Why Do We Say People With Chronic Pain Are "Hysterical"?

Source: Jonathan Borba/Unsplash

“You just want attention.”

“It’s all in your head.”

“You look healthy, so you must not be in pain.”

These phrases reflect the stigmatizing reaction people can have toward those affected by chronic pain. Chronic pain is “persistent or recurrent pain lasting > 3 months, and it affects > 30 percent of people worldwide.[1] Examples include chronic migraines, IBS, non-specific back or neck pain, fibromyalgia, etc.

In their recent research on stigma and chronic pain, Perugino et al. proposed that chronic pain stigma finds its roots in “analgesic culture”: “the dominant belief that pain should be short-lived, diagnostically meaningful, and denote a fixable problem.”[2] They highlighted how the diagnostic uncertainty, persistent nature, and often absence of clear medical tissue damage for chronic pain means it does not fit into this analgesic model. Revising stigma means revising deeply held notions about wellness.

Gender and Chronic Pain

The greater propensity for women to be diagnosed with chronic pain syndromes compounds the prejudice of those affected by chronic pain as malingerers. Perugino et al. explained that there may be biological and social reasons why more women are at a greater risk of several chronic pain disorders, such as joint pain, fibromyalgia, interstitial cystitis (bladder and pelvic pain), IBS, and trigeminal neuralgia (facial pain).[3]

Their survey of recent literature suggested that, while biological factors may come into play, psychosocial factors have the greater influence. Western gender norms, such as men’s expected stoicism and women’s expected emotionality, make it more acceptable for women to express pain than men. However, despite the larger number of women diagnosed with chronic pain conditions, Perugino et al. noted that women experiencing chronic pain are caught up in a paradox. While there is greater cultural acceptance of women’s expression of pain, many woman patients are deemed “hysterical,” leaving them “underdiagnosed and inadequately treated.”[4]

Hysteria and Malingering in History

Accusations of malingering, emotionality, and fabrication have long clouded the term “hysterical.” Medical treatises in the 1800s and 1900s explicitly warned physicians about their women patients’ theatricality, questioning the patients' morality and the reality of their physical suffering. W. S. Playfair, a Scottish professor and physician writing about women with uterine pain, warned that the patient could become “emotional and hysterical, constantly craving for sympathy, which she often obtains to a degree most prejudicial to her welfare, until at last the whole household becomes victimized by the morbid selfishness thus developed” [5].

Playfair claimed that removing the patient from “the injudicious sympathy and constant tending of friends” is essential to improve her moral condition and, therefore, her “invalid condition.”[6] Physical treatments such as tonics and the water cure would prove to no avail. Physiological treatments, such as massage, diet, and electricity, Playfair claimed, had only a “secondary effect.” “Clearly the main factor was the removal of injudicious sympathy...to break through habits of a morbid character…. To make a weakened will exert itself.”[7]

In his treatise on nerve affectation and pain, Frederic C. Skey, an English surgeon, distinguished between neuralgia and hysteria: neuralgia was linked to a particular, identifiable nerve with pain locally around that nerve; hysteria had a local pain that cannot be traced in regard to actual nerve structures.[8] Part of hysteria, according to Skey, is an unclear “relation between the respective parts, namely, the seat of the disease, and its source or centre.”[9] In other words, hysteria is the term given, rather than neuralgia, to unexplainable or untraceable pain.

He noted that one remarkable form of hysteria involves the “imitative” nature of “active or paroxysmal hysteria on a larger scale.”[10] Skey explained how in a ward of twelve women, a domino effect of attacks occurred so that no fewer than nine of the women were experiencing pain at the same time. He termed this “contagious” and “imitative” in nature. In short, the physiological basis of the pain was deemed dubious as he theorized its psychological and even immoral foundation.

The Needed Basis of Interventions Today:

The present-day stigma of those with chronic pain as hysterical, not wanting to get better, or malingering is deeply rooted in one vein of hysteria discourse–the emphasis on moral and psychological causes rather than somatic ones–as well as today’s “analgesic culture.” Perugino et al., therefore, closed their study with an emphasis on how intervention strategies, such as improving education on pain assessment and managing patients with chronic pain, can only go so far without first addressing the underlying assumptions around gendered experiences of pain and the legitimacy of persistent, diagnostically uncertain pain.