Beyond Mind Over Matter: Why Chronic Pain Demands Mechanistic Thinking, Not Just Psychological Labels

- Jordan S. Fersel, MD

For years, we have told patients a story about chronic pain that is incomplete and sometimes harmful. Research highlights that most chronic pain is psychological, shaped by stress, trauma, or unresolved emotion. While that explanation may apply in some cases, it has increasingly been used to fill gaps where clearer answers are missing.

In the process, a significant group of patients has been overlooked, those whose pain stems from mechanical and neurological causes that remain underrecognized, understudied, and too often dismissed.

The scale of the issue makes this gap impossible to ignore. According to research, more than 50 million Americans suffer from chronic pain. When a condition affects that many people, even a small percentage of mischaracterized cases represents millions of individuals navigating a system that cannot fully explain what they are experiencing.

I have spent decades working with patients in pain, and one of the most consistent patterns I have observed is the presence of suffering and the absence of explanation. Patients arrive having been told that nothing is wrong, that their imaging is normal, or that their symptoms are psychological. Yet their pain is real, persistent, and often debilitating. The disconnect between what they feel and what we can explain is where the problem begins.

To be clear, I am not arguing that psychology plays no role in pain. That would be an oversimplification. Human beings are not built to separate physical and emotional experiences. Pain, perception, memory, and emotion are deeply intertwined. If someone is injured, their emotional response will naturally follow. If someone lives with chronic discomfort, it will affect their mood, behavior, and outlook.

But what concerns me is how often we mistake correlation for causation. Just because a patient is anxious, depressed, or distressed does not mean those factors caused the pain. In many cases, they are consequences of it. As I have seen repeatedly, a patient can live a stable, functional life one day, experience a traumatic event the next, such as a car accident, and then develop both physical pain and psychological distress almost immediately. The emotional response accompanies the injury.

This distinction matters because it shapes how we treat patients. When we default to psychological explanations too early, we risk overlooking physical mechanisms that are more subtle, less visible, and not easily captured by standard diagnostic tools. And yet, these mechanisms can be highly specific, reproducible, and treatable, if we know what to look for.

In my experience, this overlooked group may represent roughly 30 to 40% of chronic pain patients, individuals whose symptoms are driven by mechanical or nerve-related issues that do not show up clearly on imaging. These are patterns waiting to be recognized.

Consider something as simple as a nerve injury resulting from trauma. A patient involved in a car accident may experience a force that compresses or stretches a nerve in a way that produces pain far from the original site of injury. The patient may report pain in the foot, while the actual issue originates in the knee. An MRI may appear normal. Traditional diagnostic frameworks may fail to connect the dots. But when you understand the mechanics of how the body moves and how nerves transmit signals, the pattern becomes clear.

This is where medicine must evolve, by integrating it with a deeper understanding of physical mechanisms. We need to move beyond isolated observations and toward pattern recognition. That requires stepping back from the individual case and looking at larger cohorts of patients who share similar experiences. When we do that, we begin to see common threads, recurring mechanisms that explain what once seemed unexplainable.

Unfortunately, our current system does not always encourage this kind of thinking. There is a tendency, particularly when treatments fail, to shift responsibility onto the patient. Labels such as drug-seeking or non-compliant can emerge, especially in pain management, where frustration runs high on both sides. But if we are honest, we must acknowledge that these labels often reflect the limits of our understanding rather than the behavior of the patient.

We also have to confront a more uncomfortable truth. We do not know as much as we think we do. If we consider the full scope of medical knowledge, what has been discovered and what remains unknown, we are likely operating with only a fraction of the total picture. That reality should inspire humility. It should push us to keep questioning, keep observing, and keep looking for mechanisms that we may have missed.

This is particularly important in a time when new technologies, including artificial intelligence, are being positioned as solutions to complex medical problems. AI can process data, identify patterns, and generate hypotheses. But it cannot replace the foundational requirement of good data and accurate interpretation. If the underlying assumptions are flawed, if we are feeding systems incomplete, biased, or erroneous narratives, then AI will simply reinforce those errors at scale.

In other words, technology cannot fix a conceptual gap. It can only amplify it.

What we need instead is a shift in perspective. For physicians, especially those who serve as the first point of contact, the gatekeepers, there is an opportunity to approach chronic pain with a broader lens. Rather than immediately categorizing symptoms as psychological or unexplained, we should begin by asking more fundamental questions: What is the mechanism? What are the biomechanics in the case of injury?

Mechanism is everything. Without it, we are guessing. With it, we can build a coherent narrative that connects cause and effect, even when the connection is not immediately obvious.

This does not mean every case will have a clear answer, or that we will eliminate uncertainty. But it does mean we can reduce the number of patients who fall into the gap between what they feel and what we can explain.

For specialists already working in this space, the call to action is similar but deeper. We must expand our focus beyond the central nervous system and consider the full range of structures that contribute to pain, including peripheral nerves and biochemical and mechanical interactions within the body. Pain is not confined to the brain or spine. It is a system-wide experience, influenced by forces both internal and external.

And for patients, the message is simple. If your experience does not align with the explanation you have been given, it is reasonable to keep looking, not because the system is broken entirely, but because it is incomplete.

The story of chronic pain is still being written. Right now, too many chapters rely on observation of individual behavior and associated assumptions, rather than a broader perspective, research, and understanding. If we want to improve outcomes, we need to rewrite that story by placing it in its proper context alongside mechanism, pattern recognition, and physical reality.

We owe patients more than a narrative that comforts us in our limitations. We owe them one that reflects the complexity of what they are actually experiencing, and gives us a better chance of helping them return to the lives they had before pain took hold.

About the Author:

Jordan S. Fersel, MD, is a physician specializing in pain management with decades of clinical experience examining the intersection of physical mechanisms and patient-reported pain. His work focuses on identifying overlooked mechanical and nerve-related causes of chronic pain through pattern recognition and biomechanical analysis. Fersel advocates for a more comprehensive approach to care that integrates physical and psychological factors while challenging assumptions that limit accurate diagnosis and effective treatment.