Personal Injury, Workers’ Compensation,
Health Psychology and Pain Psychology

The included report is of a 13/31 coded profile, Intensified pain-fear conditioning. This choice was determined by how often this is a problematic pattern and difficult case in both clinical and forensic settings: to what is the person adapting, and how do we deal with it? The etiologic proposal that I have evolved is that the prototypic initiation is the conjunction of intense fear and acute pain (as explained in detail in the Adaptation and Attachment supplement to the sample report). This classically conditioned association leads to a state in which the arousal of either element activates the other. Given the simultaneity of fear and pain, the subsequent experience of bodily pain automatically arouses fear - it is frightening to have something new go wrong. And fear in turn reduces pain tolerance: fear arousal becomes associated with bodily distress, so that fear produces concerns and complaints about bodily pain and suffering, and the pain-fear spiral is similarly activated. Many more primarily operant fear and pain escape and avoidance responses are then repeatedly reinforced by the reduction of fear and pain. This pain/fear pairing can occur in a wide variety of accidents and other physical nightmares as well as emotional traumas, e.g., abandonment or other heart-breaking occasions, where the pain is experienced as out of control and the fear is cataclysmic.


Some people feel emotional anguish overwhelmingly in their bodies. Note the suggestion of heartbreak as possibly an early and key setting of a lowered pain/fear threshold in the Marks and Seeman (1963) data: 60% of their 13/31 cases reported parent deaths which was more than any other code type (the 231 code is nearly tied at 55% in contrast to an overall sample base rate of 31.7%). See the adaptation and attachment supplement in the sample report regarding the variety of turns of events that can influence the somatic focusing of fear awareness.


This pattern is problematic when it occurs in forensic contexts. The problem is the relative disconnection of the medical consequences from the emotional impact. For example, the perception of a car accident can be much more - or less - devastating than the physical and anatomic consequences. People with major head injuries and substantial losses of consciousness on the average show less distress on the MMPI-2 than those with closed head injuries with milder consequences but only a momentary or no loss of consciousness: the conditioning appears to "lock in" at the moment of the trauma if the person remains conscious.


This disconnect frequently confounds the court, e.g., the plaintiff’s attorney may claim severe damages and the defense may focus on the limited physical/medical consequences as not justifying the large settlement being sought. On the plaintiff’s side of the ledger, this disconnect hypothesis explains how the correlation of psychological damages and objective injury is so low. That is, intense fear can genuinely activate acute distress even though the medical evidence identifies it as a relatively less severe or even minor injury. On the defense side of the ledger, such emotional impacts can be much greater when they recapitulate and intensify prior somatic conditioning. Thus if the person has a prior history of at all similar frightening traumas and subsequent medical contact, then given that fragility, the psychological impact can be much more than it might otherwise have been. The contribution of the MMPI-2 profile can then be helpful regarding the assessment of the potential for relatively extreme emotional reactions to pain and suffering, how it will be expressed, and the potential intensity of the person’s reactions to similar future events.






Caldwell, 2001, What do the MMPI scales fundamentally measure? Some hypotheses. Journal of Personality Assessment, 76 (1), 1-17.


Marks, P. A., & Seeman, W. (1963). The actuarial description of abnormal personality.
Baltimore: Williams & Wilkins.


Swenson, W. M., Pears on, J. D., & Osborne, D. (1973). An MMPI source book: Basic item, scale, and pattern data on 50,000 medical patients. Minneapolis: University of Minnesota Press.