated. However, I had another medication I was able to use with it, so it wasn’t really an issue. I had just been reporting how it worked for me to my Dr. But when he said I should try something else, I figured I would be considered a bad patient for not trying what he suggested. And I had also figured if the alternate medication didn’t work, which it didn’t, I would be able to switch back to the original.

    I contacted a patient care advocate for assistance in the matter, as I didn’t feel I could wait the full month to see my regular Doctor. The advocate passed my email off to the practice director. I didn’t receive any response. I ended up having to wait the month for my appointment. When I showed up for my appointment, I found out I had been cancelled. The director wrote a letter stating as such the day before my appointment, but didn’t actually send it until one week after my appointment. The reason stated was because I had cursed at the staff member. Technically, I hadn’t cursed AT her, and regardless, that wasn’t anywhere in the rules or guidelines which I had signed when I first joined the clinic. And if it had been, the rule would have included maintaining a therapeutic relationship and professional conduct which the physician’s assistant clearly broke first and I was merely deflecting the attack which she initiated. It was a human reaction, and just an unfortunate choice of words, nothing more. Their response to cancel me was cruel punishment and is effectively pulling the plug on my life support and kicking me out of the door. I have chronic fatigue syndrome, fibromyalgia and chronic epstein-barr virus and they prescribe several of my maintenance medications for me. It’s criminally negligent to just drop me without enough time to be able to procure another doctor who is able to take over the prescriptions and manage my care.

    Then, when I attempted to find another physician, I set up for a representative to contact me to set up an appointment from a specialist, and I was called back only to be told that I needed was a referral by my doctor, even though their literature stated they only needed referrals if required by insurance. My insurance doesn’t require referrals. When I contacted my PCP, their office stated that I don’t get to decide which specialist I see, they decide, and they don’t want me to see a rheumatologist as I had chosen to see, they want me to see a pain management specialist again, and they only refer to one. So, I wouldn’t be able to call around to find whomever would be able to get me in quickly either. They said they would set up the appointment and then contact me. This was a week ago and I haven’t heard back and my medications will run out in less than two weeks. It seems as though nobody seems to care that I’ll be completely unable to care for myself again, not to mention how it will feel with the pain, fatigue, not sleeping, … But, it’s all in my head, so I should just get over it.

  8. Alanamous—keep looking. Ignore any of these idiots who tell you its in your head. I am likely writing a book on this subject soon, as I have just (finally!!) had surgery to address my issues (the ones that were all “psychosomatic”, supposedly, despite happening in two distinct injuries). I had to have my hip repaired (torn labrum, FAI) along with a tendon and SEVEN torn core muscles.

    I’m also at a surgical institute rather far from home and everyone has the same story here. I heard from several more people today over there that it took them anywhere from 2 1/2 years, to 4 years to up to 8 or 10. YEARS. To get a diagnosis of something easily seen on an MRI. So, all things considered, I’m quite lucky that I only had to be physically disabled for 6 months. However, the things I heard from docs in that time period were so egregious as to warrant me calling every media outlet in my city and start writing about all of this. I was told I had gone into early menopause–suddenly, during a sports injury. That I was just aging. That my injuries were caused by “marital relations”. That it was in my head, asked what my psych diagnosis was and if I had a psychiatrist (it’s none and no). You know the routine.

    Then I get to a center specializing in the sports injuries and hip injuries I have, had new MRIs done, had surgery and am on the road back to full health. And surrounded by people who were all treated exactly like everyone on this thread has described–despite having injuries clearly seen on MRIs, many prior to even getting here.

    Saying it’s “all in your head” is medical speak for “I don’t know what’s causing the pain, and am therefore taking no time or interest in your problem, as it’s far easier to just refer you to a psychiatrist or gaslight you until you end up ignored into disability.

  9. Dr. Lawhern, I sincerely thank you for this article. I was involuntarily detained in a psychiatric hospital and had an ongoing domestic violence situation I was in ignored by the police because a psychiatrist, who spoke to me for all of, maybe, twenty minutes, declared that a medical condition I had been previously diagnosed with did not exist and I was really just delusional. While hospitalized, I was forced to stop taking all medications and supplements that were prescribed to me or encouraged by my medical doctors, and coerced into taking antipsychotics. Within days, I became largely unable to walk, which the hospital staff appeared to believe was intentional on my part. My doctors were left completely out of any decision-making, and the psychiatrist on staff refused to speak to them, citing that it would “feed into my delusions.” The larger tragedy for me is that I now have to live with a very dangerous situation indefinitely, because as soon as the police heard the word “delusional,” any charges that would have been brought on my behalf against the individual who was repeatedly sexually assaulting me were not. Psychiatric opinion was deemed more reliable than medically-proven fact, even when a nurse who had administered a rape kit following one of these attacks informed the police that there was, in fact, physical evidence of sexual assault. I’ve written more of my story on a blog article called, “I Am Justina Pelletier,” at http://thesystemisbrokenblog.wordpress.com/2014/03/26/i-am-justina-pelletier/. Atrocities such as these have to stop.

  10. Regardless of diagnosis, recommendation, terminology, and/or any institution or organization which acts in an authoritative role acting as a service for the public, then any individual representing such an entity should not in any way take away another individual’s rights to freely make decisions about his/her body, mind and soul as long as those decisions do not interfere with, damage or harm the rights of another person. Yet so many people seem to think that they are more intelligent, more powerful, more responsible, and/or more deserving in some way to make decisions for other people. Other people can make recommendations, suggestions, advisements and such, however they are not executive guardians, masters, promulgators, or in any other way the administrators over anybody else’s life. And furthermore, those who feel as though the severity of consequences for not adhering to the guidance and/or decisions of their misguided attempts at control is a matter of life and potentially death that is the only part in which they are correct. However, their perception is off in that the matter is that whence somebody loses the right to their own life decisions, they have lost their own life. If a person doesn’t have a right to live their life and pursue their beliefs then there isn’t a value in living inside a shell of somebody else’s beliefs.

    And sadly, in the medical community, so many will choose the easiest explanation for them, that the patient is not what they claim to be, and instead of helping they pass the buck. It’s far more work to investigate, research, and figure out what is going on with a patient than it is to make a simple statement and pass them off to somebody else who will mistreat and abuse, and collect their paycheck at the end of the day and think nothing further of anybody whom they saw in their quest to pay their bills. But why would there be so many liars? Even if everybody were psychotic, or belligerent what reasoning do patients have for going to see physicians and wasting their time? Who wants to spend money and time going to see somebody who is going to ignore them, treat them like a liar and either try to put them on antidepressants or treat them like a druggie? Illicit drugs are much less expensive and it’s much easier/cheaper to get abused anywhere/everywhere else. Dr’s and attorneys have the biggest egos, but the smallest brains sometimes.

  11. Richard and others,
    Here are some major pieces of the puzzle you are discussing . I’m coming from lived experience
    Google….. Paracelsus Klinic…. (yes with a K) just to see the approach of a most amazing place and the modalities they use.
    Also see….. yuenmethod.com……..Kam Yuen taught me his energy healing method which is very effective and is the best system for among other things relieving chronic pain or diagnosing health issues.
    Also google about Hal Huggins retired dentist and learn of his life saving dental protocols.
    Best Wishes,
    Fred

  12. Thank you this well-written article. I wish your wife continued health.

    I was seen by two neurologists and told them that my face hurt all the time and I didn’t know why. After an MRI, I was given the diagnosis of Persistent Idiopathic Facial Pain; in other words, your face hurts all the time and we don’t know why. Frustrating, but at least they don’t treat my pain as imaginary, and have prescribed anti-seizure meds in an effort to control the pain. So things are slightly better, but I’d rather they continue to search for a cause instead of throwing drugs at me.

    But my worst case of medical ignorance was with my orthopedist, whom I was seeing after a slight motor vehicle accident. Part way through physical therapy for what he considered a trapezius injury, I started having more and more difficulty moving my left shoulder up and to the back. At my 2nd follow-up, I gave him this information and tried to demonstrate but was stopped. He said there was nothing wrong with my shoulder, just the trapezius, and he prescribed more PT. At my third follow-up, I again tried to tell him that I continued to have severe pain with my shoulder and the range of motion and decreased since the last exam. He told me that I was a “nice lady” but there was nothing wrong with my shoulder, and that it was just my fibromyalgia. Bull-pucky! A second opinion and MRI showed Adhesive Capsulitis – a frozen shoulder. If he had listed at the send exam, the focus of the PT could have been changed, potentially saving me from many additional weeks of PT.

  13. I have read every word with hope and new determination. I am a Navy vet who has been in the VA health system since 2004. I was healthy for so many years but in 2008 I was diagnosed first with lichen slerosis and then six months later with squamous cell carcinoma of the vulva (pretty rare. especially at the time). I was turned down for VA care in MI (they used the fact that I had seen a non-VA gyn oncologist as an excuse) so used my Medicare to undergo the surgery at a non-VA hospital. I was given the “twilight sleep” and asked them to be very careful as I am VERY susceptible to medications of any kind. The anesthesiologist then said my doctor thought I would do better with the pain following surgery if they gave me an epidural! By the time I got to the OR the lights were already spinning and the next thing I knew I “came to” in the ICU, having flatlined when the general IV was administered. They called in cardiologist and did every sort of cardio test and discovered my heart is in great shape. (I am 74 yrs. old now). A week later I went back for surgery (removal of my vulva and clitoris) and spent the next few weeks w/ JP drains after removal os 22 lymph nodes. — I will get to the TN soon, I promise. I went 3 1/2 yrs. cancer free and we moved to FL, where my partner received a kidney in 2011 after being on the lists in MI and on dialysis for several years. Now we are going to retire and have fun, right?

    In 2012 I had a recurrence of my vulvar cancer and a GYN olcologist miraculously removed the cancer without damaging my urethra, which was inches away. I recovered and was just short of being cancer free when I discovered a lump in my groin. Outcome was a golf ball sized lymph node w/ cancer—–successfully removed but this time radiation was ordered. I had me annual mammo and was diagnosed with DCIS 2 wks. before I was to undergo radiation. I skipped a treatment to have a lumpectomy but it was unsuccessful. I opted for reincision but meantime the PET scan had shown an area in my liver/colon area so a colonoscopy was ordered (my second in 6 yrs.) I skipped another treatment for the procedure but was oversedated and it was aborted. My partner was told I “screamed out in pain”. The doctor ordered that I be injected w/ 250 mg. of Fentanyl in the IV to bring me back—also Flumazenil, Naloxone, and I guess initially Midazolam. I know nothing about these drugs but have learned that one is a strong narcotic when my records SHOULD my history w/ anesthetics, etc. I finished my radiation, was given general anesthetic in the OR for a colonsocopy (?????) where two polyps that could have become cancer were removed. I then had the second lumpectomy and ended up with a shrunken pitiful excuse for a breast and the “non-cancer” was only 1mm. from the chest wall so I opted for a mastectomy. Somewhere along the way I began having electric shock jolts on the left side of my face/head and I thought I was dying. They didn’t last long but were very scary. I told no one until recently my breast GYN oncologist whom trust so much (but who was not picked to do the surgery) saw I had had a CT scan of my brain and a chest x-ray and an echocardiagram at my request. He asked why I said I was confused, disoriented, etc. and I explained about the pain. He wrote on a small piece of paper Tic Delouroueaux and said he would be surprised if I wasn’t found to have this ailment—–worst pain in the world but there are drugs I could take to help. He said it is not life threatening however. I immediately went online and ended up on Living w/ TN which is how I received your most welcome missive. I questioned why anyone would take a pain medication when the pain lasted far shorter than the time it would take for any pain med to help. I have learned however that the “episodes” leave my totally fatiqued and I pretty much lose the day and sleep in my chair. The confusion seems to worsen too. I am wondering if instead of controlling the pain I should take the anti seizure meds? I can feel the spot where it starts behind my ear and also feel like my head is in a vice — I hold my head motionless and do nothing till it passes (thank God for retirement) as I read about surgery, etc. and you can clearly see why I just do not consider that an option with my history, unless it becomes way more frequent or more painful (don’t see how it CAN though.) I do water aerobics every day for my lymphadema as well as go for massage therapy and am almost back to normal except for one ankle /leg. I would appreciate any feedback you can spare me the time for. Thanks so much. Kay.

  14. I am an RN and injured my back in 2008 lifting a patient with a doctor . Within a year, I developed right hip pain. I was soon sent to the pain clinic and given steroid injections in my back which helped my right hip pain. Relief lasted a year. I went back to pain clinic once the effects of the injections subsided. Last year 2014, I took my injection and it didn’t work at all. I was given gabapentin 300mg and it WORKED! I was so happy. I planned a vow renal ceremony, hosted our family reunion, worked as RN instructor and my regular nursing job in Palliative care. I worked out, etc. I had a breast reduction surgery in July and noticed in August the Gabapentin wasn’t working as well. I went to Kaiser PCP to ask for help. Referred to ortho. September I re injured my back lifting again. WORKED light duty. Right leg started dragging. October I noticed a limp. November, right leg and left leg off balance. Pain in right hip at night became more horrific. Went to ER because I was walking slow and very off balance. I did therapy and got a little relief. MRIs were essentially normal. Mild degenerative changes. CT scans normal, small pineal cyst. Lumbar puncture inconclusive, WBC RBC elevated, maybe a traumatic tap Multiple restrictive bands in CSF and serum. Stopped working because I can’t perform normal duties. Neurologist at Hospital seemed to think psychogenic although the psychologist did not agree in December..
    Workers comp MD also feels it is a medical issue. He mentioned ALS. EMG was negative. He still feels strong about this.
    Today I received a diagnosis of conversion disorder because everything else is normal.
    Still walking with a severe limp on right leg, unsteady gait. Pain in right hip is still aching at night. Some days worse than others. I literally feel like I have a stick going from the top of my buttock to my hamstring when I walk. . I have worked so hard and don’t feel it’s all in my head. Had such big plans for my life. I’m used to completing my goals. This is hindering my life.