Psychogenic and Somatic Pain: Understanding the Body-Mind Connection

Psychogenic and Somatic Pain: Understanding the Body-Mind Connection

You're in pain. Real pain. Yet, after examinations, X-rays, and maybe even an MRI, you're told that everything appears normal. You wonder if anyone believes you, if your pain is being taken seriously. This is a frustrating situation experienced by thousands of Quebecers every year.

It's normal to feel lost when tests don't find anything.

• Psychogenic or somatic pain is a real neurological diagnosis, not an invention
• Your brain can generate real pain even without visible tissue damage
• These changes in the nervous system are reversible with the right treatment.
• Physiotherapy is the most scientifically validated treatment for functional neurological disorders²

This guide will help you understand what's happening in your body, why these pains occur, and how to regain control. For an overview of available treatment approaches, consult our complete guide to physiotherapy.

What is psychogenic or somatic pain?

Psychogenic or somatic pain refers to real pain felt in the body, but its origin involves mechanisms of the central nervous system rather than obvious tissue damage. It is a recognized medical condition, not a sign of weakness or imagination.

Several terms have been used over time to describe these conditions, which can create confusion:

• It is not made up or faked
• It is not "all in your head" in a derogatory way
• It does not mean you are crazy or weak
• It does not mean you are seeking attention

In fact, people living with this type of pain suffer just as much, sometimes more, than those with an identifiable physical cause. Their distress is real and deserves serious attention and care. This condition is related to the category of psychogenic or somatic pain recognized in our clinical practice.

Evolution of the Medical Concept

The way medicine understands these types of pain has evolved considerably. In the past, it was thought necessary to "prove" the absence of a physical cause to diagnose psychogenic pain. This approach was problematic because it often led to years of unnecessary tests.

Since the DSM-5 (2013), the approach has changed. We no longer seek to prove the absence of an organic cause. Instead, the focus is on the pain's impact on your life and how you react to it. This is a major shift that allows for faster and more compassionate care.

Now that we better understand what this diagnosis means, let's explore the different types of pain involving the nervous system.

What are the different types of pain related to the nervous system?

Pain is not a simple phenomenon. Your nervous system can generate it in several ways, and understanding these mechanisms helps to better target treatment.

Nociplastic pain

In 2017, the International Association for the Study of Pain (IASP) introduced this term to describe pain that occurs despite the absence of obvious tissue damage or identifiable nerve damage.³

Nociplastic pain results from an alteration in how the nervous system processes pain signals. It's as if the "volume" of pain has been turned up too high.

• Fibromyalgia
• Complex Regional Pain Syndrome
• Some persistent chronic pain conditions
• Irritable bowel syndrome
• Some inflammatory pain conditions with no identifiable cause

Functional Neurological Disorders (FND)

Functional neurological disorders represent an important category. The term "functional" means that the problem stems from a malfunction of the nervous system, not a structural lesion. It's sometimes described as a "software" problem rather than a "hardware" issue in the brain.

The CHUM Functional Neurological Disorders Clinic, the first of its kind in Quebec, has been welcoming patients with these conditions for several years. Their interdisciplinary approach (neurology, psychiatry, physiotherapy, occupational therapy, neuropsychology) aims to restore affected functions.¹

• Muscle weakness without an identifiable neurological cause
• Tremors
• Walking difficulties
• Epilepsy-like seizures (but without epileptic activity)
• Numbness or tingling

Important: FNDs are not a mental illness. They are a disorder of brain function, located at the interface between neurology and psychiatry. This type of condition is also related to functional pain.

Central sensitization

Central sensitization is a key mechanism in several types of pain. It occurs when the central nervous system becomes overly reactive to pain signals.⁴

Imagine an overly sensitive car alarm that goes off at the slightest movement. Similarly, a sensitized nervous system amplifies normal signals into intense pain signals. This mechanism can also be involved in certain nerve pains.

Understanding these mechanisms is the first step. Now, let's see how to recognize the specific symptoms.

What are the symptoms and how can they be recognized?

The symptoms of psychogenic or somatic pain are varied and very real. They can affect multiple body systems.

• Diffuse or localized pain (frequently in the back, head, jaw, and face, abdomen)
• Intense and persistent fatigue
• Sensory disturbances (numbness, tingling, abnormal sensations)
• Motor disturbances (weakness, tremors, coordination difficulties)
• Cognitive disturbances sometimes called "brain fog"

• Symptoms can fluctuate depending on the emotional context
• Possible improvement during distracting activities
• Pattern that does not exactly match classic neurological patterns
• Day-to-day variability

• Sleep Disorders
• Anxiety (present in 30-50% of cases)
• Depressive symptoms (present in 72-86% of chronic pain cases)⁵

It's important to note that the presence of anxiety or depression does not mean the pain is "made up". These conditions often coexist and influence each other. This is known as bidirectionality: pain can cause anxiety, and anxiety can amplify pain.

This understanding leads us to a fundamental question: why is this pain always real?

Why is pain ALWAYS real?

This might be the most important section of this guide. If you only remember one thing, let it be this: your pain is real.

The Neuroscience of Pain

Modern science has revolutionized our understanding of pain. Here's what we know now:

The brain acts as a "predictive brain". It constantly interprets the signals it receives and decides which sensations to produce. Sometimes, it can decide to produce pain even without a signal of injury, because it perceives a threat or danger.

Central sensitization: pain's volume turned up

When the nervous system remains in a prolonged state of alert, it can "learn" pain. Nerve connections become hypersensitive. Normally non-painful stimuli can then be interpreted as painful.

It's like someone turned up the volume on your internal alarm system. A light touch can become painful. A normal movement can trigger an excessive reaction. This phenomenon is also present in chronic nociceptive pain.

It's NOT 'in your head'

Brain imaging studies (functional MRI) have shown objective and measurable changes in the brains of people suffering from chronic pain without an obvious organic cause.⁴ These changes are real, visible, and most importantly: reversible.

> Your pain is real. It is not made up, simulated, or imaginary. It deserves to be taken seriously and treated with respect and expertise.

Knowing that your pain is real and can be treated, let's see how physiotherapy can help you.

How does physiotherapy help this type of pain?

Physiotherapy is the most scientifically validated treatment for functional motor disorders and plays a central role in managing psychogenic or somatic pain.²

The "Three P's" Approach in Quebec

In Quebec, healthcare professionals often recommend the "Three P's" approach for this type of condition:

• Physiotherapy: Main treatment for motor symptoms and pain
• Psychotherapy: Emotional support and cognitive-behavioral therapy
• Pharmacology: Medication if necessary (not always required)

This integrated approach allows for comprehensive care, "from head to toe" as some experts say.⁶

Therapeutic Education on Pain

The first step in treatment is often therapeutic education. Understanding what is happening in your nervous system is therapeutic in itself.

• Understanding that pain without injury does not mean "fake" pain
• Reducing the fear of movement (kinesiophobia)
• Changing negative beliefs about pain
• Providing a sense of control

Studies show that education on pain neuroscience alone can reduce pain intensity and improve function.⁷

Graded Movement and Progressive Exposure

Movement is medicine. However, it must be introduced gradually to retrain your brain that moving is safe. This approach is similar to what is used for movement re-education.

• Start small, increase gradually
• No "no pain, no gain"
• Listen to your body while gently challenging it
• Celebrate small victories

Specific Techniques Used

For example, the CHUM program starts with three weeks of intensive physiotherapy. The idea is to draw the brain's attention away from the pain, essentially "distracting" it to allow movement to recover.¹

What does a consultation with a physiotherapist for this type of condition actually involve?

What to Expect During Your First Consultation?

An assessment for psychogenic or somatic pain differs from a standard assessment. It generally takes longer (60 minutes) and explores multiple aspects.

1. Your complete history

• Onset and evolution of symptoms
• Life context at the time of onset
• Previous treatments
• Impact on your daily life

1. Biopsychosocial factors

• Biological factors (sleep, physical activity)
• Psychological factors (stress, anxiety, beliefs about pain)
• Social factors (work, relationships, support)

1. Physical assessment

• Neurological tests
• Movement observation
• Looking for positive signs (not just ruling out pathologies)

• Active and empathetic listening
• Validation of your experience
• Non-judgmental approach
• Clear explanation of diagnosis and treatment plan

• Focused on function (what you want to be able to do)
• Progressive and achievable
• Measurable (to track progress)

Don't be surprised if your physiotherapist asks about your mood, sleep, or work. These factors directly influence your pain and must be considered in your treatment plan.

Let's now look in more detail at the therapeutic approaches that will be used.

What therapeutic approaches are used?

Treating psychogenic or somatic pain involves several complementary approaches.

Physical Therapy

The main goal is to help you regain control of your body. Specific physiotherapy for TNF involves therapeutic education and targeted exercises.²

• Exercises tailored to your specific condition
• Individualized progression
• Working on movements you fear
• Integration into daily activities

This approach may include muscle strengthening and endurance exercises adapted to your condition.

Integrated cognitive-behavioral therapy

While not a psychotherapist, your physiotherapist can integrate certain principles:

• Identifying catastrophic thoughts ("I'll never get better")
• Recognize avoidance behaviors
• Gradually modify these patterns

If necessary, collaboration with a psychologist will be suggested.

Stress and anxiety management

Chronic stress keeps the nervous system on high alert, which amplifies pain. Simple techniques can help:

• Breathing techniques (heart coherence)
• Progressive muscle relaxation
• Introduction to mindfulness

Physical activity as medicine

Exercise has proven pain-relieving effects:

• Natural anti-inflammatory effect
• Endorphin release
• Normalizing the nervous system
• Sleep improvement

Stabilizing muscle exercises may be included in the rehabilitation program. The McKenzie approach can also be used for certain conditions.

Recovery time varies depending on several factors, which we will explore.

How long do treatment and recovery take?

Treatment duration varies significantly from person to person. Several factors influence the prognosis.

Factors that promote good recovery

• Early diagnosis: The sooner treatment begins, the better the prognosis.
• Acceptance of diagnosis: Understanding and accepting the functional nature of the condition.
• Commitment to treatment: Active participation in exercises and recommendations.
• Social support: A supportive and encouraging environment.

Factors that can slow down recovery

• Prolonged duration of symptoms before treatment
• Presence of ongoing litigation or compensation claims
• Untreated depression
• Rigid beliefs about pain

Typical observed durations

The CHUM program reports that, since adopting the predictive brain model, patients better understand their condition, more easily accept the diagnosis, and regain their abilities in 70% of cases.¹

Realistic Expectations

It is important to understand that:

• Healing is generally not instantaneous
• Progress can be non-linear (some days are better than others)
• The goal is not necessarily complete absence of pain, but improved function
• Relapses are possible and are part of the process

However, some signs require prompt medical attention. If you experience sudden acute pain with alarming symptoms, seek immediate consultation.

When to consult and who can help?

While psychogenic or somatic pain is not dangerous in itself, certain warning signs require urgent medical evaluation.

Warning signs (red flags)

• Progressive neurological symptoms (worsening weakness)
• Loss of Bladder or Bowel Control
• Numbness in the genital or perineal region
• Fever associated with the pain
• Unexplained weight loss
• Intense Night Pain That Wakes You Up
• History of Cancer

These symptoms may indicate a condition requiring urgent medical evaluation.

The multidisciplinary team

Optimal management often involves several professionals:

Resources in Quebec

• CHUM TNF Clinic: Specialized interdisciplinary program
• Chronic Pain Clinics: Available in several hospitals
• Physioactif Persistent Pain Program: Integrated approach in a private setting

For those suffering from associated joint or muscle pain, our services can also be adapted.

Physioactif stands out for its unique approach to this type of pain.

Why choose Physioactif for this type of pain?

At Physioactif, we understand that psychogenic or somatic pain requires a different approach.

Expertise in Pain Science

Our physiotherapists receive ongoing training on:

• The mechanisms of chronic pain
• Central sensitization
• Therapeutic pain education
• Research-validated approaches

We do not stigmatize. We understand that your pain is real, and we have the tools to help you.

Comprehensive Care

Our approach integrates the biopsychosocial model:

• Comprehensive assessment of biological, psychological, and social factors
• Collaboration with other professionals as needed
• Continuity of care throughout your journey

We also offer telerehabilitation services for certain follow-ups.

Proximity and accessibility

With 5 clinics across Greater Montreal, we are close to you:

• Flexible hours including evenings and weekends
• Teleconsultation available for certain follow-ups
• Welcoming and attentive team

If you are living with pain that has no clear explanation, don't give up. Solutions exist. Visit our page on pain and stiffness treatment to learn more.

What are the most frequently asked questions?

Does psychogenic pain mean I'm faking it?

Absolutely not. Psychogenic pain is a real, recognized medical condition. Your pain is real and measurable. Medical terms have evolved precisely to avoid this confusion. You are not faking it, and you are not seeking attention.

Can I be completely cured?

Many people experience significant or complete improvement. Studies show that 40 to 70% of patients improve with the right treatment. The prognosis is better when treatment starts early and when you have a good understanding of your condition.

Do medications help?

Medications can play a supportive role, but they are not the main solution. Some antidepressants have pain-relieving properties that can help. However, physiotherapy and psychological approaches are generally more effective in the long term.

My doctor can't find anything, what should I do?

Not finding an organic cause doesn't mean there's nothing to be done. On the contrary, it points towards a functional diagnosis, which has its own effective treatments. Ask for a referral to a physiotherapist trained in pain science.

Can stress really cause physical pain?

Yes, and it's scientifically documented. Chronic stress keeps your nervous system on high alert, which can amplify pain signals or even create them. It's not "just stress"; it's a real neurological mechanism.

How can I explain my condition to those around me?

You can explain that your nervous system processes signals differently, like an overly sensitive car alarm. The pain is real, but it comes from a "software" issue in the brain, not a hidden injury.

Is physiotherapy alone enough?

For many people, yes. Physiotherapy is the most validated treatment for functional neurological disorders. However, a combined approach (physiotherapy + psychological support) may be necessary in some cases.

How many sessions are usually needed?

This varies depending on the complexity of your condition. On average, a program of 8 to 12 sessions over 2 to 3 months leads to significant improvements. Longer follow-up may be necessary for some individuals.

Are there exercises I can do at home?

Yes, and they are essential for successful treatment. Your physiotherapist will teach you personalized exercises, relaxation techniques, and management strategies. Regular practice between sessions speeds up recovery. Also, check out our exercise videos section for additional resources.

How do I know if my pain is psychogenic or organic?

Only a healthcare professional can make this distinction. However, be aware that in many cases, both components coexist. Diagnosis is made through a comprehensive clinical evaluation, not by a single test.

References

1. CHUM Functional Neurological Disorders Clinic. FND Management Program. Radio-Canada. 2024. Available: https://ici.radio-canada.ca/nouvelle/2113390/trouble-neurologique-fonctionnel-cerveau-programme-chum

1. Nielsen G, Stone J, Matthews A, et al. Physiotherapy for functional motor disorders: a consensus recommendation. J Neurol Neurosurg Psychiatry. 2015;86(10):1113-1119.

1. Kosek E, Cohen M, Baron R, et al. Do we need a third mechanistic descriptor for chronic pain states? Pain. 2016;157(7):1382-1386.

1. Nijs J, George SZ, Clauw DJ, et al. Central sensitisation in chronic pain conditions: latest discoveries and their potential for precision medicine. Lancet Rheumatol. 2021;3(5):e383-e392.

1. Bair MJ, Robinson RL, Katon W, Kroenke K. Depression and pain comorbidity: a literature review. Arch Intern Med. 2003;163(20):2433-2445.

1. Ordre des psychologues du Québec. Somatization: Expressing Suffering Through Physical Symptoms. Available: https://www.ordrepsy.qc.ca/-/la-somatisation-mise-en-maux-de-la-souffrance

1. Louw A, Diener I, Butler DS, Puentedura EJ. The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain. Arch Phys Med Rehabil. 2011;92(12):2064-2071.

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Washington, DC: American Psychiatric Publishing; 2013.