Introduction

A tenet of the psychophysiological approach is that certain disorders affect and are affected by both physiology and emotion, or the mind. Many disorders considered to be strictly physical can be either exacerbated or soothed by cognitive and emotional factors. In these cases, correcting a physical imbalance, such as with medication, is not enough; psychophysiological disorders call for psychophysiological interventions.

It is incomplete to try to alter the physiology without addressing the reason for the condition. Like the acoustic howl when a speaker is moved too close to its microphone, psychophysiological disorders often include a ‘reaction to the reaction’, which in effect traps one in the vicious circle. Thus, anxiety about heartbeat feeds back into the heartbeat, making it faster. Anxiety about breathing further disrupts the breathing. In pelvic pain, anxiety about painful intercourse can alter genital physiology and create the pain that is feared.

In studying the complicated relationship between psychological and physiological factors with regard to chronic pain, researchers have explored certain themes often over the past several decades. Psychological factors, intangible except by their correlates and consequences, may be as objective as blood factors and other physical measures, but they are considered more subjective because of how they must be measured: by self-report, interviews and observation of behaviour, which are all subject to bias. Reliability (consistency of responses over time) and validity of any structured interview or questionnaire can be assessed in the way that blood tests or structural/functional tests can be. For instance, affirmative answers to questions about childhood sexual abuse are far from objective historical data, since they depend first on accurate recall, then willingness to acknowledge and name it as such, and then to acknowledge it in the particular assessment situation. What defines ‘abuse’ differs from person to person; the term is a label for personal experience, and is subject to interpretation.

Psychophysiology in historical perspective

Any study of ‘psychophysiology’, the word itself representing an amalgam of mental and physical, must start with the historical roots of mind–body dualism. Dualism studies the nature of consciousness and its relationship to the physical body, particularly the brain, as the central issue. Dualism argues that the mind is an independently existing substance (physical dualism) or group of independent properties that emerge from (emergent dualism), but cannot be reduced to, the brain. Monism is the position that mind and body are not, by substance, properties, or by development, distinct entities. Reductive physical monism asserts that all mental states and properties will eventually be explained by scientific accounts of physiological processes and states. Most modern philosophers and scientists take a reductive physicalist monism position, asserting that the mind is not separate from the body, and that the physical brain is the fundamental reality. This position has been most influential in the sciences, particularly neurosciences and allied fields such as sociobiology, evolutionary psychology and computer science approaches to artificial intelligence.

Although scientific advances have helped to clarify some mind–body issues, they are far from being resolved. How can the subjective qualities and the essence of a state of consciousness be explained in naturalistic terms? The most recognized modern form of dualism comes from the writings of René Descartes (1641) (see Marenbon 2007), and holds that the mind is a separate mental substance. Descartes clearly identified the mind with consciousness and self-awareness, and distinguished it from the brain, which he identified with intelligence. He was the first to formulate the mind–body problem in the form that it exists today.

Paradoxically, the mind–body issue within the field of psychology became dominated by behaviourism, a form of physical monism, for much of the 20th century. Behaviourism emerged in reaction to the rising popularity of introspection. Introspective reports on one’s own mental life cannot be scrutinized by someone else for accuracy, and cannot form the basis of probabilistic predictions. Behaviourists argued that without the possibility of independent confirmation or generalization, psychological data cannot be scientific. The way out was to eliminate the idea of an internal mental life and focus instead on the objective description of observable behaviour. For the behaviourist, mental events manifest only as objective behaviours or behavioural predispositions, allowing an outside observer to predict and explain behaviour.

This type of behaviourism was ultimately dismissed as mechanistic and counterintuitive, ignoring the richness of internal experience. Cognitive-behavioural psychology arose as a direct reaction to the failure of behaviourism. This new version of behaviourism incorporated thoughts, which often triggered behaviour, and reaffirmed the value of internal experience of consciousness and self. In contrast to pure introspection, however, advances in neurosciences began to define cognitive events as both experiential and neurophysiological phenomena. Considering cognitive events as brain states meant that states of consciousness could be studied both by physical scientific methodology and by subjective, experiential methodology. This included investigation of emotional, cognitive, perceptual and motivational events. The line between physical matter and experiential matter became ever thinner with every scientific advance. The increasing success of biology in explaining mental phenomena led to the gradual acceptance of the fundamental claim that every change in mental state involves a change in brain state.

Psychophysiology studies the interaction of mental faculties with specific anatomical regions of the brain, while evolutionary biology studies the origins and development of the human nervous system. Since the 1980s, sophisticated neuroimaging procedures such as functional MRI have furnished increasing knowledge about the workings of the human brain correlated with mental experience. With the expansion of such technology, it seems inevitable that understanding of mental states will be more and more correlated with observable brain events. In clinical practice, this creates the potential to access and alter states that were not previously available. For example, altering blood flow to rhinencephalic structures (brain state) can alter the perception of pain (state of consciousness). Conversely, creating the expectation of loss of control of a situation (state of consciousness) can lead to synaptic neurochemical changes related to anxiety (brain state).

Modern psychophysiological research

Much of the current emphasis is on studying either persistent or transient emotional states together with observations of physiological changes: for instance, the effect of experimental stressors on cortisol secretion. Many studies are simply correlational, with no determination of mechanism or direction of causation. In the study of chronic pelvic pain, childhood sexual abuse emerges often as a critical factor, suggesting that having such a history confers a long-term susceptibility to chronic pelvic pain disorders. The thought style of catastrophic thinking is present more often than chance in cases of chronic pain in general. An increased tendency to avoid movement and sexual activity because of fear of pain is another factor contributing to further disability. Chronic depression and anxiety also correlate with chronic pain.

A central question addressed in psychophysiological research is how emotional, behavioural and cognitive characteristics are related to pelvic floor and lower-abdomen susceptibility to pain. Are there observable malfunctions in visceral tonus, in pelvic circulation, or in muscle function and baseline levels? Or do pain thresholds simply fluctuate according to mental and emotional conditions, without objective physiological differences? This simple question has stimulated much investigation.

Psychophysiological research occupies an area on a continuum which can be described with reference to an analogy: hypothetical aliens observing people driving cars but having no knowledge of how such a process could work. From a distance they might – like the Incas first mistaking Spaniards on horseback for Centaur-like beings – perceive the car–driver combination as a single organism. After further observation, one group of aliens might focus on the workings of the automobile, and they would study the steering linkage and the engine’s coupling to the drive train. Another group might study the details of the driver’s arms and hands, and the brain that animated them. Another school of thought might take interest in how the driver decides where to drive, and how fast, and even why. A fourth group might study the ‘behaviour’ of the automobile, how fast, how far, and where it goes, with little concern about how it gets there.

More relevant to clinical concerns, suppose a particular automobile keeps veering out of its lane and hitting the curb. Where should one look for the malfunction? The driver’s intent, the driver’s sensory system, the driver’s muscles and limbs, the steering system, or an uneven road? To the aliens, it might seem that all possibilities should be considered. In this analogy there are several possible levels of analysis, all legitimate, for addressing the fact that people drive cars. Without the existence of both cars and drivers, however, the phenomenon would disappear, so declaring one level of analysis as more objective or closer to the truth seems fanciful.

Psychophysiology’s domain is the entire region between the driver’s mind and the car’s behaviour. An example of a ‘psychophysiological’ disorder in terms of this analogy might be rapid wear of the brake linings, requiring frequent replacement. A mechanic could examine all the component parts for malfunction, but the ultimate reason might be that the driver, fearful of collision, simply rides the brake excessively. Where, in this case, is the fault?

The psychophysiological approach is complex, requires more complete knowledge of a given disorder and organ system, and may not appeal to extremists at either end of the spectrum, but it can provide a comprehensive understanding of any disorder that has both somatic and emotional aspects. This understanding will increase the options for clinical treatment.

The origin and maintenance of medically unexplained chronic pelvic pain appears to be multidetermined and intertwined with psychological factors. Two reviews of the subject reached similar conclusions:

A wide variety of provocative events can lead to localized acute tissue reactions with resulting nociceptive pain. This acute pain most often resolves on resolution of the provocative factors. In the presence of organic and psychological predisposition this pain may become chronic pain with the addition of neuropathic elements to the nociceptive factors. With urogenital pain, psychological, sexual and functional states are adversely affected adding a psychophysiological element to the chronic pain. Figure 4.1 depicts some potential relationships among biological and psychological factors in chronic pelvic pain.

Figure 4.1 • Idiopathic lower urogenital tract disorders model

What follows is a summary of representative research findings in support of the generalizations above, along with some speculations and assumptions guiding both research and treatment.

Prostate and pelvic pain

One recent study (Ullrich et al. 2007) of benign prostate hyperplasia (BPH) implicated the hypothalamic-pituitary-adrenal (HPA) axis and sympathetic nervous system reactivity in prostate enlargement. Eighty-three men with BPH underwent an experimental stress task (public speaking, videotaped). The degree of stress was defined physiologically as rises in cortisol and blood pressure. Personal appraisal of the situation was not assessed. Subjects showing stronger stress responses were found to have larger prostate volume and more objective and subjective indications of urinary tract dysfunction. Among the hypotheses for this relationship were decreased apoptosis (slowed prostatic cell death) as a result of chronically greater sympathetic input; increased pelvic floor muscle tension; greater prostate contractility (stimulated by exogenous epinephrine and norepinephrine); and stress-induced hyperinsulinaemia promoting prostate growth. Not all BPH cases involve pain, but when pain is present it can stimulate the sympathetic system, create a feedback loop, and add to the problem.

Anderson et al. (2005, 2008, 2009) compared men with chronic pelvic pain syndrome (CPPS) with asymptomatic controls for evidence of differences in stress levels. Various psychological tests revealed more perceived stress and anxiety in the CPPS patients, plus more somatization, hostility, interpersonal sensitivity and paranoid ideation. Salivary cortisol on awakening was also measured and found to be significantly higher in the pain patients. This rise in cortisol is thought to indicate the hippocampus preparing the HPA axis for anticipated stress. Cortisol has been found to be higher in situations such as waking on the day of a dance competition (Rohleder et al. 2007), in high-school teachers reporting higher job strain (Steptoe et al. 2000), and waking on work days compared with weekends (Schlotz et al. 2004).

Anderson and Wise have advanced an explanation of chronic, otherwise unexplained pelvic pain as frequently stemming from myofascial trigger points (Wise & Anderson 2008) (see Chapter 16). In their view, much long-term pelvic pain develops from the shortening and tensing of pelvic muscles, eventually creating and then aggravating trigger points, and this condition can be treated with manual release techniques. The more complete treatment, however, involves cultivating a skill for dropping into deep relaxation along with changing attention (‘paradoxical relaxation’) in a way that contradicts the usual tensing and bracing against pain. This is achieved (in their programme) by progressively more muscular and emotional self-calming.

Trigger points were shown to be exacerbated by stressful emotion (Hubbard & Berkoff 1993, McNulty et al. 1994). EMG was recorded from an upper trapezius trigger point along with a signal from an adjacent area of the muscle without a trigger point. As emotional stress increased, the trigger point EMG increased its voltage even though the rest of the muscle did not. Also, described in Chen et al. (1998) was a demonstration of how electrical activity associated with trigger points in rabbits was abolished by phentolamine, a sympathetic antagonist. This supports the role of the autonomic nervous system in maintaining trigger points, and also is congruent with the cited research on the aggravating effect of negative emotion (anxiety) on trigger points (Simons 2004). Wise and Anderson’s protocol for pelvic pain treatment includes both thorough relaxation training and manual release of trigger points. One is temporarily curative, the other preventive.

Alexithymia and pelvic pain

The word ‘alexithymia’ refers to a relative inability to name feelings, or to verbally elaborate on feeling states. Its Greek roots belie its recent creation, less than 40 years ago, by psychiatrist Peter Sifneos (1973). The phenomenon and the concept existed long before its final naming. Physicians and psychotherapists had noted for many years the tendency of some patients to use very few words to describe their feelings; complex emotional states were reduced to simple terms such as ‘feeling bad’ or ‘upset’ without elaboration. This difficulty with feelings includes reflecting on them, naming them, discussing them and expressing them.

Alexithymia seems to be a trait rather than a state, an enduring and stable aspect of behaviour seen by many as a disability. It is the opposite of the concepts ‘emotional intelligence’ and being ‘psychologically minded’. Alexithymics tend toward concrete thinking and restricted imagination. Knowing when their physical sensations and symptoms are emotionally based (rapid heart beat, changes in face temperature, agitated breathing) is not easy for the alexithymic person.

Researchers have pursued correlations between high scores on alexithymia scales such as the Toronto Alexithymia Scale (Bagby et al. 2006) and other problems such as dissociation, Asperger’s, autism, substance abuse, anorexia nervosa, somatic amplification and somatoform disorders. A functional disconnection between the two cerebral hemispheres or a right hemisphere deficit has been suggested, with incomplete evidence (Tabibnia & Zaidel 2005).

Most research on chronic pain and alexithymia has found a correlation between them. Celikel and Saatcioglu (2006) found that female chronic pain patients scored more than twice as high on alexithymia scales as controls, and there was also a positive correlation between alexithymia scores and duration of pain. Since the study design was not intended to distinguish direction of causation, it is conceivable that prolonged pain damages the right hemisphere, interfering with full experiencing and transfer of emotional material.

Porcelli et al. (1999) found a strong association between alexithymia and functional gastrointestinal disorders (66% had high alexithymia scores, whereas the population average is below 10%), and later (Porcelli et al. 2003) demonstrated that higher alexithymia scores predicted worse treatment outcome. Although anxiety and depression also predicted worse treatment outcome, the alexithymia scores were stable and independent of anxiety and depression, suggesting a unique contribution to failure to improve.

Hosoi et al. (2010) studied 129 patients with chronic pain from muscular dystrophy. Degree of alexithymia was significantly associated with higher pain intensity and more pain interference. Finally, Lumley et al. (1997) compared chronic pain patients to patients seeking treatment for obesity and nicotine dependence, to control for the variable of ‘treatment-seeking’. As predicted, the chronic pain patients scored higher on the alexithymia measures than either of the other groups. They also had higher levels of psychopathology, which can by itself confound and weaken treatment programmes for chronic pain.

There are few theories as to how alexithymia specifically contributes to chronic pelvic pain states; however, the value of patients both naming and differentiating feeling states at the conscious verbal level is emphasized. A person who routinely does this is likely to consider the material objectively, to process, express, and otherwise deal with material that is commonly relegated to the ‘unconscious’ domain. This effective processing of feelings has vast potential influence on automatic (autonomic) functioning by differentiating true physical threat from the much more common triggers for social anxiety or symbolic threats. Local pelvic circulation, adjustments in pelvic floor muscle tension, and changes in breathing are subject to the flux of emotions until they are released from functional service. Strong negative emotions associated with traumatic memories, apprehension, sexual conflict and accidents of elimination can influence the complex structures and functions of the pelvic region.

Processing of emotional experience often involves revisiting traumatic or otherwise disturbing memories, which can be done alone or with the help of a friend, relative or therapist. Psychologist James Pennebaker has led the way in a body of research that repeatedly confirms the value of simply writing about undisclosed experiences and the deep feelings that have been kept private (Berry & Pennebaker 1993; Pennebaker 1997). This process of transforming inchoate memories and feelings into a linear, word-based account of an experience seems to be a key step in ‘adjusting’ to something unpleasant. Part of the value of psychotherapy lies in providing a safe forum for verbalizing one’s feelings about something for the first time, and this activity has therapeutic value regardless of response from another person.

This self-adjusting activity, however, is precisely what the individuals describable as ‘alexithymic’ are not good at. Their poverty of verbal labels for body sensations related to emotional states is their defining characteristic, and may block necessary processing of experiences in real time. Emotional adjustment and acceptance benefit from review, reflection, hindsight, considering contextual factors, and if possible, ‘normalization’ by an accepting and supportive listener. Pennebaker (2004) has concluded that undisclosed disturbing experiences cause persistent conflict, partly over-suppressing them; the topic stimulates ruminative worry, and this eventually has ill-health effects. Graham et al. (2008) showed that in a large group of chronic pain patients, writing about their anger constructively resulted in better control over both pain and depression, compared with another chronic pain group asked to write about their goals. Junghaenel et al. (2008) also studied the effects of written self-disclosure on chronic pain patients, and found that only those with ‘interpersonally distressed’ characteristics (denoting deficient social support, feeling left alone, etc.) benefited from the expressing of emotional events.

The role of a listener is apparently optional; Pennebaker’s research protocol, extended and repeated by many other researchers over the past 20 years, does not include feedback from another person, but studies only the actual expression, whether through writing, speaking into a tape recorder, or even using sign language or dance. Expression may represent a transfer of affective material from the relatively mute minor (usually right) cerebral hemisphere to the major, speech-dominant hemisphere. The full powers of judgement, rational perspective and philosophical acceptance depend primarily on the major hemisphere, which is dominated by words. So the alexithymic person is at a disadvantage for this process. As a result, strong emotional experiences may remain unprocessed and unexamined. The physiological aspects of this condition may continue to reverberate, causing inappropriate responses to emotion provoking stimuli and situations.