This article is part of the Expert Guide “Understanding Pain”.

Psychological Pain: An Invisible but Very Real Form of Suffering

Why does this article matter?

When someone has a fracture, a burn, or inflammation, the reality of their pain is rarely questioned. When they describe suffering caused by bereavement, a breakup, humiliation, or rejection, the reaction is sometimes different: “it’s only psychological,” “you need to move on,” or “it’s all in your head.”

This opposition rests on a confusion. Every conscious experience, whether physical or psychological, involves the brain. Saying that suffering is “in the head” therefore makes it neither imaginary nor voluntary. The real question is not whether it exists, but what distinguishes it from physical pain and why it can become so intense.

Suffering can be invisible and leave no identifiable lesion, yet still profoundly alter sleep, attention, emotions, behavior, and the functioning of the body.

To study it rigorously, however, two opposite shortcuts must be avoided: reducing psychological pain to a mere metaphor, or claiming that it is biologically identical to physical pain. Clinical history and neuroscience point to a more nuanced position.

1. Does psychological pain really exist?

Psychological pain refers to an experience of inner suffering that may accompany a loss, a break in social bonds, a sense of abandonment, humiliation, overwhelming guilt, depression, or certain melancholic states. It mainly concerns the affective and existential dimension of experience, rather than a signal coming from damaged tissue.

This terminological caution in no way diminishes the reality of the experience. Intense psychological suffering can take over consciousness, disrupt sleep, reduce the capacity to act, and change appetite, concentration, and social relationships. In some severe depressive states, it can become the central feature of the clinical picture.

A clinical insight formulated as early as the 19th century

This insight is not new. As early as 1835, the Belgian physician Joseph Guislain described, in his Traité des phrénopathies [Treatise on Phrenopathies], a “moral, intellectual, or cerebral pain” — phrenalgia — which he considered capable of constituting, on its own, an entire illness (Guislain, 1835; Masson & Muirheid-Delacroix, 2014).

Guislain therefore did not reduce this experience to ordinary sadness. He described suffering capable of invading thought and profoundly altering the person’s relationship with themselves and with the world. Psychiatry would later develop the notion of moral pain, notably in the description of melancholia.

What has changed since the 19th century is therefore not the clinical insight, but our ability to study this suffering. Brain imaging now makes it possible to observe the neural networks engaged during certain experiences of rejection, loss, or exclusion.

Figure 1 — From phrenalgia to neuroscience. As early as 1835, Joseph Guislain described a “moral pain” (phrenalgia). Modern neuroscience then made it possible to objectively document the brain networks involved in this suffering.

2. What does neuroscience actually show?

In the early 2000s, several studies sought to determine whether the suffering caused by social exclusion or the breaking of a bond engaged brain regions similar to those observed during physical pain.

Social exclusion studied through brain imaging

In 2003, Eisenberger, Lieberman, and Williams used a virtual game called Cyberball. Participants believe they are tossing a ball back and forth with two other people, and are then gradually excluded from the game. This exclusion is accompanied by increased activity in certain regions, notably the dorsal anterior cingulate cortex and the anterior insula, which were then often associated with the affective component of pain (Eisenberger et al., 2003).

This study helped popularize the idea of a “common system” for physical pain and social pain. It did not, however, demonstrate that the two experiences were identical: the regions observed are also involved in attention, in detecting important events, and in processing negative emotional states.

The suffering linked to a romantic breakup

In 2011, Kross and colleagues studied people who had recently gone through a breakup they had not wanted. Participants looked at a photograph of their former partner while recalling the rejection, and then, in another condition, received a painful heat stimulus. The authors observed an overlap between certain activations produced by physical pain and those linked to reliving the romantic rejection (Kross et al., 2011).

These results suggest that certain forms of intense social suffering may recruit systems involved in salience, negative affect, and certain components of bodily pain. They are not enough, however, to conclude that the brain “makes no difference” between a burn and a breakup.

Finer-grained neural signatures remain distinct

In 2014, Woo and colleagues re-examined this question using multivariate methods capable of comparing brain activation patterns with greater precision. They showed that, despite a coarse anatomical overlap, heat pain and social rejection rely on partly distinct neural representations (Woo et al., 2014).

The most rigorous conclusion is therefore the following: physical pain and psychological pain can engage certain shared networks, notably those that evaluate threat, salience, and distress, but they do not constitute one and the same biological experience.

Figure 2 — Physical pain and psychological pain: a partial overlap. Some brain regions are shared by both experiences, but their neural signatures remain partly distinct (Woo et al., 2014).

3. Why can a loss or a rejection “hurt”?

Human beings depend deeply on their social bonds. From childhood onward, safety, emotional regulation, and a large part of learning rely on the presence of others. In adulthood, belonging to a group, emotional relationships, and social recognition continue to play a major role in psychological balance.

Several authors have proposed that the alarm systems linked to separation or rejection may have partly built, over the course of evolution, on circuits already involved in protecting bodily integrity (Eisenberger, 2012). This hypothesis could explain why everyday language spontaneously uses bodily expressions: “a broken heart,” “a deep wound,” “grief that hurts.”

Psychological pain can thus be understood as an alarm signal concerning not the integrity of a tissue, but the affective, relational, or existential integrity of the person. Like any alarm signal, it can be appropriate to a real situation, become disproportionate, or persist beyond the event that triggered it.

Figure 3 — Why does the brain produce psychological pain? A widely discussed hypothesis holds that it is an alarm system that favors the protection and restoration of the social bonds essential to survival.

4. Can psychological suffering change the body?

Drawing a strict opposition between body and mind does not reflect how biology works. Intense psychological suffering engages the autonomic nervous system, the hormonal stress systems, attention, memory, and behavior. It can therefore be accompanied by genuine bodily manifestations.

These manifestations do not prove that psychological suffering is the sole cause of a physical symptom. They do show, however, that psychological experience transforms the overall state of the body and can influence the way bodily signals are perceived and regulated.

5. When does psychological pain become long-lasting?

Acute psychological pain can be an understandable reaction to a loss or to a threatening event. In many cases, it evolves with time, social support, and the person’s coping capacities. But it can also persist, particularly when the event goes on, recurs, or reactivates earlier experiences.

Several mechanisms may then help sustain it: rumination keeps attention focused on the loss; disrupted sleep reduces the capacity for emotional regulation; social withdrawal decreases opportunities for support and positive experiences; hypervigilance increases sensitivity to signs of rejection or threat.

This course does not mean that the person “chooses” to remain in their suffering. It reflects the establishment of biological, cognitive, emotional, and social loops that reinforce one another.

Figure 4 — The consequences of prolonged psychological pain. When it persists, psychological suffering can gradually affect cognitive, emotional, bodily, and social functioning.

6. Psychological pain, depression, and anxiety: are they the same thing?

No. Psychological pain describes a dimension of lived suffering. Depression and anxiety disorders are broader clinical entities, defined by several symptoms, a duration, and a functional impact. A person can experience intense psychological pain without having major depressive disorder; conversely, depression can combine moral pain, loss of interest, slowing down, fatigue, sleep disturbances, and feelings of worthlessness.

The notion of psychological pain should therefore not serve as a general diagnostic label. Above all, it helps recognize an often-underestimated experience: that of inner suffering which can become as all-consuming and disabling as bodily pain.

7. Why does recognizing this pain change the way we see it?

Recognizing psychological pain first of all helps move beyond a sterile opposition between “real” suffering and “psychological” suffering. An experience does not need to be visible on an X-ray to be genuine. It needs to be heard, described, and placed back in its context.

This recognition also avoids reducing the person to a lack of willpower. Persistent suffering changes the resources available for acting, concentrating, sleeping, working, or maintaining relationships. Telling someone to “pull themselves together” does not eliminate the mechanisms that sustain this suffering.

Finally, distinguishing physical pain from psychological pain without setting them against each other paves the way for a more complete understanding of chronic situations. Prolonged bodily pain can impair sleep, independence, work, and relationships; conversely, psychological suffering can increase hypervigilance, reduce modulation capacities, and amplify the perception of physical symptoms.

Figure 5 — Physical pain and psychological pain: two interacting realities. They have neither the same origin nor the same function, but they can influence each other and contribute to the persistence of suffering.

Note: this content presents general knowledge and cannot be used to establish a diagnosis. Intense or persistent psychological suffering, or suffering accompanied by suicidal thoughts, requires prompt evaluation by a healthcare professional or an emergency service.

© Gil Ayache. The concepts, diagrams, terminology, and principles presented on this page constitute a work protected by copyright. They are made available to Blue Portance under an intellectual property license agreement, without transfer of economic rights or of authorship.