CATR: To start, can you give us your take on the neurological process around pain? What’s going on in the brain that causes a patient pain?
Dr. Schubiner: All pain is generated by what the neuroscientists call a salience network, or as I like to call it, the danger alarm mechanism. All pain is real. It’s just a question of whether that pain is being triggered by a physical injury or by something else. Studies show that emotional injury activates the same areas of the brain as does physical injury (Kross E et al, National Academies of Sciences 2011;108:6270–6275). So, that gets us to the challenge of distinguishing between psychogenic pain and structurally induced pain.

 

CATR: Let’s talk about psychogenic pain—that is, physical pain caused by emotional, behavioral, or mental health factors. How common is it?
Dr. Schubiner: I’ve found that a large proportion of patients with chronic pain do not have an identifiable structural cause for their pain. There’s also a category of people with mixed pain, where there seems to be a combination of structural and psychogenic pain. Since going into this field, I’ve found it to be very common for people to have purely psychogenic symptoms. In fact, even with epilepsy, clinicians who routinely do video EEG monitoring find that up to 50% of patients with seizure disorders have psychogenic seizures (Reuber M, Epilepsy and Behavior 2008;12(4):622–635). About 24% of those referred for refractory seizures were found to have psychogenic non-epileptic seizures (PNES) after video/EEG monitoring; up to 50% of those with refractory status have PNES. That’s an astoundingly high number. From my own clinical experience, I see a significant number of patients with chronic pain that can’t be explained. I also see a number of patients I’m able to diagnose with purely psychogenic pain after connecting the pain to another disorder.

 

CATR: Can you tell us how to begin the process of assessing and treating a patient’s pain?
Dr. Schubiner: I divide pain disorders into purely psychogenic, purely structural, and mixed. I believe this is a critical distinction. Obviously, we would treat psychogenic paralysis differently than we treat paralysis due to stroke or polio or Guillain-Barré syndrome. Typically, for psychogenic pain, what we see is that the pain often shifts from one location in the body to another. So, someone may at times have pain in the lower back, and at other times pain in the upper back. To me, that suggests that the brain is inducing that pain because of a non-structural cause. Chronic pain that spreads over time, for example starting in the lower back and then spreading up the spine, does not make sense neurologically. Psychogenic pain is commonly bilateral in distribution; it will start on one side and go to the other side in a mirror image fashion. The brain is very good at doing that. Obviously, some structural disorders can be bilateral too, but that’s less common. So, in most patients with bilateral pain, I would suspect that the pain is psychogenic.

CATR: What are some of the triggers for psychogenic pain?
Dr. Schubiner: This is pain that can be triggered by stressful situations, and pain that goes away in situations where the brain is engaged or relaxed. So, for example, I had a recent patient who had 24/7 constant back pain, and when she went on vacation for a week, the pain completely disappeared. In another instance, I saw a patient who had a clinical diagnosis of repetitive strain injury in her wrist. The pain was worse Monday through Friday: The more she typed, the more she had hand pain. The clinical exam showed that there was no significant physical finding, suggesting that there wasn’t any deformity, such as arthritis or inflammation. The patient noted, too, that she got pain on Sunday evening in anticipation of going to work the next day. For me, that was the clinical clue that led to the diagnosis of psychogenic pain, which then allowed her to fully recover following therapy. In these cases, though, we always need to look at imaging to first rule out structural problems.

CATR: Sounds like pain itself can be a defense mechanism against feeling certain emotions.
Dr. Schubiner: Yes. And oftentimes we see pain or other symptoms completely disappear on the spot by taking a mindfulness approach—we work to have patients observe symptoms without fear, without worry, and without danger, and oftentimes those symptoms will just literally turn off and evaporate on the spot.

CATR: It seems that, when there isn’t a structural issue, many people don’t want to be told that “it’s all in their head,” since that can make them feel that you are accusing them of causing their own pain. As part of all this, how do you talk to patients about pain disorders?
Dr. Schubiner: Saying “it’s all in your head” is pejorative and a horrible thing to tell someone. When you say this, you’re implying the pain isn’t real, that the person is imagining or faking it, or that they are to blame for it. What many people want to say to the clinician who tells them that is, “You live in my body for a day and then tell me what it feels like!” So, here’s a better approach: When I’m working with patients, step 1 is empathy. We need to show caring and compassion for patients and understand how severe their symptoms are. We need to connect with them on their level. After all, if they don’t think you care, they are not going to trust what you tell them to do to alleviate their pain.

CATR: So, once you show patients you have empathy toward their pain, what do you do next?
Dr. Schubiner: For me, the second step is reviewing what’s been tried. And typically, patients with chronic pain have tried frustrating and unsuccessful treatments. But listening to their previous experiences plants the seed that you empathize with them and reinforces that, even though there doesn’t seem to be any structural problem, their pain is real. Listening to them earns their trust and confidence. The third step, then, is to explain pain.

CATR: What does explaining pain entail?
Dr. Schubiner: I explain pain using 3 brief stories. The first is of a man who was alone on a construction site who shot a nail into his hand by mistake and had zero pain. Even in the instance of an obvious physical injury, this story shows that the brain is powerful enough to control pain. The second story I tell is about a man written up in the British Medical Journal who jumped off the scaffolding on a construction site, impaling his foot on a nail that pierced all the way through his boot. This guy had severe pain, was rushed to the hospital, and given IV medication for pain. The nail was found to be precisely between his toes—there was no injury (Fisher JO et al, BMJ 1995:310–370).

CATR: Interesting. How do you reinforce with patients the “moral” of those stories?
Dr. Schubiner: I tell them it’s important to recognize that the brain can create pain—real, severe pain, even in the absence of a physical injury. Explaining how the brain does that through a danger alarm mechanism will resonate with most patients.

CATR: How do you further connect patients to the idea that their pain might be psychogenic, and possibly related to stress or a traumatic experience?
Dr. Schubiner: The third story I tell them was told to me by another physician, who was in the Vietnam War as a young man. His company was ambushed, a lot of guys died, and he received a shrapnel injury to his leg. He had significant pain, and he was taken from the battlefield by helicopter to receive emergency treatment. I point out that—fortunately—his structural injuries eventually healed and he became pain-free. But almost 20 years later, a helicopter buzzed close by as he was walking down the street, and suddenly he got the exact same pain in his leg that he had had all those years earlier from the shrapnel. This story illustrates that neural pathways or neural circuits can learn pain, remember pain, and then activate pain due to a triggering mechanism. Those triggering mechanisms can be a variety of things, including foods, movements, lights, sounds, and stressful life events.

CATR: What do you do next?
Dr. Schubiner: The next step is to look for clues. Does the patient’s pain fit into a pattern that could be placed clearly in the camp of psychogenic pain, structural pain, or mixed pain? Then I personalize that information and have a discussion with the patient about this idea of brain-induced pain. I provide resources to read and videos to watch, and I suggest that there is much more hope for people with brain-induced pain than there is for people with chronic, structural pain.

CATR: But doesn’t everybody with chronic pain have a psychological component to their pain?
Dr. Schubiner: Of course. All pain, especially chronic pain, has a psychological component, and the methods we use can be helpful for people with mixed pain or even with purely structural pain—but only to a certain degree. Conversely, in people where we can clearly make the diagnosis of brain-induced pain, the chance of recovery becomes 100%—meaning the pain can actually be eliminated as opposed to coping with it and managing it with medications, which can be potentially problematic for those with existing substance use disorders. From our point of view, one of the problems in the field of chronic pain is the phrase “pain management.” In the field, all pain is presumed to be structural or mixed, and therefore all pain—even if it’s diagnosed as central pain such as fibromyalgia—is treated with a coping model rather than what could be a central pain recovery model (Litt MD and Tennen H, Pain Manag 2015;5(6):403–406).

CATR: Let’s talk further, though, beyond musculoskeletal pain. For example, there is psychogenic pain that manifests itself through abdominal and nerve pain too, correct?
Dr. Schubiner: Of course, and through headaches as well. The data suggest that brain-induced pain and its associated conditions are very common. Roughly 40%–50% of people presenting to primary care offices have at least one medically unexplained symptom, and 25%–33% can be diagnosed with a somatoform disorder—in other words, they have symptoms that cannot be fully explained by any underlying general medical or neurologic condition (Haller H et al, Deutsches Arz Int 2015;112(16):279–287).

CATR: It seems like this is a good place to talk about how you approach treatment of psychogenic pain. What can you tell us here?
Dr. Schubiner: I think it’s important that patients first hear a clear, careful, and caring explanation of these disorders. This step can be quite difficult. We refer them to reading materials and videos to help them understand it, and sometimes it can take several weeks for people to grasp these ideas. We then use cognitive and behavioral interventions very similar to those employed in standard pain therapies, which include cognitive behavioral therapy, mindfulness, acceptance and commitment therapy, and other modalities.

CATR: Can you give us a couple of high-level examples of how you approach those therapies?
Dr. Schubiner: Sure. I like to use words that empower patients to not shrink in the wake of their symptoms, to remind themselves that they are healthy and not damaged, and to be able to reduce their fear in the wake of having symptoms. We also challenge some of the triggers of symptoms by actively engaging in specific movements or activities, especially those that have caused symptoms in the past. But we do this with the mindset of, “I am not damaged and I will be fine.” Mindfulness meditation is used as an adjunct in this situation, and again what we have found is that mindfulness is actually much more effective in a setting of, “I’m not damaged,” as opposed to a setting of, “I’m damaged and I’m coping as best I can with these symptoms.”

CATR: What are the final steps in your treatment strategy?
Dr. Schubiner: We go through emotional processing. Not all patients need this part of the approach, but some do, and it is well-known that people with adverse childhood events have much higher rates of chronic pain and other disorders later in life. This involves asking patients to experience, express, and release emotions that may have been avoided earlier in life, including anger, guilt, sadness, and compassion. Part of this treatment is to enhance compassion for oneself and forgiveness for the self and others. The final component of the treatment is to make necessary changes in one’s life as they are identified. Some people are in difficult situations in relation to family members, work, etc—dealing with those challenges can often be an important part of the treatment. Overall, all the treatment is directed to decreasing fear, and ultimately toward helping patients with their pain.

CATR: I’d like to also specifically ask about patients who are either on opioids or have an opioid use disorder, and are also coping with psychogenic pain. Can you talk about how to approach treatment in that scenario?
Dr. Schubiner: People who are on opioids often have a difficult time reducing or eliminating those doses. The primary reason for this difficulty is fear of increased pain. And when patients are presented with the ultimatum of reducing opioid doses, oftentimes that further activates the danger alarm mechanism in the brain and produces more pain. That becomes counterproductive when trying to get people off of these medications. So, with people who are on opioids and in whom I’ve diagnosed a brain-induced disorder, I don’t suggest reducing the dose at all. First, I work on reducing or eliminating the pain, and once that occurs, it’s much easier to reduce the doses or wean off of the opioid medications.

CATR: So, the step-by-step treatment that you’ve outlined can actually take place while someone is still taking the opioids or has another co-occurring substance use disorder?
Dr. Schubiner: Yes, in my experience that’s been the case.

CATR: Thank you for your time, Dr. Schubiner.