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The Overdiagnosis of Pain as a “False Alarm” (Member Post)

 •  • by Paul Ingraham
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Weekly nuggets of pain science news and insight, usually 100-300 words, with the occasional longer post. The blog is the “director’s commentary” on the core content of a library of major articles and books about common painful problems and popular treatments. See the blog archives or updates for the whole site.

A woman walked into a physical therapist’s office, her first visit for a “new” problem, about two months old and still worsening — back pain, but a bit strange, a bit lateral, almost more ribs than back. The PT was some kind of fancy pain troubleshooter, her doctor told her: “He’s really great with this kind of thing.”

She was optimistic. Like most people, she reasonably assumed that “this kind of thing” is pretty manageable. It’s the 21st Century. Medicine is “advanced,” right? Especially relatively simple, body mechanic stuff!

“The fancy therapist told me it was a ‘false alarm’,” she said.

“My brain was over-reacting to some minor tissue insult that was probably over, and it would calm down about it in time. He explained the neurology to me in detail, which I liked at the time. Looking back on it now, it was more of a pedantic lecture, a one-size-fits-all speech. We talked a lot about how stressed and run-down I was, how I could work on the pain indirectly by improving my overall health and fitness. We joked at the end about how physical therapy wasn’t anything like I expected, more like counselling.

“Now I cringe thinking about how nice that all seemed.”

The predictable punchline

The pain was not a false alarm, of course. A serious medical problem was brewing. I’ll reveal the rest of the story at the end of the post, for PainSci members only.

But the real attraction, what this post is all about, is an exasperated, detailed rant about the overdiagnosis of “false alarms.” If you’re a chronic pain patient who has been frustrated with ineffective care, you may appreciate the wrist-slap this post gives to some professionals for this poor behaviour.

If you’re a professional, you may feel vindicated… or defensive. 😉 Or both! It’s complicated. Still ahead in this post (a 9-minute read):

  • Telling too many patients their pain is a “false alarm”
  • Two problems with excessive “false alarm” diagnosis: misdiagnosis and insult!
  • The pendulum pushers who are encouraging “false alarm” diagnoses… like yours truly
  • Pushing the pendulum where? The alternatives to structuralism
  • Integrating psychological and social factors into pain care is hard!
  • Ham-handed psychosocialism: the psychosocialists
  • Dangerous distractions
  • My personal example: “well there’s your problem”
  • Paying lip service to both new and old paradigms
  • Revolutions seem to be impossible without some zealotry
  • How did we get into this mess?
  • Where does the pendulum belong? In the middle, duh
  • And the diagnosis is…

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Telling too many patients their pain is a “false alarm”

Having my thumb on the pulse of the world of therapy for pain, I have come to believe that way too many pros are telling too many patients that their chronic pain is a “false alarm,” or words to that effect. That it is mostly about sensitization or amplification driven by mental and general health factors. That “pain is weird,” basically, and sometimes there is nothing going on but pain’s weirdness.

These are real and important ideas, and I have worked hard to encourage everyone to learn about them and always consider them. How strange for me to now see people taking it too far!

Two problems with excessive “false alarm” diagnosis: misdiagnosis and insult!

  1. It’s often wrong. Lots of pain is still mainly driven by issues in the tissues, and some patients eventually prove it with an accurate diagnosis and an effective cure. I have seen many interesting examples: cysts, nutritional deficiencies, diseases, nerve entrapments, claudication, and so on. I have been collecting examples for years now. But I see way too many professionals virtually abandoning diagnostic challenges in favour of blaming pain on… itself. On its own strange properties.
  2. Even when it’s right, if that message isn’t crafted quite carefully, it sounds a lot like “your pain is all in your head” to patients. And that is a disastrous result, from any perspective. Chronic pain amplified by psychosocial factors is not the same thing as hypochondria (medical anxiety), or malingering (faking pain, which barely exists). But many professionals, embracing an exciting new paradigm a little too hard, are failing to make this distinction clear… with serious and obnoxious consequences.

And these things are happening partly because I have pushed the pendulum hard away from the old ways and towards the new! I don’t want to take too much credit for it, because of course is just one of many sources.

The pendulum pushers who are encouraging “false alarm” diagnoses… like yours truly

I have spent my career trying to swing the rehab pendulum away from “structuralism,” which I have defined as an excessive focus on simplistic “mechanical” causes of injury and pain, such as ankle pronation or a slouched posture. Structuralism is a major paradigm in rehab and musculoskeletal pain treatment: it has been by far the most popular way for healthcare professionals to think about musculoskeletal and pain medicine for decades.

For instance, a while back posted three small items about back pain, each of them about the tendency to over-interpret back pain as a by-product of things like fragility, instability, and asymmetry. This is why MRI gets overused and abused, why people get way too obsessed with core strength to stabilize their spines, and why far too much money is spent on therapy to fix fanciful misalignments.

So that’s been the main way of thinking about these things for decades… and much of my work on for many years has been about helping push the pendulum away from structuralism.

But towards what, exactly?

Pushing the pendulum where? The alternatives to structuralism

I’ve been pushing the pendulum towards two things:

  1. A much more sophisticated biomedical perspective than structuralism, which is really just a simplistic parody of the “bio” in the “biopsychosocial” model of pain. The real bio is a jungle, not a complex machine, the dizzying complex biological risk factors and pathological causes of pain. Things like:

    • drug side effects and complications
    • the seemingly infinite flavours of inflammation and autoimmune dysfunction the bizarre world of post-infection syndromes
    • subtle connective tissue disorders
    • subtle early stages of pathologies, which cause trouble for years before finally being diagnosed
    • weird genetic factors (like a gene that exaggerates pain)
  2. The psychological and social factors that can distort and magnify our pain like a funhouse mirror — a modern and influential perspective on the science of pain which places more emphasis on concepts like sensitization, hyperarousal of the nervous system, and danger versus safety signals.

Integrating psychological and social factors into pain care is hard!

That second item there is a major and useful change in the history of the science of pain, and there’s not really any scientific doubt that this is actually how pain works: lots of “tuning” by the brain, sometimes dramatically.

But we’re all still learning how to help people with this knowledge. Regrettably, the messy truth doesn’t easily translate into treatment. It doesn’t play nicely with familiar habits and methods and patterns of thinking about pain.

I have tackled the awkwardness of the paradigm shift before, in a post titled “Are clinicians becoming paralyzed by Pain Science?” I think some are. But many others who want to leave the old behind are just barging ahead without a clear idea of where they are headed, getting overconfident about some simplistic translations into patient care.

And this is where I have to do a little scolding.

Ham-handed psychosocialism and the psychosocialists

The “biopsychosocial” model of pain supposedly embraces all of the above, explaining pain as a complex product of messy biological and psychological and social factors. But some pros are now overemphasizing and oversimplifying the psycho and the social so strongly that I have started to (disparagingly) think of them as “psychosocialists” … in much the same exasperated way that I have always disparagingly used the term “structuralists.”

Don’t get me wrong: psychosocialism is a way, way smaller problem than structuralism, which remains overwhelmingly dominant. But it’s worrisome to see these important new ways of understanding pain being applied so clunkily.

Overdiagnosis of pain as a psychosocially-powered “false alarm” is almost as bad for patients as the product of biomechanical bogeymen ever was. It’s a tragic failure of the new paradigm.

A dangerous distraction

The most insidious danger of quackery is that it distracts everyone from legitimate diagnosis and treatment. While you’re trying to get your “stagnant energy” flowing again with acupuncture needles and magnets, real problems march onwards, and sometimes get far worse.

Psychosocialism is not quackery… and yet it might as well be if it’s not actually a good way to explain a patient’s pain.

It too can distract from what actually matters. Good diagnostic investigation can grind to a halt; the all-too-real possibility of a sneaky pathological cause of pain can be given short shrift, even ignored entirely, in favour of, say, an “explanation” like “conversion disorder” — the ultimate all-in-your-head diagnosis, legitimized by jargon, and applied to patients much too frequently in recent years.

It’s inherently awful how often the message the patient takes home is “I’m doing this to myself.” But it’s even worse that it shuts down medical investigation.

My personal example: “well there’s your problem”

I’ve personally had my own nasty chronic pain nightmare boiled down to “you’ve just gotten sensitized”… and so the only treatment options on the table were “de-sensitization strategies” ranging from seeing a psychologist to meditation to biofeedback to a therapy dog.

I worked earnestly with that perspective on my pain for months. And it was all a waste of time.

Those options were tragically doomed to failure, because I was not just sensitized: I had a simple and concrete organic problem that was diagnosed and decisively fixed not long after (tonsil stones). It’s not that there was no psychosocial amplification at all, but it was a relatively minor and inevitable consequence of a “bio” nightmare. It was just another symptom, not the bones of my nightmare.

Heaven help the person who has a full-blown painful pathology that’s neither simple nor treatable, but no one’s even looking for the cause because of a misdiagnosis of sensitization or conversion disorder.

Close-up of my tonsil stone, a grey, craggy little tonsillar calculi resting on a Q-tip.

My strange tonsil stone in 2015, the clear & specific cause of months of misery — hard, sharp as a burr & stuck in a tender crack in my craw. NOT A FALSE ALARM, DAMMIT.

Paying lip service to both new and old paradigms

Old-school structuralists have always paid lip service to these modern biopsychosocial factors while continuing to neglect them in practice. They just keep cranking on about the biomechanical bogeymen they know and love (all their scapular dyskinesias and dead butts), every treatment impulse guided by their obsession with these scapegoats.

I am starting to see a mirror image of this old problem in the new paradigm. New-school “psychosocialists” are now paying lip service to the diagnostic possibilities they have left behind, but gravely underemphasizing them in practice.

“Of course sometimes there are important biological and pathological factors in chronic pain,” they declare. “Everyone knows that!

But they don’t really know what to do with that squishy mess, and so in practice they ignore any possibility of ongoing pathology and focus on poorly defined mind-over-pain techiques. Which, so far, don’t seem to work much better for anyone than anything else ever has for chronic pain.

Revolutions seem to be impossible without some zealotry

New paradigms often get just as entrenched and blinkered as what they replace, but I think that process is accelerating in the crucible of social media, with its tendency to spawn echo chambers.

It’s one thing to be so keen on a new set of ideas that you give the old ones short shrift, an ordinary case of baby-with-bathwater disposal. But quite a few experts are out there actively campaigning and railing against biomedical and structural diagnoses exactly as if they never matter at all (while conceding, without much conviction, that “of course they matter sometimes”).

It’s getting downright dogmatic. They are digging in, getting entrenched, growing deft at defending their biases, quick to dismiss anyone who challenges them as a troll or a dinosaur. They pump out memes mocking structuralist ideas — which amused me for years and I can still enjoy on Tuesdays and Thursdays — but I am also starting to recognize it as a sign of the end of meaningful debate.

Habitual, reflexive mockery of one type of simplistic idea by the champions of another isn’t going to get us anywhere.

How did we get into this mess?

I think it was partly reactionary, a determined and inspired rejection of the dumpster fire of structuralism. But oversimplification of the BPS model is seductive: it empowers clinicians to “solve” and “explain” really frustrating pain cases.

Clinicians get more out of clumsy psychosocialism than the patient: they get to have the answers (which was always a perk of structuralism too). All the patient gets is responsibility for their pain. Their brain gets the blame.

A lot of this behaviour is really starting to look like head-in-the-sand, holier-than-thou bullshit to me. It’s all disturbingly similar to the PACE disaster with chronic fatigue syndrome (that’s a great read, by the way), where a medical faction disastrously ignored patient experience under the cover of following sexy new science.

For some healthcare professionals, the pendulum has swung too far. And I say this as someone who started out pushing on that pendulum with them.

Where does the pendulum belong? In the middle, duh

I think we need to stop overcompensating in any direction and focus on the center of the Venn diagram, where bio, psycho, and social all messily overlap, and are all given roughly equal weight. A true biopsychosocial model must integrate all factors … without oversimplifying any of them.

Structuralism is a particularly shabby old biomedical perspective, and should simply remain outside in the cold.

Psychosocialism is more legitimate, but not if it’s pursued at the expense of biomedical factors. Oversimplification and applying too much of it will turn it into the same kind of failure that structuralism always was.

And the diagnosis is…

I introduced this topic with a case study of slowly progressive back/flank pain. It turned out to be… *drum roll*

A slowly worsening kidney infection!

Things got pretty bad before the correct diagnosis was possible. It was not a happy story. There was some hospital time.

It was an unusually back-o-centric kidney infection. What’s up with that? Visceral pain and body pain often get mixed up, thanks to imperfections in our wiring, sensory bottlenecks (“viscerosomatic convergence”). The back pain might have dominated due to some pre-existing vulnerability that made it the more “credible” source of pain. The brain knew something was wrong, but made an honest mistake about where it was wrong.

In retrospect, the patient actually did notice other fishy symptoms all the way back at the start… but she didn’t take them seriously. When encouraged to see her pain as a false alarm, she took them even less seriously, at exactly the time when she should have been going to a doctor and pushing for more investigation.