Pain, Touch & Psychopathology

by Pam Torga

Today’s blog is about psychopathology—Wow, psychopathology sounds schmancy you may say! But what’s it about? And how does it have anything to do with the cutaneous senses?

In a nutshell, psychopathology is about anything psychologically out of the ordinary. As the scientific study of mental disorders, it concerns itself with psychological and behavioral dysfunctions like schizophrenia or bulimia nervosa. One of the most commonly known mental disorders is depression. It affects millions of people around the globe, with the number of diagnosed patients increasing by 20% every year (Healthline, 2016).

As complex as the disorder already is, one thing frequently associated with depression is pain. Studies conducted by Large (1980), Chandarana et al. (1987) and Magni et al. (1990) show that depression is diagnosed in 18%-30% of chronic pain patients. This suggests that depression in these patients is not only a consequence of pain, but may itself cause or enhance pain (Adler & Gattaz, 1993). In addition to psychodynamic mechanisms, Carriere (1981) suggested that a decrease of the pain threshold is genuinely related to depression.

Numerous studies on pain threshold in depressed patients have been done. However, the exact effect of the disorder on one’s perception of pain is still unclear as the thresholds reported by researchers appear to be inconsistent. Most authors report a decrease in the pain threshold in depressed patients (Ward et al., 1982; Otto et al., 1989; Moroz et al., 1990 as cited in Adler & Gattaz, 1993), some report an increase (Marazziti et al., 1991 as cited in Adler & Gattaz, 1993). One study devoted to the somatosensory perception threshold (SPT) and pain perception threshold (PPT) in individuals diagnosed with major depression found that PPT is negatively correlated with anxiety (Adler & Gattaz, 1993) . This suggests that a reduction of pain perception thresholds for patients with depression may be attributed to anxiety and impaired stress-coping.

As I was trying to comprehend the results of similar studies, one underlying idea became salient for me: Psychological disorders have the power to alter our senses or, at least, what we perceive our senses to be telling us. Now more than ever, it became quite clear to be that the mind has control over what the body believes it experiences. This control outweighs external influence, e.g.,the perception of pain is altered not by an increase of pain stimulation from the surrounding but rather by a change in the person’s internal vulnerability to it.

A prime example of how the mind dictates the senses is observed in somatic symptom disorder. This abnormality emphasizes the centrality of medically unexplained symptoms. To be diagnosed,  one must satisfy the following criteria set by the Diagnostic and Statistical Manual of Mental Disorders: (a) one or more somatic symptoms that are distressing or result in significant disruption of daily life; (b) excessive thoughts, feelings, or behaviors to the somatic symptoms or associated health concerns, and; (c) persistent state of being symptomatic (American Psychiatric Association, 2013).

A distinctive characteristic of many individuals with somatic symptom disorder is not the somatic symptoms per se, but instead the way they present and interpret them. Incorporating affective, cognitive, and behavioral components into the criteria for this disorder provides a more comprehensive and accurate reflection of the true clinical picture than can be achieved by assessing the somatic complaints alone. With that said, individuals with disorders having prominent somatic symptoms are commonly encountered in primary care and medical settings and are less commonly encountered in psychiatric and other mental health settings (American Psychiatric Association, 2013)

A number of factors may contribute to somatic symptoms and related disorders. This includes genetic and biological vulnerability (e.g., increased sensitivity to pain). The experienced somatic symptoms, oddly, have no sufficient physiological basis—the hallmark of somatoform disorders. So, the feeling of  pain or sickness is there, but a physiological manifestation is absent.

Surprisingly, these there-but-not-really symptoms aren’t rare. In a study of the general population, 81.6% of the participants reported at least one medically unexplained symptom (MUS) and 22.1% reported mild impairment associated with at least one MUS (Hiller, Rief & Brähler, 2006). Three out of four cases in a primary care study  reported medially unexplained physical symptoms (Körber, et al., in press as cited in Witthöft, Basfeld, Steinhoff, & Gerlach, 2012).

The existence of somatoform disorders elucidates that touch isn’t most strongly influenced by external stimuli. Touch, it turns out, is the result of cortical stimulation.Although it seems almost intuitive that the idea of a sensation~must~ be triggered by an actual sensation experienced by the body, somatoform disorders prove that that isn’t always the case. But that isn’t the case. Symptoms like pain or ache for somatoform disorders are not caused by physiological stimulation. Rather, these are “all in the mind.” From this one can appreciate just how multifaceted cutaneous senses are. It isn’t a straightforward relationship between being touched and perceiving touch. It is more accurately a route from being touched to thinking we are touched, which is more or less simultaneous with the perception of touch. Psychopathology is a window to the actual mechanisms of somatosensory perception. Chronic pain is not a symptom but a syndrome in its own right, and requires therapists from a wide range of disciplines.

Cognitive theories of medically unexplained (“somatoform”) symptoms stress the importance of alterations in attention and memory processes. Accordingly, specific schemata are hypothesized to (mis-)guide the processing of somatosensory stimuli leading to the formation of symptom-like perceptions. Health complaints or somatic symptoms for which no sufficient medical explanation can be found are a frequent and normal phenomenon in the general population (e.g., Eriksen & Ursin, 2004 as cited in Witthöft, Basfeld, Steinhoff, & Gerlach, 2012) and the hallmark of somatoform disorders (Witthöft & Hiller, 2010).

Although the duration and the level of distress associated with the respective symptoms are important clinical criteria according to the Diagnostic and Statistical Manual of Mental Disorders DSM–IV–TR (American Psychiatric Association, 2000), the exact turning point at which somatic complaints turn into clinically relevant somatoform disorders is poorly understood. Moreover, although somatoform disorders are the most prevalent mental disorders in primary care (e.g., Hanel et al., 2009; Toft et al., 2005), compared with other mental disorders such as affective or anxiety disorders, research concerning the etiology and pathogenesis of MUS is rather limited.

Another interesting study connecting somatosensory perception and psychopathology was done by Pavony & Lenzenweger (2014). They particularly looked at the relationship between somatosensory processing and borderline personality disorder, where they focused on pain perception, proprioception, and exteroceptive sensitivity.

Approximately two thirds of those with borderline personality disorder (BPD) who self-injure report diminished sensitivity to pain during acts of self-harm. Research on pain perception suggests that abnormalities of the motivational-affective domain likely contribute to the commonly reported hypo-analgesia evidenced in BPD. It is not that BPD individuals cannot detect or feel painful stimuli, rather their response to it seems to reflect differences in tolerance and willingness to report a stimulus as painful. Although specific processes involved with pain insensitivity have been debated in literature, the likelihood of generalized dysfunction in the somatosensory systems in BPD has not been considered. Prior BPD research has focused only on the pain submodality of somatosensation. Pavony & Lenzenweger (2014) assessed pain perception (nociception), basic touch (exteroception), and body sense (proprioception) somatosensory submodalities, in an effort to determine if generalized somatosensory deficits are present in BPD. Their findings are consistent with (but do not prove) a specific dysfunction in the pain-specific mechanism of sensitivity and perception in BPD, perhaps one that does not disturb the other somatosensory modalities. Data such as this helps to provide a more established empirical basis for pain insensitivity as an genetic determinant  of BPD.

Versteeg et al. (2010) found that somatosensory amplification mediates sex differences in psychological distress. They examined whether females with an implantable cardioverter defibrillator (ICD) would report more psychological distress than males, and whether somatosensory amplification mediates this relationship. Versteeg et al. (2010) concluded that somatosensory amplification did in fact mediate the relationship between female sex and heightened anxiety, phobic anxiety, and somatic health complaints in ICD patients. Women may be more likely to misinterpret bodily sensations as indicative of deterioration in their condition. The researchers suggested that nterventions focusing on modifying these dysfunctional beliefs may reduce their psychological distress.

Most people may be perplexed by the lack of a clear-cut boundary and/or connection between cutaneous senses and abnormal psychology. However, I encourage you to stand back, appreciate and be at awe for this intricate relationship. Perhaps someday, when we have access to more advanced technology, we will be able to see how our mind and our sense of touch are exactly intertwined.

Finally, before I end this blog, here are dog GIFs:

References:

American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, DC: American Psychiatric Association.

Healthline (2016). Depression Statistics: Unhappiness by the Numbers [INFOGRAPHIC]. Retrieved May 15, 2016, from http://www.healthline.com/health/depression/statistics-infographic

Pavony, M. T., & Lenzenweger, M. F. (2014). Somatosensory processing and borderline personality disorder: Pain perception and a signal detection analysis of proprioception and exteroceptive sensitivity. Personality Disorders: Theory, Research, and Treatment5(2), 164-171. doi:10.1037/per0000017

Versteeg, H., Baumert, J., Kolb, C., Pedersen, S. S., Denollet, J., Ronel, J., & Ladwig, K. (2010). Somatosensory amplification mediates sex differences in psychological distress among cardioverter-defibrillator patients. Health Psychology29(5), 477-483. doi:10.1037/a0020337

Witthöft, M., Basfeld, C., Steinhoff, M., & Gerlach, A. L. (2012). Can’t suppress this feeling: Automatic negative evaluations of somatosensory stimuli are related to the experience of somatic symptom distress. Emotion, 12(3), 640-649. doi:10.1037/a0024924

 

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