Habenstein, Astrid

Michel, Konrad

Reisch, Thomas

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LETTER TO THE EDITORBrain regions associated with psychological painAstrid Habenstein & Thomas Reisch & Konrad MichelPublished online: 12 April 2013# Springer Science+Business Media New York 2013To the EditorWe read with great interest the overview of neural corre-lates of psychological pain by Meerwijk et al. (2012), abroad concept widely used in clinical practice. As theauthors had noted in an earlier publication (Meerwijk andWeiss 2011), various concepts of psychological pain havebeen put forward, but so far, no commonly agreed definitionhas been established. From their review of the literature,Meerwijk et al. define psychological pain as “a lasting,unsustainable, and unpleasant feeling resulting from nega-tive appraisal of an inability or deficiency of the self”. Theystate that “psychological pain is a lasting feeling in that itendures, it does not pass quickly, and it takes time toresolve”. From our work with suicidal patients, we wouldlike to argue that suicidal psychological pain as it wasinvestigated in our study (Reisch et al. 2010) does not fitinto this definition.For their review, Meerwijk et al. only found two neuro-imaging studies using an established measure of psycho-logical, or mental, pain (OMMP, Orbach et al. 2003). Inboth studies, psychological pain was related to suicidality.Van Heeringen et al. (2010), in their patient sample, foundan association between OMMP scores and suicidality.Reisch et al. (2010) related neural activation in suicideattempters to autobiographically recalled mental painimmediately preceding (triggering) an episode of suicidalself-harm.A suicidal crisis is generally understood as an acute andtime-limited form of psychological pain, characterized byphysiological arousal and the feeling of unbearability (Ruddet al. 2004, p.30). The high levels of psychological painhave been stressed by Shneidman (1993), who argued thatsuicide occurs when a person’s individually determinedpsychological pain threshold is exceeded. This is consistentwith the association of suicide with dissociative symptoms(Orbach 1994), as an expression of high emotional arousal.In the OMMP validation study, Orbach et al. (2003) foundfeelings of irreversibility, loss of control, emptiness, emo-tional flooding, emotional freezing, and estrangement to bethe main factors – symptoms that are usually associated withdissociative experiences. We therefore believe that suicidalpsychological pain is not only acute and time-limited innature, but is also an extreme form of pain, usually exceed-ing the individual pain threshold. Psychological modelsconsistent with this notion have, for example, been formu-lated by Baumeister (1990), and Maltsberger (2004).The patients examined in our fMRI study (Reisch etal. 2010) reported high levels of dissociation. Consistentwith this, during recall of mental pain associated with thesuicidal behavior, we found a striking similarity of brainactivation with neural correlates of trauma reactivationknown from PTSD studies (e.g. Lanius et al. 2001), inparticular reduced activity in the left medial prefrontalcortex (BA 6, 10/11) and the anterior cingulate gyrus(BA 32). This is not surprising in view of the fact thatthe association of suicidal behavior with trauma is wellestablished (Orbach 1994; Mann and Currier 2010;Bruffaerts et al. 2010).Psychological pain is invariably associated with appraisal,which is a major factor moderating intensity and duration.Cognitive appraisal of psychological pain as uncontrollableand unsustainable may result in suicidal behavior as the onlysolution, while other forms of coping such as self-soothing,help-seeking, etc. will help to contain psychological pain andallow it to subside (Rudd et al. 2004, p.237). Interestingly,in our fMRI study, when patients were asked to recall how, asa response to intense mental pain, they planned and initiatedan action of self-harm, we found increased activation in cer-tain cortical areas. This finding is in line with the classicalstudy by Ochsner et al. (2002), who showed that stressfulA. Habenstein : T. Reisch :K. Michel (*)University Hospital of Psychiatry, Bern, Switzerlande-mail: konrad.michel@spk.unibe.chBrain Imaging and Behavior (2013) 7:243–244DOI 10.1007/s11682-013-9229-0emotional experiences are associated with prefrontal deacti-vation, while the use of cognitive coping strategies as aresponse to negative emotions is related to increased activa-tion in prefrontal cortical areas. Appraisal mechanisms prob-ably explain why some studies found decreased activity in theventromedial PFCwhile others reported an increase of activityrelated to psychological pain.To summarize, we understand psychological pain associat-ed with suicidal crises as an acute and time-limited intensiveemotional experience with the quality of a traumatic experi-ence. We believe that psychological pain such as it occurs ingrief or unhappiness represent different entities with differentneurobiological correlates. Therefore, in our opinion, futureneuroimaging studies will be best advised to focus on clearlydefined and specific forms of psychological pain, to includethe time dimension, and to apply a validated measuring in-strument (such as the OMMP) of psychological pain.Conflict of interest The authors state that there is no conflict ofinterest pertaining to the work of Meerwijk et al.ReferencesBaumeister, R. F. (1990). Suicide as escape from self. PsychologicalReview, 97(1), 90–113.Bruffaerts, R., Demyttenaere, K., Borges, G., Haro, J. M., Chiu, W. T.,et al. (2010). Childhood adversities as risk factors for onset andpersistence of suicidal behaviour. The British Journal of Psychi-atry, 197(1), 20–27.Lanius, R., Williamson, P. C., Densmore, M., Boksman, K., Gupta, M.A., Neufeld, R. W., et al. (2001). Neural correlates of traumaticmemories in posttraumatic stress disorder: a functional MRI inves-tigation. The American Journal of Psychiatry, 158, 1920–1922.Maltsberger, J. T. (2004). The descent into suicide. The InternationalJournal of Psychoanalysis, 85, 653–668.Mann, J. J., & Currier, D. M. (2010). Stress, genetics and epigeneticeffects on the neurobiology of suicidal behavior and depression.European Psychiatry, 25, 268–271.Meerwijk, E. L., & Weiss, S. J. (2011). Toward a unifying definition ofpsychological pain. Journal of Loss & Trauma, 16(5), 402–412.Meerwijk, E. L., Ford, J. M., & Weiss, S. J. (2012). Brain regionsassociated with psychological pain: implications for a neuralnetwork and its relationship to physical pain. Brain Imaging andBehavior [Epub ahead of print].Ochsner, K. N., Bunge, S. A., Gross, J. J., & Gabrieli, J. D. (2002).Rethinking feelings: an FMRI study of the cognitive regulation ofemotion. Journal of Cognitive Neuroscience, 14, 1215–1229.Orbach, I. (1994). Dissociation, physical pain, and suicide: a hypoth-esis. Suicide & Life-Threatening Behavior, 24(1), 68–79.Orbach, I., Mikulincer, M., Sirota, P., & Gilboa-Schechtman, E.(2003). Mental pain: a multidimensional operationalizationand definition. Suicide & Life-Threatening Behavior, 33,219–230.Reisch, T., Seifritz, E., Esposito, F., Wiest, R., Valach, L., & Michel, K.(2010). An fMRI study on mental pain and suicidal behavior.Journal of Affective Disorders, 126, 321–325.Rudd, M. D., Joiner, T. E., & Rajab, H. (2004). Treating suicidalbehavior (2nd ed.). New York: Guilford.Shneidman, E. S. (1993). Suicide as a psychache. Journal of Nervousand Mental Diseases, 181(3), 145–147.van Heeringen, K., Van den Abbeele, D., Vervaet, M., Soenen, L., &Audenaert, K. (2010). The functional neuroanatomy of mentalpain in depression. Psychiatry Research, 181, 141–144.244 Brain Imaging and Behavior (2013) 7:243–244

Brain regions associated with psychological pain

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Brain regions associated with psychological pain

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