In a busy outpatient clinic in India, it is not uncommon to meet a middle-aged woman with persistent back pain, a daily wage worker crippled by headaches, or an amputee tormented by pain in a limb that no longer exists. They might have lived with the pain for years despite repeated consultations, investigations, and ‘normal’ scans. These experiences challenge the conventional understanding of pain as a simple signal of tissue damage. 

For several decades, pain has been understood by the traditional Cartesian model of tissue injury being the primary cause. Yet reality tells a more complex story. Pain may persist long after tissues have healed, it may appear in the absence of identifiable pathologies, or it may continue even when the body part itself is gone.  

What is psychogenic pain? 

Psychogenic pain is defined as pain where the onset, intensity, or persistence of symptoms are primarily influenced by psychological or emotional factors. The person affected does not ‘imagine’ the pain; it is very real to them. Stress, trauma, depression, anxiety, and inadequate coping can intensify the processing of pain, resulting in the brain possibly misinterpreting signals. Neurobiological research also demonstrates that emotional discomfort can intensify pain pathways in the brain, changing perception and reducing pain thresholds. This phenomenon is sometimes written off as an ‘over reaction’ or dismissed as ‘made up.’  

Recognising the involvement of the mind, the International Association for the Study of Pain defines pain as “an unpleasant sensory and emotional experience.” This theory has been supported by developments in neuroscience, which have largely localised it to the anterior cingulate cortex of the brain. Dispersed brain networks involving emotion, memory, and expectancy are responsible for pain perception. 

Features of psychogenic pain 

• Despite many investigations, a clear physical cause cannot be demonstrated. 
• Pain is aggravated by stress and emotional upheavals.  
• Pain may be localised or general and may not follow known neural pathways. 
• Little response to conventional treatment including analgesics, heat or cold compresses etc. 

Management of psychogenic pain 

Once a comprehensive evaluation has ruled out underlying physical conditions, the focus shifts to psychological factors. Early intervention is crucial to prevent the pain from becoming ingrained and chronic.  

These are some of the techniques that have been used in the management of psychogenic pain: 

• Trauma focussed counselling to address emotional conflicts and providing insight into the connection between emotions and pain. 
• Cognitive Behaviour Therapy, effective for identifying emotional triggers to pain.   
• Anti-depressants are often used. 
• Regular, low-impact exercise (walking, swimming, yoga) helps reduce the fear of movement and reduces pain. 
• Meditation, mindfulness, biofeedback, and guided imagery can reduce stress and help individuals manage pain perception.
• Acupuncture, massage, and physiotherapy have also been tried.   

What is phantom pain? 

Phantom pain is pain experienced in a part of the body that has been amputated such as a leg or a hand. Here, the brain refuses to let go of the removed body part, and this results in a maladaptive reorganisation of the brain. The pain continues to be generated by the brain, and, since pain is also a perception of the nervous system, patients continue to feel it.  

An estimated 70-80% of amputees may feel some kind of pain or sensation in their lost limbs. This pain can be excruciating, interfering a good deal with persons’ lives and functioning. An effective treatment for phantom pain was developed by well-known Indian-American neuroscientist V.S. Ramachandran. This form of therapy, known as ‘mirror therapy’, uses visual feedback from the patient to help in reorganising the brain. 

Mental health disorders 

There is an overlap between pain and mental disorders. Various social stressors such as poverty, caregiving burdens, gender inequities, and exposure to trauma, further intensify this relationship. Beyond individual suffering, pain that is poorly understood reinforces stigma, delays help-seeking and leads to repeated investigations and unsuccessful treatments. This is especially true for women and older adults, whose pain is often normalised or minimised. 

The diagnosis of a patient in pain is often overlooked or misdirected. It is usually missed in routine clinical settings, where this ‘pain’ is investigated as a comorbidity or as a symptom of another diagnosis. At the same time, many persons are not comfortable with the idea of labelling their pain as ‘psychological’, further reinforcing the stigma around mental health. 

Untreated pain in India 

India is disproportionately affected by pain, one of the main causes of disability worldwide. India has a history of insufficient and disjointed pain management. 

Among the obstacles are: 

• Insufficient undergraduate and graduate training in both pain management and mental health. 
• Inadequate incorporation of mental health into overall healthcare. 
• Limited availability of multi-disciplinary pain services, particularly outside of cities. 

These inadequacies are recognised by institutional and national rules. The national standard treatment guidelines and All India Institute of Medical Sciences (AIIMS) pain management policy emphasise comprehensive, step-by-step methods to pain management, encompassing both non-pharmacological and pharmaceutical techniques.  

Policy environment 

Advocacy for palliative care has been essential in expanding access to pain management on a national scale, especially for cancer pain. In order to enhance access to opioids for appropriate medical usage, organisations, including Pallium India, have played a significant role in advocating for policy changes, including modifications to the Narcotic Drugs and Psychotropic Substances (NDPS) Act. However, outside of urban areas, access to comprehensive pain services is still restricted, particularly for neuropathic, psychogenic, and non-cancer pain. 

One of the most damaging consequences of poorly understood pain is the phenomenon of ‘doctor-shopping.’ In trying to find a cause and a definitive cure, patients move from clinic to clinic, undergoing repeated investigations and, at times, unnecessary interventions. This repeated process often leads to financial hardship, especially for families living on the margins. 

Using stigmatising language of labelling and invalidating patients’ experiences of their pain as ‘all in the head’ does not help. Clear communication can help patients come to terms with their pain.  

Towards holistic management 

Addressing psychogenic and phantom pain requires a shift toward integrated, multi-disciplinary care. Evidence supports the effectiveness of combining physiotherapy with psychological interventions such as Cognitive Behavioural Therapy (CBT), which help patients reinterpret pain signals, reduce fear-avoidance behaviours, and regain function. Unfortunately, such integrated pain clinics remain scarce in India. 

Beyond individual treatment, the economic implications of untreated ‘invisible’ pain are profound. Chronic pain often reduces productivity and increases absenteeism. From a policy point of view, there is a clear need for better integration between chronic pain services and mental health initiatives under India’s National Mental Health Policy. Recognising pain as both a public health and mental health priority could transform outcomes for millions. 

(Dr. R. Thara and Shruti Rao are with the Schizophrenia Research Foundation (SCARF), Chennai.)

(This article was first published in The Hindu’s e-book, Pain and Relief: Demystifying the Science of Suffering)