When a patient presents with pain, it is important that physicians and other health care professionals accept the reality of the pain for the patient. Chemically dependent individuals may feign pain in order to obtain opioid medications, but this is a rare occurrence apart from emergency settings where patients do not have ongoing relationships with their physicians. Previous studies have suggested that 3%-19% of patients in chronic pain clinics also may have substance abuse problems. These patients may inappropriately seek opioid medications, but it is unfair and misleading to think of these patients as lying about their pain. A great deal of overlap exists between “mental” and “physical” pain in patients with chronic pain.

One of the major difficulties health care professionals encounter in assessing patients with pain is the lack of a clear correlation between the amount of pain reported and the amount of tissue pathology as revealed by diagnostic tests and physical examination. Individuals can experience severe pain in the presence of minimal organic pathology or little or no pain despite extensive disease processes. For example, Gore et al. (1987) found no relationship between radiological findings and the severity of neck pain experienced. Jensen et al. (1994) reported that only 36% of the asymptomatic subjects had normal lumbar spines on magnetic resonance imaging scans. Any attempt to determine whether pain is in excess of what might be expected runs aground on the multiple psychosocial factors that influence the clinical pain experience, including the amount of threat to the person and his or her interests associated with the pain, cultural expectations about pain, and the family’s history of coping with pain. It is very tempting but dangerous to resort to concepts such as “exaggerated pain” or “psychogenic pain” in patients with significant mismatch between pain reports and physical findings. Variance between pain reports and physical findings is common in clinical pain problems, and no validated method exists for determining when the mismatch is typical or “pathological.”

Ongoing attention to the physical aspects of chronic pain problems is essential. It is a serious error to assume that the presence of a mental disorder in a patient with pain precludes a concurrent physical disorder. Either the psychiatrist or another collaborating physician must monitor physical conditions that may be playing a role in the pain. These physical conditions may precede the pain problems (e.g., injury or disease) or result from the chronic pain (e.g., through disuse, limping, splinting). Although a physician may fail to recognize existing physical causes because certain medical conditions have not yet reached the threshold for clinical detection, it appears that inadequate physician training in the diagnosis of pain-related conditions also may be responsible.

The degree to which psychological factors play a role in pain is often difficult to discern. Traditional psychological testing instruments have been used to aid in this judgment, but the validity of the information they provide is controversial. For example, for many years it was believed that the “Conversion V” or “neurotic triad” configuration on the Minnesota Multiphasic Personality Inventory (MMPI; Hathaway and McKinley 1943) indicated that psychological factors played a preeminent role in pain. However, subsequent research found that this MMPI configuration, in which the hypochondriasis and hysteria scales are elevated with a normal or minimally raised depression score, is nonspecific and is associated with other chronic health problems (Naliboff et al. 1982; Watson 1982). Other widely used psychological instruments also may provide distorted views of patients’ pain. Williams and Richardson (1993) found that elevated Beck Depression Inventory (Beck 1978) scores of chronic pain patients may be misleading because elevated scores on somatic items (e.g., sleep disturbance, tiredness, low libido) appeared to be more related to the pain itself. Thus, although these testing instruments may help to assess the psychological status of patients with pain, results must be interpreted with an understanding that the pain itself can significantly increase patients’ scores. It is important to realize that psychosocial factors can be very important in clinical pain without implying that this pain is purely psychogenic.