hallucinated pain syndrome

   A term introduced in or shortly before 1968 by the American psychiatrist Gordon Forrer as an expansion of his concept of *hallucinated headache. Starting from the hypothetical construct hallucinated headache, Forrer reasons that "pain can be hallucinated in any portion of the anatomy; certain headaches being but specific manifestations of more general psychosomatic phenomena." As he continues, "In expanding the concept ofhallucinated pain, three diagnostic criteria defining the boundaries thereof have been established." These diagnostic criteria are (1) distribution and character ofthe pain (i.e. a description ofpain in vague, uncertain, inappropriate or bizarre terms, or a description that violates neu-roanatomical boundaries, as in cases of hysterical * topalgia); (2) contingent circumstances (i.e. the presence of a psychological or actual state of relative emptiness such as hunger or thirst); and (3) the effects of oral activity (i.e. the improvement or disappearance of pain when the affected individual engages in oral activity such as eating or drinking). A fundamental objection against Forrer's concept of hallucinated pain stems from the argument that a subjective experience such as pain can never be imagined or 'unreal'. In philosophy this is known as the self-intimating aspect of pain experiences. As summarized by the American logician and philosopher of language Saul Kripke (b. 1940), "For a sensation to be felt as pain is for it to be pain". In Forrer's defense, however, attention may be drawn to the experience of dentists and other health professionals that feelings of physical pain are not seldom expressed moments before a tooth or other body part is touched, to the oft-reported persistence of local pain after an attack of neuralgia has subsided (referred to as hallucinated neuralgia), and to the experience of hypnotists that pain can be evoked and aggravated as well as alleviated through suggestion. Moreover, Forrer's notion deserves credit for filling a conceptual void in relation to the subjective reports of painful hallucinations of bodily sensations. As noted by the Swiss psychiatrist Eugen Bleuler (1857-1939), "Any organ can be the seat of the most severe pain. The scalp can become so sensitive that the slightest touch of the hair may produce terrible pain. Every bone in the body may ache. The patients are beaten and burnt; they are pierced by red-hot needles, daggers or spears; their arms are being wrenched out; their heads are being bent backwards; their legs are being made smaller; their eyes are being pulled out so that in a mirror it looks like they are entirely out of their sockets; their head is being squeezed together; their bodies have become like accordions, being pulled out and then again pressed together. They have ice inside their heads; they have been put in a refrigerator. Boiling oil is felt inside their bodies; their skin is full of stones. Their eyes flicker, as do their brains. They are being plucked as one pulls horsehair out of a mattress. A cartridge ball rolls around in a spiral inside their skull from base to vertex. There is a feeling in their stomach as if the food was not retained; they feel bloated. Their lungs are stretched as if a stout man were being drawn through the body from the genitals through the abdomen into the chest. They feel heartbeats in their navels. Their heartbeat is at times slow; sometimes it is speeded up. Their respiration is hampered, their urine drawn off or blocked. Any and every organ has been removed, cut-up, torn to pieces, inverted. One testicle is swollen. The nerves, the muscles, various organs are being tightened." As summarized by Bleuler, "The hallucinations of bodily sensations present such kaleidoscopic multiplicity that no description could possibly do justice to them". It is perhaps doubtful whether the notion of a hallucinated pain syndrome does justice to painful symptoms such as those listed by Bleuler, but at least it offers a conceptual approach with conceivable practical consequences for diagnosis and treatment. Forrer proposes to classify hallucinated pain as a type of * somatic hallucination. The notion should not be confused with * allodynia, *algohallucinosis, or * hyperalgesia, or with pain due to an unknown somatic condition.

   References

   Bleuler, E. (1950). Dementia praecox or the group ofschizophrenias. Monograph series on schizophrenia no. 1. Translated by Zinkin, J. Madison, WI: International Universities Press.

   Forrer, G.R. (1968). The hallucinated pain syndrome: A new diagnostic triad. Headache: The Journal of Head and Face Pain, 8, 71-75.

   Kripke, S. (1980). Naming and necessity.Cam-bridge, MA: Harvard University Press.

   Raij, T.T., Numinnen, J., Närvänen, S., Hiltunen, J., Hari, R. (2005). Brain correlates of subjective reality of physically and psychologically induced pain. Proceedings ofthe National Academy of Sciences of the United States of America, 102,2147-2151.