Psychogenic Pain and Aggression: The Syndrome of the Solitary Hunter

DAVID C. TINLING, M.D., and ROBERT F. KLEIN, M.D.*

Fourteen men with intractable psychogenic pain shared a cluster of characteristics: (1) psychogenic pain, (2) solitary hunting, (3) problems with aggression, and (4) depression. All except one showed, in addition, one or more of the following: a marked interest in driving or "hot rods;" accident-prone behavior; and problems with work, school, and success. The pain is discussed in relationship to aggression. Some recommendations about treatment are made. RECENTLY, we have seen several men with intractable psychogenic pain and a penchant for solitary hunting. They share several other characteristics. Engel first noted that pain-prone men often are preoccupied with hunting.1 He did not elaborate on this observation; most of his reported patients have been masochistic women who atone for guilt feelings by suffering pain. 1 ' 2 When the authors saw the patient whose case is discussed in detail below, Engel recalled his prior observation and indicated that he had
From the Departments of Psychiatry and Medicine, University of Rochester Medical Center, Rochester N. Y. Supported in part by grants from the U. S. Public Health Service (MH 7521-01) and the Ford Foundation. We wish to acknowledge the invaluable advice and encouragement of Dr. George Engel in the preparation of this manuscript. We also feel indebted for the help of other members of the Medical-Psychiatric Liaison Service and the Department of Psychiatry of the University of Rochester. Received for publication Oct. 22, 1965. "Present address: Department of Medicine, Duke University Medica Center, Durham, N. C.

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continued to see men with psychogenic pain and an intense interest in hunting. We decided to pursue the matter to see how common the problem was and to define its exact nature. Subjects After the initial patient had been seen at Strong Memorial Hospital, 2 more were seen there, 1 was seen at Duke Medical Center, and 10 were seen at an Army hospital in West Germany. Most patients were referred from the medical service where the patients were diagnostic enigmas. At the Army hospital there were 17 referrals for evaluation of psychogenic pain, and 10 of them shared the features of this syndrome. Excluding a 52-year-old man, the age range was from 19 to 38, and the mean and median ages were 28. One was single, and the remainder were married; 3 of the latter had married twice, and 1 had married 3 times. All were Caucasian, of lowerclass or low-middle-class origins, and had spent considerable time as children

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backaches; 2, of abdominal pain; and 1, of leg pains. Seven complained of pain in 2 or more areas of the body, and 1 said he "hurt all over." Five had experienced the pain for a period of 1 month to a year. Nine had had the pain for over a year; of these, 1 had the same pain for 3 years, 1 for 7 years, and 1 for 17 years. They had seen many doctors and had not benefited from various treatments. Doctors were angered and frustrated by these patients. Psychology of the Pain-Prone Individual Engel1 said that pain-prone individuals usually show some or all of the following features. 1. A prominence of conscious and unconcious guilt, with pain serving as a relatively satisfactory means of atonement 2. A background that tends to predispose to the use of pain for such purposes 3. A history of suffering and defeat and intolerance of success (masochistic character structure); and a propensity to solicit pain, as evidenced by the large numbers of painful injuries, operations, and treatments 4. A strong aggressive drive which is not fulfilled, pain being experienced instead 5. Development of pain as a replacement for a loss at times when a relationship is threatened or lost 6. A tendency toward a sadomasochistic type of sexual development, with some episodes of pain occurring in settings of conflict over sexual impulses. 7. A location of pain determined by unconscious identification with a love object, the pain being either one suffered by the patient himself when in some conflict with the object or a pain suffered by the object, in fact or in the patient's fantasy 8. Psychiatric diagnoses including

or adolescents in rural settings. Ten men were seen several times. Four men were seen once. In some cases, family members were interviewed. An openended interview technique was used. All of the 14 men had the following in common: (1) intractable pain unexplained by organic processes, but with evidence of psychogenic pain; (2) a penchant for solitary hunting; (3) conflicts over the expression of aggression; and (4) depression. Except for 1 man, all showed one or more of the following: (1) a fascination with driving and "hot rods"; (2) accident proneness; (3) unrealistic ambitions and problems with success and work. It is meaningful to discuss these men in more detail, in relation to Engel's model of the pain-prone patient,1 in order to indicate the criteria used to support a diagnosis of psychogenic pain, as well as the features distinguishing these men from the model and justifying the description of a new syndrome. The Fain Engel indicated the importance of the patient's description of pain.1 The painprone patient often describes his pain in a highly individualistic way which has little relationship to commonly understood peripheral pain patterns. This was true in all our patients. The descriptions were elaborate and personalized and did not resemble standard patterns of organic illness. Rather, there seemed to be considerable psychological meaning in such descriptions. There was a frequent analogy to violence. One patient said, "My head feels like someone is hitting me with a hammer." Another patient said of his abdominal pain, "It's as if someone were sticking a knife in and pulling it out." These descriptions made sense only after we understood the psychological factors involved. Nine complained of headaches: 2, of
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conversion hysteria, depression, hypochrondriasis, and paranoid schizophrenia, or combinations of these, although some patients with pain do not fit into any distinct nosologic category. We analyzed the case histories of our patients in terms of the above features, and our findings were as follows. Guilt Guilt was closely linked to problems with aggression in these men. Many expressed a variety of guilt feelings over loss of control of aggressive impulses. Some expressed a strong need to control their feelings because they feared what they would do otherwise. Background In 11 patients, sufficient data were obtained about the parents to make certain judgments about them. In only 1 case did the patient report a satisfactory relationship between his parents and a positive feeling for both of them. It is noteworthy that in 8 cases the mother was dominant and the father was unable to stand up to her. Patients described such mothers as castigating and openly contemptuous of men. In 2 cases the fathers were dominant and brutal men who had given the patients savage beatings. Our data are consistent with Engel's observation that aggression, suffering, and pain played an important role in early family relationships. Masochism We did not find evidence for a masochistic character structure as Engel observed in his female patients, nor did we discover a tendency to solicit painful experiences through operations. Nevertheless, we did observe accident-prone behavior. In 8 patients, an inquiry into accidents and injuries was made; 7 seemed to have an inordinate number

PAIN AND AGGRESSION

of accidents. One man had been shot while hunting. Several had been involved in severe car accidents. One, overcome with grief, had lacerated all the flexor tendons and major nerves and arteries in his hand when he thrust it through a window. Aggression Engel noted that guilt could be provoked by intense aggressive feelings in such patients and that some would find any expression of aggression unacceptable, while others would feel remorse after it had been expressed. AH our patients had major problems in coping with aggressive impulses. In 7 this finding was inferred from an excessively controlled and obsequious manner coupled with expressions concerning fear of loss of control. One patient who was very subdued and retiring recalled how his father had been sent to prison after going berserk, trying to kill the family and police. As a boy, the patient had frequently been knocked unconscious by his father. He always avoided fights. Tho controlled and obsequious patients preferred to walk away when they were angry. The other 7 men admitted to frequent fightine and some episodes in which thev were literally murderous. One said his temper was so bad he hadn't worked in years. He had lost numerous jobs after explosive arguments and fights with supervisors. Another had murderous dreams and feared he would kill someone. Another threatened to dynamite his landlord's house and shoot a man who had hit him. One patient had only two fights in his life, but constantly feared losing control of his temper. The first time he fought his brutal father as a teenager and then ran away from home. The second time, he said, "I almost killed a man with one punch." The relationship between severity of
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Location of Pain As did Engel, we found the location of the pain was pertinent to the history of past painful illnesses of the patient or of important love objects. In only 3 men were we unable to find evidence of such prior pain patterns. Six patients described past painful injuries or illnesses which they had suffered where the pain resembled the current pain. Five described painful illnesses similar to theirs in important family figures. The most dramatic example was a 29-year-old man who complained of neck pain and headaches. His father had died of a head injury and his mother of a stroke. One brother had died of a head injury and another had drowned. Psychiatric Diagnosis Engel noted that patients with a variety of psychiatric diagnoses have psychogenie pain and that some patients do not fit into any distinct nosologic category. Our patients seemed to belong to the latter ill-defined group. In a broad sense they could be considered to have character disorders with problems of impulse control and conversion symptoms, but it seems impossible (and undesirable) to pigeonhole them in one nosological group which might obscure the traits which seem most important and relevant to their problems. Special Characteristics of the Syndrome It is apparent from Engel's model that there is considerable positive psychological evidence in these men to support the view that the pain was psychogenic. There are some differences that have been noted between his patients and ours, particularly in terms of sex (most of his patients were women) and sadomasochistic traits. There are also special features demonstrated by our patients

pain and aggressive feelings was inconsistent. Some men felt that if they became angry, the pain became worse; others said that angry feelings sometimes were associated with more severe pain, but not always; and some noticed no relationship between feelings and pain. Generally, it seemed to vary from man to man and from day to day with each man. Object Loss and Onset of Pain In all but 2 cases the men referred to stressful life events at the time the pain developed. In each, the stress seemed to involve an actual or threatened object loss which mobilized feelings of helplessness, One man began to have headaches soon after his older brother had a head injury. The brother had been like a father to him, and when the brother later was killed, the headaches became worse. Another man began having abdominal pain when his wife had surgery and he feared she would die. Another man began to have pain after both parents had died a few months apart. Separation from family or home was frequently perceived as stressful and often preceded the painful illness. This was particularly true of the group of soldiers in Germany. In the 2 men who could not recall the life events around the onset of pain, the length of time seemed to be significant. One could only say that he had life-long headaches, and the other complained of backaches and headaches since adolescence, which had been a very stormy period for him. Sadomasochistic Sexual Development We did not observe a sadomasochistic sexual development or pain episodes at times of conflict over sexual feelings, as described by Engel. There was no evidence of sadomasochistic sexual perversion in any of the men.
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which seem highly pertinent to their problems with pain. Solitary Hunting All the men were intensely interested in hunting and pursued it by themselves. Some felt that hunting meant as much to them as anything else in life. They claimed to be excellent shots and it was typical to hear, "I always get my deer," or "1 never miss." Four were bow-andarrow enthusiasts. Only 2 men indicated pleasure in killing. Both were violent men, deluged with murderous impulses. The other 12, when asked what their feelings were about killing animals, either expressed no feelings or justified the killings in terms of man's place in Nature. The need for solitude was present in every man. Each pointed to the dangers of irresponsible hunting companions. All enjoyed camping for days on end in the woods, and frequently spoke in broad, general terms of their love for Nature. One man said, "I like to be by myself with my dog." Another said, "I love to get on a horse and ride off out in the woods by myself." Depression All expressed a range of depressive affects varying from feeling helpless to cope with pain or aggression to feelings of loss and grief after deaths and separations. As was noted before, the events which led to such feelings were important in the genesis of the painful illness. We were struck by the clinical depression demonstrated by these men. The nature of our sample, however, may have tended to emphasize depression, since we normally saw men after they had become discouraged about the possible benefits of medical care; moreover, it must be remembered that 10 of the 14 men were in Europe and very unhappy about being away from home. Interest in Driving

PAIN AND AGGRESSION

Of 8 men queried as to their driving habits, 3 were avidly interested in hot rods and had raced cars. Auto racing was on a par with solitary hunting as a recreational interest to them. Three others expressed an intense fondness for driving and indicated that driving helped them relax. One man who felt an intense need to get away from unpleasant situations, especially when he was angry, found that driving only made his back, neck, and head pain worse. Another man became very anxious when driving in traffic. Problems with Work, School, and Success Only 3 patients expressed and demonstrated satisfaction in their work. One was a hard-working mechanic, who loved working with automobiles. Two were career soldiers who were fond of the army, but who at times had severe troubles with the authoritarian aspects of the military system. The other 11 men had problems which had begun in school. Many had had physical fights with teachers, and most had dropped out of school. Often they lost jobs because they could not get along with peers or supervisors. They wanted people to leave them alone and liked work where they were on their own. One man had not worked for 8 years because of poor control of his temper. Another man had worked for several years by himself in the woods, accepting any odd jobs he could find. Three soldiers were separated from the army for, among other things, failure to adapt to the military, and 2 were considered for such action. In 4 of the men, there was an inordinate striving and unrealistic ambition. One patient, a career soldier who quit racing because of a phobic fear of it which developed after a wreck, said his
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Case Report The following case is presented in some detail to highlight the features of the syndrome described above.

main ambition was to become the best stock-car driver in America. Another spoke of his intention to build a perpetual-motion machine, something he had been working on for several years. The detailed case history below will amplify this point.

A 30-year-old electronics technician, married and the father of 5, complained of progressively severe generalized headaches of 6 months' duration. He described the Course of the Illness pain as constant, dull, and throbbing, These men have significant problems located at the occiput and vertex regions, with pain and aggression, and in the with an occasional sharp component in the long run they may do very poorly. Prior frontal region bilaterally. He likened the to "having a skull cap on which to being ill, they had been mobile, ac- sensation was constricting." The pain was most severe tive, and ambitious. If one had seen in the midafternoon and evening. When it them at such a time of relative health, was most intense, he also noted blurring of they might have seemed masculine and peripheral and distant vision, and a sense robust. Seven of the 14 patients settled of losing balance when upright. into a pattern of being depressed and The headaches began while the patient dependent. One man had not worked for was working in California in May ] 962. He had seen two general physicians; the first 8 years. His wife worked at a job, and he did the housework at home. Four diagnosed "nerves," and the second referred him to a neurosurgeon. He was then rewere young soldiers who gave up and ferred to a psychiatric facility, which advised had to be separated from the army. They him to enter a general hospital for further were depressed and unable to perform tests to rule out brain tumor. Unable to their duties. Four others seemed to be afford the hospitalization, he returned to his on the verge of giving up their more home in New York in November 1962. His masculine pursuits, and "succumbing" wife agreed that he had been irritable, withdrawn, and intolerant of his children to the pain. One young man with abdom- during the present illness. inal pain, who had an excellent record as The patient and his wife stressed the a soldier, feared he would end up just magnitude of his disability from the headlike his father, who hadn't worked for 15 aches. He had lost two jobs and had to sell years because of similar abdominal pain. their property, household furnishings, and Another man felt utterly helpless to automobile. He stated, "It wiped out 12 handle a number of serious realistic years of progress." Six months after the problems, and finally he "hurt all over" onset of his headaches, he and his family and had to be hospitalized. When others were receiving welfare support. He was admitted to the hospital to conwere able to assist him and he could see some possible solutions to his problems, sider further the possibility of brain tumor, although there were no confirmatory physhe was able to make significant efforts ical findings. A neurological consultant sugat coping with them. Two men seemed gested neurotic and muscle-tension headable to continue at work as aggressive, aches. A lumbar puncture, radioactive mermasculine characters. Only 1 man ap- cury brain scan, and skull X-rays were all peared able to live with his pain and within normal limits. On interview, the carry on in his usual style. This man patient appeared to be a young, handsome man, with a black patch over his left eye. had lost his older brother, and as the He was glib and ingratiating, taking care oldest male in the family, he felt he had not to express anger. He repeatedly emphato carry on for his brother. sized how his illness could be mental inVOL. XXVIII, NO. 5, 1966

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stead of physical, since he had been under considerable "nervous strain" in California when the illness began. He explained his eye patch by saying that at age 15, while on a hunting trip with a 14-year-old friend, a shotgun lying against a log accidentally discharged and severely damaged the patient's left eye. Enucleation was required, followed later by an insertion of a prosthesis. The prosthesis caused the development of an orbital cyst which was associated with headaches for a period in 1960. These headaches were much like the present ones and had ceased upon drainage of the cyst. He had also suffered intermittent backaches and episodes of brief chest pain, neither of which led him to seek medical attention. On two occasions in the past, he had experienced transient fugues, walking around in a daze, saying "mean things" to his wife and unaware of his identity or actions. He was the first child of native New York parents, with sisters 2 and 5 years younger, and a brother 7 years younger. His father was described as "a wonderful, generous man with a sense of humor." While the father's main occupation was that of mailman, he had always yearned to be an inventor or independent in business. His one nearly patented idea was stolen from him by a co-worker. The patient's relationship with his father was close, and he grieved following the father's death in 1956. The father had a heart attack, with chest pain as the predominant symptom. The mother of the patient was described as a "hypochondriac," a woman with a violent temper, who was demanding and argumentative, and could not be pleased. She derided her husband and sons as inadequate but often declared to the patient, "You will never be half the man your father was." She dominated the household and held back her husband's plans and business ventures. She meted out physical punishment frequently. The patient traced his own short temper to the influence of his mother. He described frequent childhood fighting with peers and a tendency, as an adult, to fight quickly when offended. He was active in school sports but preferred hunting most of all, deriving particular pleasure from solitary hunting. At 17 he began working as an apprentice plumber, then spent 1 year in

PAIN AND AGGRESSION

electronics-technician training, acquiring a diploma. He married at 19 to a woman his own age who had been an orphan since early childhood. He described her as energetic, attractive, and "wonderful to put up with me." His wife related that the patient never seemed able to escape from his mother's attempts to plan his life. She commented that "he was always trying to prove liis manhood by having intercourse nightly and occasionally attempting to see how many times nightly he could." During their early years of marriage, he was unfaithful to her on two occasions. His employment history was erratic. He had discovered that in his work for engineering firms he could ascend quickly from technician's to engineer's tasks. He was paid accordingly, but found upon changing jobs that he had to start as a technician. While successful at this, he felt unsatisfied and tried 4 times "to get into business for myself." A frequent pattern was for him to supply an idea to go with someone else's capital. One plan was to form a group of "professional. handy men" to contract for work in private homes. All the attempts failed within a few months. He remained active and stressed his constant thinking of new ideas. "I've got five patentable ideas" was a proud expression. He continued to hunt frequently and remarked that "even the eye injury didn't stop me." After two business ventures failed, he decided to move with his wife and 5 children to California to resume electronics employment. For the first time he was significantly separated from his mother. He obtained work there in a firm which did applied research in electronics equipment, and soon he was again performing the work of and being paid as an engineer. Together with a fellow employee, he developed a circuit device which could be patented and promised considerable success and stature to the discoverers. While working long hours on this project, he began to notice easy fatigue and intense anxiety when driving in the heavy traffic to and from work. He feared he would collide with someone at high speed and consequently avoided the freeways. While at work in the afternoon, he began to notice headaches, which greatly impaired his work performance. At the firstphysician's suggestion, he took 2 weeks'
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havioral traits shared by such men is striking. This mutuality has led us to view the composite picture as a clinical syndrome. It is particularly meaningful to consider the relationships between psychogenie pain, aggression, hunting, and the need for solitude. Our data indicate that the patients have had enormous problems as children and adolescents. The poverty of adequate'object relations and suitable male figures is striking. Somewhere in their development, seemingly in adolescence, they turn away from people to things. As Searles has discussed concerning the schizophrenic, the nonhuman environment takes on an exaggerated significance.3 The keen interest in driving and hot rods demonstrated by some of the men is an example. They seemed to borrow strength from their cars, a kind of strength that had been notably absent in their fathers. All the men found a pleasure in being alone, particularly alone in the woods. They felt a kinship with Nature and animals, a kind of warmth that seemed lacking in their human relations. It is here that the hunting and aggression seem to overlap. All the men had difficulties controlling their aggressive impulses, but in the woods they could be murderous. Solitary hunting allowed them to be murderous without fear of killing someone else or of being injured themselves. There was something counterphobic about the way they sought animals, the woods, or even cars. They seemed to desire the danger and excitement, but they did not want other humans involved. They felt a tremendous relief when in the woods, and it appeared that both the solitude and the freedom to express aggression were important. The pain must be viewed in terms of the behavioral traits. It seems reasonable to speculate that these men are more pain-prone than others because of

vacation, but the headaches persisted and he stopped his research job altogether. It was then that he sought further medical help described in the present illness. After the onset of headaches, he became irritable and sulky, and complained of the unfriendly atmosphere for himself and his family in their neighborhood. He became furious at a neighbor who was racing a go-cart in front of the patient's home, and threatened to shoot the man with a pistol. This near-loss of control was the event which led to the patient's returning with his family to New York to live in his mother's house, In the hospital he was completely free of headaches for several days following a lumbar puncture. He related later that his explanation for the headaches was that the orbital cyst had returned and fluid had spread to inside his head. The sensory symptoms were variable, as demonstrated by changes following procedures, examinations, and interviews. There was no sign of an orbital cyst. When informed of the diagnosis of psychogenic headache, the patient declined psychiatric therapy, feeling that he would work out a solution by regaining employment. During a 6-months follow-up, the headaches continued, but he was less concerned. His wife described him as passive and timid about job seeking, suddenly preoccupied with religion, jealous, and clinging to her. In interviews he reported feeling sad, beaten, and uncertain of his capabilities. He regretted the latter most of all, since his resourcefulness had been his pride. He felt guilty over his dependence upon his mother and angry that he couldn't please her. He said, "I keep trying, hoping some day to get a pat on the head." Discussion This study has pursued a clinical observation by Engel relating, psychogenic pain in men to an interest in solitary hunting. It is apparent that this relationship is not uncommon, especially when cases from a predominantly rural population are seen. The number of beVOL. XXVIII, NO. 5, 1966

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certain behavioral characteristics. The problems with aggression are most germane, especially as they evolved over the years. The explosive familial problems, the chronic concern over loss of control, and the need to assert one's masculinity vigorously, all highlight the special significance of aggression. The guilt that followed either actual or fantasied aggressive acts seems relevant to the genesis of pain. Engel's model of psychogenic pain as a conversion symptom seems to apply in most of our men. The hunting could be considered a defense against murderous wishes, and when such wishes cannot be dealt with appropriately, guilt may supervene, with the need to atone through suffering. Pain is readily available in these men as a suitable symptom. First, pain is such a natural consequence of an aggressive act that it seems highly appropriate for these men to turn it on themselves. Second, they seem prone to accidents and, therefore, can serve as models for their own painful experiences, to say nothing of the self-punishment inherent in accident-prone behavior. It is interesting to note that reports of accident-prone individuals and hot rodders indicate that they are similar to our patients.4-5 Third, pain has been very important in terms of their early object relations, be it in terms of fights with father or peers, or painful illnesses suffered by loved ones. These are fragile men who nose as hypermasculine characters and who often vastly overestimate their own potential. When they fail, they fall hard. The defeated picture of some of these men is as if they had been stripped of all their hypermasculine, counterphobic traits and the helpless little boy within revealed to the world. It is interesting that such a crisis seems to evolve at times of stress when they are threatened with loss, or when separation or loss may be coupled

PAIN AND AGGRESSION

with increased responsibility. For all their "manliness," they have considerable difficulty with responsibility. Giving up and giving in to the pain allows for considerable secondary gain, for the patient can rationalize his defeat as logical and necessary, because of the pain, and he can treat the pain as something foreign and outside him, over which he has little or no control or responsibility. Treatment Treatment is very difficult. This can be seen by the frequent outcome of depression and regression, in which the patient becomes a shell of a man, the opposite of his former aggressive self. By the time we saw the men, they had usually seen many doctors, with little satisfaction. Such individuals seem to have difficulty entering into the doctorpatient relationship, and they seem to provoke rejection on the part of the physician. We have been able to establish a general approach to treatment which may be helpful. The single most important aspect of treatment is the attitude of the physician. He must believe with the patient that the pain is real. Any indication that the pain is "imaginary" only humiliates the patient, in a way making him appear to be a liar, and treatment may then be impossible. A positive approach which respects the patient's symptoms and an agreement to be his doctor are fundamental. It also seems wise to avoid hasty referrals, especially to psychiatrists, for these will be seen as rejections, and the patients are not likely to want psychiatric help. (A typical patient's response is to say, "How can it all be in my head when I hurt here?") There may be a time when formal psychotherapy is indicated; however, in such instances the physician should make it clear that he will conPSYCHOSOMATIC MEDICINE

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perspective. The patient can be told that the doctor will be his doctor throughout the illness, and that the patient can expect to have some good days and some bad days. Sometimes, when the patients are deeply depressed and agitated and have considerable pain, it has been helpful to hospitalize them for a few days. The rest, the removal from certain life stresses, and the sedation help. This gives one time to investigate factors in the patient's life at home or at work which could be manipulated or altered in a positive way. Hospitalization may also be vitally needed by a patient who feels helpless and unable to cope with his pain.
Summary

(inue as the doctor and work with the psychiatrist to help the patient. If the patient is able to discuss life problems in a meaningful way, and if he relates his pain or other symptoms to problems he is having, it may be the right time to approach, cautiously, the question of seeing a psychiatrist. (Many of the men we saw equated seeing a psychiatrist with being crazy.) These patients are often "dumped" onto new doctors or other clinics, and as they move from clinic to clinic and doctor to doctor, they become more distrustful of physicians and consequently more difficult to treat. Another problem area is that of medication. Often the patient has taken many pain relievers, including at times, narcotics. On first seeing such a patient, the physician may be tempted to prescribe his favorite analgesic, but it is probable that it will not help much and that the patient has taken it before with little or no benefit. It is often helpful to review with the patient his medication history. Usually, he has a medicine chest at home full of pills, none of which have helped. The doctor can then point out that since medicines have not done much good, perhaps they are not the answer. Usually the patient will agree. It is helpful to let him know that if the pain is ever absolutely unbearable, he may have medicine. At such a time sedation coupled with analgesics may bring relief. If there is much chronic anxiety, one could prescribe small doses of phenobarbital or a tranquilizer. Never promise, however, to cure the pain. It seems helpful to point out to the patient that some people have pain just as some people have arthritis or rheumatism, and that just as arthritis will wax and wane, so will the pain. If a patient can understand that a doctor does not cure arthritis and does not cure pain, he may be able to see his illness in a better
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A syndrome of intractable psychogenie pain has been presented: the syndrome of the solitary hunter. Fourteen cases are reviewed in terms of these salient features: (1) psychogenic pain, (2) solitary hunting, (3) problems with aggression, and (4) depression. In addition, many of the patients had a marked interest in driving or in "hot rods," many seemed accident-prone, and most had a number of problems with school and work. Almost all came from disturbed homes, usually where the mother was dominant and belittled men, but 2 had brutal fathers. The problem can be serious, and many patients became depressed and dependent, quitting work and settling into a chronic defeated state. Treatment is therefore complicated. Some suggestions are made regarding treatment. It is hoped that analysis of this syndrome will contribute to our understanding of the problem of psychogenic pain.
Department of Psychiatry Strong Memorial Hospit.nl Rochester, N. Y. 14620

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References 1. ENGEL, G. L. Psychogenic pain and the pain-prone patient. Amer J Med 26:399, 1959. 2. ENGEL, G. L. Primary atypical facia] neuralgia an hysterical conversion symptom. Psychosom Med 13:375, 1951.

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SEAHLES, H. F. The Nonhuman Environment. Internat. Univ. Press, New York, 1960.
NEAULES, J. C, and WONOKUR, G. The

hot rod driver. Bull Menninger Clin 21: 28, 1957. LESHAN, L. L. Dynamics in accidentprone behavior. Psychiatry 15:73, 1952.

Seventh International Congress of Psychotherapy

The Seventh International Congress of Psychotherapy will be held in Wiesbaden, Aug. 21-26, 1967. The leading subject will be: PsychotherapyPrevention and Rehabilitation. Applications for lectures on the leading subject will be received at the secretariat general until Nov. 30, 1966, and should be addressed to Prof. Dr. W. Th. Winkler, Westf. Landeskrankenhaus, Hermann Simonstrasse 7, 483 Guetersloh/Westf., German Federal Republic. All inquiries as to participation should be made at the administrative secretariat (Conference Services Limited, 11 Whitehall Court, London SW 1, England.)

PSYCHOSOMATIC MEDICINE