Response

In their article, Duranté et al ^{Reference Duranté, Ribeiro, Gaspard-Boulinc, Boutron, Henry and Petit1} provide a wide-ranging examination of how different forms of pain – encompassing psychological, social and other non-physical pain – are investigated in a biological context. As the authors rightly emphasise, their study is meta-research mapping exercise that describes how concepts and methods have been used, rather than an attempt to define or validate non-physical pain itself. The present commentary therefore aims to complement this approach by articulating, from a clinical perspective, normative expectations and translational questions that extend beyond the scope of a methodological mapping study. The review brings these constructs together under the shared banner of ‘non-physical pain’. Although these experiences may converge in certain biological patterns, there may also be divergences. For instance, psychological and social pain are conceptually distinct: psychological pain is deeply intrapersonal and self-focused, whereas social pain hinges on perceived external threats to belonging or social status. While these distinctions are clearly identified at the conceptual level in the reviewed literature, they remain difficult to operationalise in clinically actionable ways. Grouping heterogeneous constructs under a single umbrella term may therefore limit their clinical interpretability, as it risks overshadowing important differences in aetiology, subjective quality and clinical significance. Such blurring may be particularly relevant when considering how personal history, cultural context or specific social dynamics shape whether an individual perceives a given intrapersonal or interpersonal experience as ‘painful’.

From a clinical and translational standpoint, it is noteworthy that studies focusing on social exclusion or social rejection – constructs that are central to contemporary theories of social pain ^{Reference Eisenberger2} – were not included. The authors explain that their review prioritised direct assessments of pain, which is methodologically coherent within a mapping perspective. However, much influential work in the field relies on paradigms such as Cyberball, originally developed to investigate social exclusion, which reliably elicit aversive subjective experiences that are often interpreted as pain-related. While these paradigms do not establish that the elicited experience constitutes pain per se, they remain highly relevant to understanding how socially mediated distress is experienced and reported by patients, as social distress is conceptualised as a form of social pain in prominent theoretical models. ^{Reference Eisenberger2} In these paradigms, participants systematically report distress, hurt feelings or pain intensity following both inclusion and exclusion phases; moreover, in clinical populations such as individuals with borderline personality disorder, feelings of exclusion may be reported even during inclusion phases. Social exclusion can also be investigated in non-experimental contexts, where subjective perception remains central. ^{Reference Mwilambwe-Tshilobo and Spreng3}

It is not the concept of psychological or social pain that poses the main challenge, but rather the way these terms are applied across studies. ^{Reference Eisenberger2,Reference Meerwijk and Weiss4} This echoes long-standing concerns regarding conceptual ambiguity in the literature ^{Reference Meerwijk and Weiss4,Reference Holden, Mehta, Cunningham and McLeod5} and the need for greater operational clarity in clinical and neuroscientific research. ^{Reference Eisenberger2} To address these issues from a clinical perspective, future studies could more explicitly situate their work within existing theoretical frameworks of psychological and social pain, and clarify how these frameworks inform hypotheses, tasks and outcome measures. Researchers might also benefit from using clinically established instruments specifically developed to assess psychological pain – such as the Psychache Scale ^{Reference Holden, Mehta, Cunningham and McLeod5} or the Physical & Psychological Pain Visual Analog Scale (PPP-VAS) ^{Reference Guillaume, Jaussent, Courtet and Jollant6} – which are widely used in psychiatric research, while acknowledging ongoing debates regarding their psychometric properties. ^{Reference Charvet, Boutron, Morvan, Le Berre, Touboul and Gaillard7} Finally, when using paradigms of social exclusion, systematically assessing whether participants experience pain – and in what sense – could help clarify the relationship between social exclusion and psychological pain as currently theorised. In line with Duranté et al’s own conclusions, these proposals are intended to complement the review’s meta-research findings by highlighting clinically driven priorities for future research on pains not primarily felt in the body.