Pain as a Model of Somatic Symptom Formation

The proverb “all that glitters is not gold” is one of the traditional gentle injunctions used by parents and educators to urge their young charges to look beyond first impressions in evaluating the world around them. In an attempt to communicate some understanding of the complexities involved in the formation of pain as a symptom, one could perhaps begin with a gentle reminder to all of us raised on the Western medical model that “all that hurts is not somatic”. This has a double meaning, which is intended. On the one hand it refers to the long historical record (Merskey and Spear, 1967), expressed in literature, etymology, religion and philosophy of “pain”, “hurt”, and related words being used as much to refer to emotional events as to physical ones. A second meaning is that pain in the clinical situation does not always have an identifiable somatic basis or so-called “peripheral input”. Particularly in the case of patients with chronic pain, keeping these two basic concepts in mind will contribute greatly to their understanding and to more effective clinical management.