I've got a new article on the psychology of back pain in the February issue of Best Life (the one with Jeff Gordon on the cover):
From the perspective of the brain, there are two distinct types of pain. The first type of pain is sensory. When we stub our toe, pain receptors in the foot instantly react to the injury, and send an angry message to the somatosensory cortex, the part of the brain that deals with the body. This is the type of acute pain that doctors are trained to treat. The hurt has a clear bodily cause: if you inject an anesthetic (like novocaine) into the stubbed toe, the pain will quickly disappear.The second pain pathway is a much more recent scientific discovery. It runs parallel to the sensory pathway, but isn't necessarily rooted in signals from the body. The breakthrough came when neurologists discovered a group of people who, after a brain injury, were no longer bothered by pain. They still felt the pain, and could accurately describe its location and intensity, but didn't seem to mind it at all. The agony wasn't agonizing.
This strange condition - it's known as pain asymbolia - results from damage to a specific subset of brain areas, like the amygdala, insula and anterior cingulate cortex, that are involved in the processing of emotions. As a result, these people are missing the negative feelings that normally accompany our painful sensations. Their muted response to bodily injury demonstrates that it is our feelings about pain - and not the pain sensation itself - that make the experience of pain so awful. Take away the emotion and a stubbed toe isn't so bad.
Chronic pain is the opposite of pain asymbolia. It's what happens when our brain can't stop generating the negative emotions associated with painful sensations. These emotions can persist even in the absence of a painful stimulus, so that we feel an injury that isn't there. It's like having a permanently stubbed toe.
Doctors have traditionally focused on the bodily aspects of chronic pain. They assume that a healed body is a painless body. If a patient has chronic back pain, for example, then he is typically prescribed painkillers and surgery, so that the pain signals coming from his spinal nerves are stopped. But the dual pathways of pain mean that this approach only treats half of the pain equation. Unless you find a way to treat the emotional pathway, then the chronic pain will continue.
Researching the piece definitely changed the way I think about my own back. For instance, it's made me much less concerned with my potential structural flaws - like herniated discs - and much more concerned with my emotional state of mind.
Comments
Marcus Aurelius seems to have recognized the emotional aspect of pain in his Meditations: Take away your opinion, and then there is taken away the complaint, "I have been harmed." Take away the complaint, "I have been harmed," and the harm is taken away.
Posted by: Alan | January 30, 2008 10:49 AM
That is really rather cool. Pain asymbolia sounds like a rather nice condition, as brain damage goes. I'd love to have pain be a more or less neutral signal rather than a disaster. Are there negative aspects? Is emotional flattening seen across the board?
In that vein, might it be possible to temporarily induce pain asymbolia in pain patents with TMS?
Posted by: phisrow | January 30, 2008 11:07 AM
I wonder if this explains my experience with my wisdom teeth being removed. I woke up during the procedure, while they were breaking up my lower right molar with some medieval device. I remember that it hurt like hell, but that, thanks to the intravenous valium, I did not care. It didn't bother me nearly as much as that itch on my nose that I could not scratch because there were too many people and too much equipment in the way.
Posted by: Anon | January 30, 2008 11:25 AM
Neat, but we should not be surprised. We have known that some people are wired to interpret what most of us call pain as pleasure for millennia. Finding the specific areas of the brain (or at least pointers to them) is interesting. As phisrow points out, figuring out a way to bring on pain asymbolia in people, on a temporary basis, would be a huge boon.
Unfortunately, there is also the danger that it could be a huge curse as well. While allowing doctors and patients the option of either traditional anesthesiology or a simple mechanical or pharmacological invocation of pain asymbolia would be great (if I recall correctly, there are a lot of simple surgical procedures where the anaesthesia is the danger, not the surgery itself), consider:
1. miss-use in sports. Yes, 'playing with the pain' is often part of the game, but the degree of pain is the warning that body is taking (or has taken) damage. Without the emotional baggage of the pain a career-threatening injury could be made worse; or even crippling.
2. one benefit would be the option of allowing soldiers wounded in the field to survive, perhaps even functioning well enough to survive in situations where they would have otherwise been killed. The other side of the coin would be pain asymbolia 'zombies'; troops drugged (or, worse, surgically modified) to be able to fight through injuries.
I am sure that there are other dangers, those are just the two that come to mind on first reading.
I suppose that there is also the question of how this interacts with shock. Would someone with pain asymbolia still go into shock from a major injury? I do not know if we have any idea how much of the effects of shock on the body are physical and how much of it is due to the emotional side of pain.
A quick search on the web produced lots of links to the syndrome, and a book of possible interest "Feeling Pain and Being in Pain" by Nikola Grahek, MIT Press, ISBN-13: 978-0262072830.
Posted by: Vnend | January 30, 2008 11:58 AM
That is the reason why antidepressants and anticonvulsants are now a part of chronic pain management even in patients not diagnosed with depression or seizure disorder per se. Though, I don't know if and how they attack the specific pathophysiology of chronic pain, they're for the most part clinically effective; it's why many drugs (e.g. Lithium) are routinely given even if we do not know exactly how they work.
Posted by: Dr. Feelgood | January 30, 2008 3:28 PM
The article is online now --
http://www.bestlifeonline.com/cms/publish/health-fitness/The_Psychology_of_Back_Pain.shtml
Posted by: DanN | January 30, 2008 6:04 PM
Thanks for the tip, Dan! I've corrected the post...
Posted by: Jonah | January 30, 2008 8:20 PM
Many will thank you for this one, Jonah. Dr. Sarno's book(1991)"Healing Back Pain: the Mind Body Connection" is still popular and he has several more recent ones. In a review of one of them the writer says that the main cause of chronic pain is the brain's ability to restrict oxygen to tissues where the pain is expreienced. In exercises like Jon Kabat Zinn's body scan people progressively relax different parts of the body by visualizing that they are breathing in oxygen and sending it to specific parts of the body. Any hard science to support this cause of chronic pain and would this exercise help?
Posted by: jb | January 30, 2008 8:24 PM
Intriguing post and great comments. Makes me wonder about my mysterious, intermittent TMJ (or tooth) pain.
Posted by: Pawlie Kokonuts | January 30, 2008 9:13 PM
In that vein, might it be possible to temporarily induce pain asymbolia in pain patents with TMS?
Posted by: phisrow | January 30, 2008 11:07 AM
Good question! I think on any new breakthrough or discovery one of the first things to do is ask how can this be used beneficially!
Dave Briggs :~)
Posted by: Dave Briggs | January 31, 2008 12:54 PM
Not sure if you saw this on the NYTimes web site today: http://well.blogs.nytimes.com/2008/02/04/antidepressants-dont-ease-back-pain/index.html?hp.
Interesting, especially in light of your Best Life article and blog post.
Posted by: Scott | February 4, 2008 1:13 PM
I was about to post a link to the same NYTimes article. This also reminds me of "The Pain Perplex," a chapter in Atul Gawande's Complications. Have you read that?
Posted by: Brett Keller | February 5, 2008 1:55 AM
i read your article in its original context and have to say that you did not seem to be aware that Sopher whom you referenced, had gotten a lot of the mechanisms wrong. an important ingredient in the perception or pain which you never mentioned is the issue of threat. and the process you described at the end of the article has a name -- it's called MRI Biofeedback.
let me say that given that this is not your area of expertise, it was a decently researched and written piece. what is beginning to bother me though is that you seem to be a bit all over the place, with expertise on just about everything. you're a smart guy but you're at risk of becoming the Britney Spears of the blogosphere. a bit overexposed. at which point the deficits start becoming evident. and i know whereof i speak because i happen to be a clinical psychologist with some expertise in the treatment of chronic pain.
Posted by: tennischick | February 9, 2008 12:49 AM
Hi Tennis chick,
thanks for your comments. actually, in the article i do criticize the lack of evidence surrounding the theories of Sarno and Sopher. (The evidence, in other words, is all anecdotal. though there are a lot of anecdotes.) i actually had a section on threat perception and learned helplessness but, alas, it was cut for reasons of space. chronic pain, as you well know, is a vast subject. and i had 5000 words.
and i don't pretend to be an expert on everything. i'm just a science writer. to make a living, i write on a wide variety of topics. that's what makes my job fun.
Posted by: Jonah | February 9, 2008 8:37 AM
Seven years ago I was diagnosed with very bad fibromyalgia. (I was only 30 atthe time) It was bad enough that I ended up on oxycontin, morphine, and a whole medicine cabinet of other meds to control the pain and sleep disorder. Then I found Zen. No- really, I know, corney but true. I began meditating regularly and after a few years of this and many meditative insights I began to deal with my stress more in a witness fashion than a reactive fashion. Last fall my Dr. anounced that I was officially in remission and I am now lowering my last medication each month till I am off it. The meds didn't cure me...Buddhist philosophy...and more important...implementing that philosophy is what "cured" me. If anyone is interested check out the audio book by Shintzen Young (sp?) on breaking thru pain. Also Dr.Sarno out of NYC really addresses the whole mind-body issues of back pain. It didn't work for me but completely cured a family friend who'd had terrible back pain for over 20 yrs. Good Luck everyone...Jonha- keep up the great work. This is the first blog I have ever read top to bottom that is worth reading! Entertaining and informative!
Posted by: Lynn | February 9, 2008 10:32 PM