Psychosomatic Medicine 24:119-132 (1962)
© 1962 American Psychosomatic Society

A Psychological Basis for Indifference to Pain

¹ Department of Psychiatry, University of Michigan Medical Center, Ann Arbor, Mich.

Neurological, psychiatric, and psychological findings concerning 3 patients showing indifference to pain were reviewed. It was proposed that an early alteration in ego development might account for this symptom. Three alternative hypothetical reconstructions were offered, based upon the theoretically close relationship between the defense mechanism of denial and the affect of pain. The first of these reconstructions, that pain indifference resulted from a massive use of denial in very early childhood, was felt to be untenable because none of the patients showed psychopathologic changes extensive or severe enough to be consonant with such a gross early ego disturbance. The primary traits of character shared by these patients--their denial of weakness, helplessness, and passivity, and their insistence upon personal invincibility--suggested the possibility of an ego alteration during a somewhat later (i.e., phallic or oedipal) phase of development, similar to that found in counterphobic personalities. A second reconstruction, that indifference to pain represented the end product of the conversion process, was rejected because the symptom failed to fulfill one cardinal criterion of true conversion symptoms and it did not seem to be a symbolicrepresentation of repressed instinctual impulses.

A third hypothesis, that the symptom arose as a result of the regressive reactivation of denial by the ego under the impact of phallic or oedipal conflicts, seemed to be most credible. Such a reconstruction, if at all accurate, makes the use of the term "congenital" indifference to pain incorrect, since it would hold that these patients felt pain at one time, but could not recall this experience. Subsequent reaction formations of the ego undoubtedly helped to cement the character structure which was so evident in these cases.

Of course, we have no conclusive answer to the problem of the genesis of indifference to pain. More suitable psychological and/or organic explanations of the phenomenon can only accrue from the continued investigation of such cases. In addition to the neurological and neuroanatomical work presently being carried out, several avenues of psychological exploration appear to hold promise. The intensive study of children with this anomaly may be most fruitful. It is unfortunate that hypnotic procedures were not attempted with the present subjects, to see if they experienced pain under hypnotic suggestion (the patient reported by Cohen et al.⁴ did not react to noxious stimuli under these conditions). Patient 2, who reported that 5 of his 6 boys showed indifference to pain, would not allow his children to be examined, but several aspects of an evident familial indifference remain intriguing. Finally, psychotherapy or psychoanalysis with such patients may ultimately provide us with our best leads, although not only are these cases rare but, if they resemble the patients studied here, they are hardly the sort to present themselves for treatment. However, if either the sensation of pain or the early memory of pain reappeared during the course of treatment, this would lend considerable support to the idea that there can be a psychological basis for the condition and afford an invaluable contribution to our knowledge about its genesis, structure, dynamics, and economy.

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