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It's All Real. Some people who evince little or no vocal or visible reaction when they are obviously hurt say they have a high threshold for pain. Many more, who do not try to suppress their feelings, admit to having a low threshold. There is no physiological evidence of any differences in the pain sensors and therefore in the basic pain sensations in these two groups. Whatever differences there are apparently exist entirely in the emotional reactions. These also vary with cultural attitudes. The stoicism of the American Indian and the Chinese is proverbial, although ethnic variations in sensitivity have not been proved. Descendants of "old American" families make a greater effort to suppress their reactions to pain than other cultural groups, such as Italians, among whom an outcry is socially acceptable. For yet others, the "wailing wall" psychology provides a rationale: the vocal protest is supposed to ease the pain. Many a man will groan aloud to alleviate cramping pains in his belly, though he may remain silent under other kinds of pain.
The one personality trait, regardless of culture, that most consistently accompanies exaggerated sensitivity to pain, says Sternbach, is neurotic anxiety. This is not the anxiety associated with a specific situation, such as an impending operation, but the persistent, seemingly baseless anxiety that often has its roots in the unconscious. From many observations, Sternbach concludes: "The quiet, brooding, anxious and resentful individual is the one who is most likely to have symptoms of pain and is least able to tolerate them." By contrast, victims of the more crippling emotional illnesses, the psychoses, are far less likely to complain of pain.
If pain exists without letup, says Neurosurgeon Benjamin L. Crue of the City of Hope, the chances are 10 to 1 that it is neurotic or at least psychogenic. "Organic pain doesn't work that way," says Crue. "It comes and goes, with a few exceptions such as some cases of cancer. Nearly all the rest of the pain that patients call 'constant' or 'unremitting' is psychological." This is not to say that such pain is not "real." Most medical authorities now agree with Sternbach, who says: "Excluding the malingerer, who by definition is a deliberate faker, all pain is real." It does no good for a doctor to say "It's all in your mind." The important thing for the pain-relieving physician to do is to determine the source of the pain, whether in mind or body, or even in the amputee's "phantom limb," and then select the most effective treatment.