Abstract
This paper evaluates the joint influence of peripheral neurophysiological factors and higher-order cognitive and affective processes in triggering or modulating a variety of phantom limb experiences, including pain. Part 1 outlines one way in which the sympathetic nervous system may influence phantom limb pain. A model involving a sympathetic-efferent somatic-afferent cycle is presented to explain fluctuations in the intensity of sensations referred to the phantom limb. In part 2, the model is extended to explain the puzzling finding that onlyafter amputation are thoughts and feelings capable of evoking referred sensations to the (phantom) limb. While phantom pains and other sensations frequently are triggered by thoughts and feelings, there is no evidence that the painful or painless phantom limb is a symptom of a psychological disorder. In part 3, the concept of a pain “memory” is introduced and described with examples. The data show that pain experienced prior to amputation may persist in the form of a memory referred to the phantom limb causing continued suffering and distress. It is argued that two independent and potentially dissociable memory components underlie the unified experience of a pain memory. This conceptualization is evaluated in the context of the surgical arena, raising the possibility that under certain conditions postoperative pain may, in part, reflect the persistent central neural memory trace left by the surgical procedure. It is concluded that the experience of a phantom limb is determined by a complex interaction of inputs from the periphery and widespread regions of the brain subserving sensory, cognitive, and affective processes.
Similar content being viewed by others
References
Abramson, A. S., & Feibel A. F. (1981). The phantom phenomenon: its use and disuse.Bulletin of the New York Academy of Medicine, 57 99–112.
Allen, I. M. (1928). Unusual sensory phenomena following removal of a tumour of the sensory cortex.Journal of Neurology and Psychopathology, 9 133–145.
Arena, J. G., Sherman, R. H., & Bruno, G. M. (1990). The relationship between situational stress and phantom limb pain: Cross-lagged correlational data from six month pain logs.Journal of Psychosomatic Research, 34 71–77.
Bach, S., Noreng, M. F., & Tjéllden, N. U. (1988). Phantom limb pain in amputees during the first 12 months following limb amputation, after preoperative lumbar epidural blockade.Pain, 33 297–301.
Bailey, A. A., & Moersch, F. P. (1941). Phantom limb.Canadian Medical Association Journal, 45 37–42.
Berger, M., & Gerstenbrand, F. (1981). Phantom illusions in spinal cord lesions. In J. Siegfried & M. Zimmermann (Eds.),Phantom and stump pain (pp. 66–73). New York: Springer-Verlag.
Bindra, D. (1978).A theory of intelligent behavior. New York: Wiley.
Boas, R. A., Schug, S. A., & Acland, R. H. (1993). Perineal pain after rectal amputation: a 5-year follow-up.Pain, 52 67–70.
Bors, E. (1951). Phantom limbs of patients with spinal cord injury.Archives of Neurology and Psychiatry, 66 610–631.
Bradway, J. K., Malone, J. M., Racy, J., Leal, J. M., & Poole, J. (1984). Psychological adaptation to amputation: An overview.Orthotics and Prosthetics, 38 46–50.
Brena, S. F., & Sammons, E. E. (1979). Phantom urinary bladder pain — Case report.Pain, 7 197–201.
Bressler, B., Cohen, S. I., & Magnussen, F. (1955). Bilateral breast phantom and breast phantom pain.Journal of Nervous and Mental Disease, 122 315–320.
Brodal, A. (1981).Neurological anatomy in relation to clinical medicine (3rd ed.). New York: Oxford University Press.
Bromage, P. R., & Melzack, R. (1974). Phantom limbs and the body schema.Canadian Anaesthetists' Society Journal, 21 267–274.
Butler, D. J., Turkal, N. W., & Seidl, J. J. (1992). Amputation: Preoperative psychological preparation.Journal of the American Board of Family Practice, 5 69–73.
Campbell, J. N., Meyer, R. A., Davis, K. D., & Raja, S. N. (1992). Sympathetically maintained pain: A unifying hypothesis. In W. D. Willis Jr (Ed.),Hyperalgesia and alodynia. New York: Raven Press.
Caplan, L. M., & Hackett, T. P. (1963). Emotional effects of lower-limb amputation in the aged.New England Journal of Medicine, 269 1166–1171.
Carlen, P. L., Wall, P. D., Nadvorna, H., & Steinbach, T. (1978). Phantom limbs and related phenomena in recent traumatic amputations.Neurology, 28 211–217.
Coderre, T. J., Katz, J., Vaccarino, A. L., & Melzack, R. (1993). Contribution of central neuroplasticity to pathological pain: Review of clinical and experimental evidence.Pain, 52 259–285.
Conomy, J. P. (1973). Disorders of body image after spinal cord injury.Neurology, 23 842–850.
Critchley, M. (1971).The parietal lobes. New York: Hafner.
Danke, F. (1981). Phantom sensations after amputation: The importance of localization and prognosis. In J. Siegfried & M. Zimmermann (Eds.),Phantom and stump pain (pp. 56–61). New York: Springer-Verlag.
Dawson, L., & Arnold, P. (1981). Persistent phantom limb pain.Perceptual and Motor Skills, 53 135–138.
Delius, W., Hagbarth, K. E., Hongell, A., & Wallin, B. G. (1972). Manoeuvres affecting sympathetic outflow in human skin nerves.Acta Physiologica Scandinavica, 84 177–186.
Dernham, P. (1986). Phantom limb pain.Geriatric Nursing, 7 34–37.
Diamond, J. (1959). The effect of injecting acetylcholine into normal and regenerating nerves.Journal of Physiology (London), 145 611–629.
Dorpat, T. L. (1971). Phantom sensations of internal organs.Comprehensive Psychiatry, 12 27–35.
Doupe, J., Cullen, C. H., & Chance, G. Q. (1944). Posttraumatic pain and the causalgic syndrome.Journal of Neurology, Neurosurgery and Psychiatry, 7 33–48.
Ejlersen, E., Bryde Anderson, H., Eliasen, K., & Mogensen, T. (1992). A comparison between preincisional and postincisional lidocaine infiltration and postoperative pain.Anesthesia and Analgesia, 74 495–498.
Engel G. L. (1959). ‘Psychogenic’ pain and the pain-prone patient.American Journal of Medicine, 26 899–918.
Evans, J. H. (1962). On disturbance of the body image in paraplegia.Brain, 85 687–700.
Frazier, S. H., & Kolb, L. C. (1970). Psychiatric aspects of pain and the phantom limb.Orthopedic Clinics of North America, 1 481–495.
Friedmann, L. W. (1978).The psychological rehabilitation of the amputee. Springfield: C. C. Thomas.
Gallinek, A. (1939). The phantom limb: Its origin and its relationship to the hallucinations of psychotic states.American Journal of Psychiatry, 96 413–422.
Gloyne, H. F. (1954). Psychosomatic aspects of pain.Psychoanalytic Review, 41 135–139.
Haber, W. B. (1956). Observations on phantom-limb phenomena.Archives of Neurology and Psychiatry, 75 624–636.
Hagbarth, K. E., Hallin, R. G., Hongell, A., Torebjörk, H. E., & Wallin, B. G. (1972). General characteristics of sympathetic activity in human skin nerves.Acta Physiologica Scandinavica, 84 164–176.
Henderson, W. R., & Smyth, G. E. (1948). Phantom limbs.Journal of Neurology, Neurosurgery and Psychiatry, 2 88–112.
Henry, J. A., & Montuschi, E. (1978). Cardiac pain referred to site of previously experienced somatic pain.British Medical Journal, 2 1605–1606.
Hutchins, H. C., & Reynolds, O. E. (1947). Experimental investigation of the referred pain of aerodontalgia.Journal of Dental Research, 26 3–8.
Isen, A. M. (1987). Positive affect, cognitive processes, and social behavior. In L. Berkowitz (Ed.),Advances in experimental social psychology. New York: Academic.
Jacome, D. (1978). Phantom itching relieved by scratching phantom feet.Journal of the American Medical Association, 240 2432.
James, W. (1887). The consciousness of lost limbs.Proceedings of the American Society for Psychical Research, 1 249–258.
Janovic, J., & Glass, J. P. (1985). Metoclopramine-induced phantom dyskinesia.Neurology, 35 432–435.
Jensen, T. S., Krebs, B., Nielsen, J., & Rasmussen, P. (1985). Immediate and long-term phantom pain in amputees: incidence, clinical characteristics and relationship to preamputation pain.Pain, 21 268–278.
Jensen, T. S., & Rasmussen, P. (1989). Phantom pain and related phenomena after amputation. In P. D. Wall & R. Melzack (Eds.),Textbook of pain (pp. 508–521). Edinburgh: Livingstone Churchill.
Kallio, K. E. (1950). Permanency of results obtained by sympathetic surgery in the treatment of phantom pain.Acta Orthopaedica Scandinavica, 19 391–397.
Katz, J. (1992). Psychophysical correlates of phantom limb experience.Journal of Neurology, Neurosurgery and Psychiatry, 55 811–821.
Katz, J., France, C., & Melzack, R. (1989). An association between phantom limb sensations and stump skin conductance during transcutaneous electrical nerve stimulation (TENS) applied to the contralateral leg: A case study.Pain, 36 367–377.
Katz, J., Kavanagh, B. P., Sandler, A. N., Nierenberg, H., Boylan, J. F., Friedlander, M., & Shaw, B. F. (1992). Preemptive analgesia: Clinical evidence of neuroplasticity contributing to postoperative pain.Anesthesiology, 77 439–446.
Katz, J., & Melzack, R. (1990). Pain “memories” in phantom limbs: Review and clinical observations.Pain, 43 319–336.
Katz, J., & Melzack, R. (1991). Auricular TENS reduces phantom limb pain.Journal of Pain and Symptom Management, 6 73–83.
Katz, J., Vaccarino, A. L., Coderre, T. J., & Melzack, R. (1991). Injury prior to neurectomy alters the pattern of autotomy in rats.Anesthesiology, 75 876–883.
Kolb, L. C. (1954).The painful phantom: Psychology, physiology and treatment. Springfield: C. C. Thomas.
Krebs, B., Jensen, T. S., Krøner, K., Nielsen, J., & Jørgensen, H. S. (1985). Phantom limb phenomena in amputees 7 years after limb amputation. In H. L. Fields, R. Dubner, & F. Cervero (Eds.),Advances in pain research and therapy (pp. 425–429). New York: Raven Press.
Kristen, H., Lukeschitsch, G., Plattner, F., Sigmund, R., & Resch, P. (1984). Thermography as a means for quantitative assessment of stump and phantom pains.Prosthetics and Orthotics International, 8 76–81.
Krøner, K., Krebs, B., Skov, J., & Jørgensen, H. S. (1989). Immediate and long-term phantom breast syndrome after mastectomy: Incidence, clinical characteristics and relationship to pre-mastectomy breast pain.Pain, 36 327–334.
Lacroix, R., Melzack, R., Smith, D., & Mitchell, N. (1992). Multiple phantom limbs in a child.Cortex, 28 503–507.
Lakoff, R. (1990). The psychology and psychotherapy of the chronic pain patient. In T. W. Miller (Ed.),Chronic pain (pp. 499–524). Madison, CT: International Universities Press.
LeDoux, J. E. (1989). Cognitive-emotional interactions in the brain.Cognition and Emotion, 3 267–289.
Lenz, F. A., Kwan, H. C., Dostrovsky, J. O., & Tasker, R. R. (1989). Characteristics of the bursting pattern of action potential that occurs in the thalamus of patients with central pain.Brain Research, 496 357–360.
Leriche, R. (1947). De la douleur comme objet de connaissance.Le Progrès Médical, 5 115–129.
Leventhal, H. (1982). The integration of emotion and cognition: a view from the perceptual-motor theory of emotion. In M. Clark & S. Fiske (Eds.),Affect and cognition: The 17th annual Carnegie Symposium on Cognition. Hillsdale, NJ: Erlbaum.
Lindesay, J. (1985). Multiple pain complaints in amputees.Journal of the Royal Society of Medicine, 78 452–455.
Livingston, W. K. (1943).Pain mechanisms. New York: Macmillan.
Lundberg, S. G., & Guggenheim, F. G. (1986). Sequelae of limb amputation.Advances in Psychosomatic Medicine, 15 199–210.
Marbach, J. J. (1978). Phantom tooth pain.Journal of Endodontics, 4 362–372.
Marks, L. E. (1978).The unity of the senses: Interrelations among the modalities. New York: Academic Books.
Marsland, A. R., Weekes, J. W. N., Atkinson, R., & Leong, M. G. (1982). Phantom limb pain: A case for beta blockers?Pain, 12 295–297.
McGrath, P. A., & Hillier, L. M. (1992). Phantom limb sensations in adolescents: A case study to illustrate the utility of sensation and pain logs in pediatric clinical practice.Journal of Pain and Symptom Management, 7 46–53.
Melzack, R. (1971). Phantom limb pain: Implications for treatment of pathologic pain.Anesthesiology, 35 409–419.
Melzack, R. (1989). Phantom limbs, the self, and the brain (The D.O. Hebb Memorial Lecture).Canadian Psychology, 30 1–16.
Melzack, R., & Bromage, P. R. (1973). Experimental phantom limbs.Experimental Neurology, 39 261–269.
Melzack, R., & Casey, K. L. (1968). Sensory, motivational and central control determinants of pain. In D. Kenshalo (Ed.),The skin senses (pp. 423–439). Springfield: C. C. Thomas.
Melzack, R., & Loeser, J. D. (1978). Phantom body pain in paraplegics: Evidence for a central ‘pattern generating mechanism’ for pain.Pain, 4 195–210.
Melzack, R., & Wall, P. D. (1988).The challenge of pain (2nd ed.). New York: Basic Books.
Merskey, H. (1989). Psychiatry and chronic pain.Canadian Journal of Psychiatry, 34 329–336.
Minski, L. (1943). Psychological reactions to injury. In W. B. Doherty & D. D. Runes (Eds.),Rehabilitation of the war injured (pp. 115–122). New York: Philosophical Library.
Mitchell, S. W. (1871). Phantom limbs.Lippincott's Magazine of Popular Literature and Science, 8 563–569.
Morgenstern, F. S. (1964). The effects of sensory input and concentration on postamputation phantom limb pain.Journal of Neurology, Neurosurgery and Psychiatry, 27 58–65.
Morgenstern, F. S. (1970). Chronic pain: A study of some general features which play a role in maintaining a state of chronic pain after amputation. In O. W. Hill (Ed.),Modern trends in psychosomatic medicine (pp. 225–245). London: Butterworth.
Muse, M. (1985). Stress-related, posttraumatic chronic pain syndrome: Criteria for diagnosis, preliminary report on prevalence.Pain, 23 295–300.
Muse, M. (1986). Stress-related posttraumatic chronic pain syndrome: Behavioral treatment approach.Pain, 25 389–394.
Nathan, P. W. (1962). Pain traces left in the central nervous system. In C. A. Keele & R. Smith (Eds.),The assessment of pain in man and animals (pp. 129–134). Edinburgh: Livingstone.
Nathan, P. W. (1985). Pain and nociception in the clinical context.Philosophical Transactions of the Royal Society of London, 308 219–226.
Noordenbos, W. (1959).Pain. Amsterdam: Elsevier.
Noordenbos, W., & Wall, P. D. (1981). Implications of the failure of nerve resection and graft to cure chronic pain produced by nerve lesions.Journal of Neurology, Neurosurgery and Psychiatry, 44 1068–1073.
Nyström, B., & Hagbarth, K. E. (1981). Microelectrode recordings from transected nerves in amputees with phantom limb pain.Neuroscience Letters, 27 211–216.
Obrador, S., & Dierssen, G. (1966). Sensory responses to subcortical stimulation and management of pain disorders by stereotaxic methods.Confinia Neurologica, 27 45–51.
Overson, P., Krøner, K., Ørnsholt, J., & Bach, K. (1991). Phantom-related phenomena after rectal amputation: prevalence and clinical characteristics.Pain, 44 289–291.
Parkes, C. M. (1973). Factors determining the persistence of phantom pain in the amputee.Journal of Psychosomatic Research, 17 97–108.
Parkes, C. M., & Napier, M. M. (1975). Psychiatric sequelae of amputation [Special publication].British Journal of Psychiatry, 9 440–446.
Pilowsky, I., & Kaufman, A. (1965). An experimental study of atypical phantom pain.British Journal of Psychiatry, 111 1185–1187.
Price, D. B. (1976). Phantom limb phenomenon in patients with leprosy.Journal of Nervous and Mental Disease, 163 108–116.
Reisner, H. (1981). Phantom sensations (phantom arm) in plexus paralysis. In J. Siegfried & M. Zimmermann (Eds.),Phantom and stump pain (pp. 62–65). New York: Springer-Verlag.
Reynolds, O. E., & Hutchins, H. C. (1948). Reduction of central hyper-irritability following block anesthesia of peripheral nerve.American Journal of Physiology, 152 658–662.
Riddoch, G. (1941). Phantom limbs and body shape.Brain, 64 197–222.
Rosen, V. H. (1950). The role of denial in acute postoperative affective reactions following removal of body parts.Psychosomatic Medicine, 12 356–361.
Schilder, P. (1950).The image and appearance of the human body: Studies in the constructive energies of the psyche. New York: International Universities Press.
Sherman, R. A. (1976). Case reports of treatment of phantom limb pain with a combination of electromyographic biofeedback and verbal relaxation techniques.Biofeedback and Self Regulation, 1 353.
Sherman, R. A. (1984). Direct evidence of a link between burning phantom pain and stump blood circulation: a case report.Orthopedics, 7 1319–1320.
Sherman, R. A. (1989). Stump and phantom limb pain.Neurologic Clinics, 7 249–264.
Sherman, R. A., & Bruno, G. M. (1987). Concurrent variation of burning phantom limb and stump pain with near surface blood flow in the stump.Orthopedics, 10 1395–1402.
Sherman, R. A., Gall, N., & Gormly, J. (1979). Treatment of phantom limb pain with muscular relaxation training to disrupt the pain-anxiety-tension cycle.Pain, 6 47–55.
Sherman, R. A., Sherman, C. J., & Bruno, G. M. (1987). Psychological factors influencing chronic phantom limb pain: An analysis of the literature.Pain, 28 285–295.
Sherman, R. A., Sherman, C. J., & Parker, L. (1984). Chronic phantom and stump pain among American veterans: Results of a study.Pain, 18 83–95.
Shukla, G. D., Sahu, S. C., Tripathi, R. P., & Gupta, D. K. (1982). A psychiatric study of amputees.British Journal of Psychiatry, 141 50–53.
Sicuteri, F., Nicolodi M., Fusco, B. M., & Orlando, S. (1991). Idiopathic headache as a possible risk factor for phantom tooth pain.Headache, 31 577–581.
Simmel, M. L. (1956). On phantom limbs.Archives of Neurology and Psychiatry, 75 637–647.
Simmel, M. L. (1959). Phantoms, phantom pain and ‘denial’.American Journal of Psychotherapy, 13 603–613.
Singer, J. A., & Salovey, P. (1988). Mood and memory: Evaluating the network theory of affect.Clinical Psychology Review, 8 211–251.
Sliosberg, A. (1948).Les Algies des Amputés. Paris: Masson.
Smith, O. A., & DeVito, J. L. (1984). Central neural integration for the control of autonomic responses associated with emotion.Annual Review of Neuroscience, 7 43–65.
Solomon, G. F., & Schmidt, K. M. (1978). A burning issue: Phantom limb pain and psychological preparation of the patient for amputation.Archives of Surgery, 113 185–186.
Squire, L. R. (1987).Memory and brain. New York: Oxford University Press.
Steigerwald, F., Brass, J., & Krainick, J. U. (1981). The analysis of personality factors in the prediction of phantom limb pain. In J. Siegfried & M. Zimmermann (Eds.),Phantom and stump pain (pp. 84–88). New York: Springer-Verlag.
Stengel, E. (1965). Pain and the psychiatrist.British Journal of Psychiatry, 111 795–802.
Szasz, T. S. (1949). Psychiatric aspects of vagotomy: IV. Phantom ulcer pain.Archives of Neurology and Psychiatry, 62 728–733.
Szasz, T. S. (1975).Pain and Pleasure (2nd ed.) New York: Basic Books.
Tasker, R. R., Organ, L. W., & Hawrylyshyn, P. A. (1982).The thalamus and midbrain of man. Springfield: C. C. Thomas.
Turgay, A., & Sonuvar, B. (1983). Emotional aspects of arm or leg amputation in children.Canadian Journal of Psychiatry, 28 294–297.
Van Bogaert, L. (1934). Sur la pathologie de l'image de soi (Études anatomo-cliniques).Annales Médico Psychologiques (Paris), 14 519–555, 714–759.
Wall, P. D. (1981). On the origin of pain associated with amputation. In J. Siegfried & M. Zimmermann (Eds.),Phantom and stump pain (pp. 2–14). New York: Springer-Verlag.
Wall, P. D. (1989). To what would Gaston Labat be attending today?Regional Anesthesia, 14 261–264.
Wall, P. D., & Gutnick, M. (1974). Properties of afferent nerve impulses originating from a neuroma.Nature, 248 740–743.
Wallgren, G. R. (1954). Phantom experience at spinal anaesthesia.Annales Chirurgicae et Gynaecologicae Fenniae, 43 (Suppl., 486–500.
Weinstein, S. (1962). Phantoms in paraplegia. In:Proceedings of Eleventh Annual Clinical Spinal Cord Injury Conference, 11, 138–152.
Weiss, S. A. (1958). The body image as related to phantom sensations: A hypothetical conceptualization of seemingly isolated findings.Annals of the New York Academy of Science, 74 25–29.
Wynn Parry, C. B. (1980). Pain in avulsion lesions of the brachial plexus.Pain, 9 40–53.
Zubek, J. P., Flye, J., & Aftanas, M. (1964). Cutaneous sensitivity after prolonged visual deprivation.Science, 144 1591–1593.
Author information
Authors and Affiliations
Additional information
Preparation of this manuscript was supported by a Medical Research Council of Canada Research Fellowship.
Rights and permissions
About this article
Cite this article
Katz, J. The reality of phantom limbs. Motiv Emot 17, 147–179 (1993). https://doi.org/10.1007/BF00992218
Issue Date:
DOI: https://doi.org/10.1007/BF00992218