Pain

Paul Grobstein's picture

Welcome to the on-line forum associated with the 2008 senior seminar in Neural and Behavioral Sciences at Bryn Mawr and Haverford Colleges. Its a way to keep conversations going between course meetings, and to do so in a way that makes our conversations available to other who may in turn have interesting thoughts to contribute to them.

Thoughts this week about

and our conversation based on them ....
Paul Grobstein's picture

addendum

Interesting article in the NYTimes today.
K. Smythe's picture

Pain

            Pain seems to me to be one of the most interesting sensations that we have.  Although all sensations are subjective, pain to me is interesting because it is such a strong and internal sensation and because we do believe that there are very common differences (we talk about everyone having a different “pain tolerance”).  It is easy for me to accept that individuals are able to deal with pain in very different ways and thus deal with very different levels of pain in their everyday lives; however I wonder if there is an actual “threshold” that may be somewhat evolutionarily conserved where we actually pass out from pain.  It is entirely possible that this is again totally individual (can’t find any studies on it-would be difficult to do ethically obviously) however it seems plausible to me that our bodies ultimately have similar limits where it is necessary physically rather than emotionally to deal with pain.

            I also wonder why it is that certain people might have higher “pain tolerances” than others.  Is this a natural phenomenon that has to do with our physical, bodily differences or is it a learned threshold based on past social and personal experiences?  As with most scientific dichotomies I expect it is a mixture of both but it would be interesting to know even what experiences effect pain tolerance and in what way.  Do painful experiences dull your sensation/make you more accustomed to dealing with pain and thus reduce your threshold or do they do the opposite and make you more aware of what pain is and feels like and thus make you more sensitive to it.  Also, do pain experiences at different times in your life affect you differently and how do the reactions of those around you affect your experience and thus threshold.  It seems that the reaction of other definitely affects us, examples are especially obvious when we are young and are taking many emotional cues from our parents but I believe these “environmental” factors (or social factors) affect us even when we are older, just in more subtle ways.

Andrea G.'s picture

Underprescription of Pain Meds

A lot of people have brought up the issue of prescribing pain medication and the problematic situation of a doctor having to decide whether a patient is in enough pain to merit the use of narcotics.  It often seems as though pain medication is being overprescribed, with all we hear about people addicted to painkillers, drug seeking at every area hospital until one doctor realizes what's going on and cuts the person off.  In reality, though, studies show that narcotics are generally underprescribed.

In one study I read (http://www.bmj.com/cgi/content/full/314/7073/23), doctors underrated the pain level of just over 50% of their patients with HIV.  Of the patients who rated themselves as being in severe pain, only 15% were prescribed narcotics, while 50% were not prescribed any painkillers at all.  The same pattern held for those patients who rated themselves as having moderate pain.  Correlated strongly with not being treated adequately for pain was a measure of quality of life in these HIV patients.

This study, along with many others, shows the need for doctors to look past fears of the DEA and the potential for addiction and treat their patients' pain, especially in the case of chronic, potentially end-of-life, situations.  The trade off between a terminal cancer patient being relatively pain-free during their last weeks or months of life and the same patient possibly becoming dependent on whatever narcotic they've been described seems clearly worth the risk.  It becomes slightly fuzzier for chronic, non-terminal diseases, where a dependence on opiates could cause serious problems later in life, but for end of life situations, I see no reason why doctors shouldn't continue to prescribe narcotics at whatever dose is necessary.
Ian Morton's picture

Suffering

In thinking about pain I would like to take a less scientific approach and put forth some of the ideas about pain presented by Emmanuel Levinas. Levinas describes pain and suffering in terms of their effect on consciousness and being. Pain, Levinas describes, is something directly given to consciousness. Yet despite pain’s given nature to consciousness, it is also in-spite-of-consciousness; pain is a rejection of meaning. This requires elaboration.

According to Levinas, pain escapes out ability to interpret or conceptualize it. One may quickly here retort that societies have applied hundreds of meanings to pain (a punishment from some supernatural force, a right of passage, a function of the mind to overcome etc.), but Levinas would counter that such justification is only applied post-hoc. In the moment of suffering, one does not attribute meaning, but is instead consumed by one’s suffering. In sum, pain – as immediately experienced – appears to defy meaning by virtue of its ability to absorb consciousness. In Levinas’ language, pain refuses to be a meaning.

Not only does pain/suffering escape meaning, but it is also extreme/original passivity. Levinas describes this passivity as the “woe.” The woe is the combination of one’s pain, one’s consciousness of the pain (or pain’s absorption of consciousness), and one’s consciousness that pain was not freely assumed. In this sense, pain is a pure undergoing, during which the only consciousness available is consciousness of one’s passivity in suffering. Again, pain can be seen as a refusal of meaning since the only content of pain is the woe. Levinas’ point is to illustrate how in suffering, pain completely overwhelms consciousness. (Side note: remember that game show on fox where contestants had to answer questions while subjected to extreme cold or heat? This demonstrates the capacity of pain to limit consciousness.

While I may resist some of Levinas’ views, I believe it is important to recognize that pain/suffering is a suppressive force capable of shattering consciousness. Pain has the ability to isolate one to the world of one’s suffering; one’s world shrinks to the boundaries of immediate pain perception. Consequently, I am inclined to agree that suffering may be the greatest experience of passivity man can experience. With this in mind (and keeping with tomorrow’s discussion topic), I am inclined to consider the extent of suffering to the moral domain. As suffering can be described as extreme passivity with the consumption of consciousness, it seems that this by nature demands for the interpersonal. The one in extreme passivity is dependent on an Other to come pull him/her out of the bondage of suffering. So perhaps inherent to suffering is the foundation for a universal imperative?
atuttle's picture

A response to Levinas

 

Ian, I think you raise some interesting points by bringing Levinas’s description of pain to our attention. Pain appears to have a dual nature in several different domains: It is both a physical and emotional reaction, it can induce aversive or affiliative behavior. I also agree that pain is a complex experience which transcends our ability to accurately describe its true nature, in much the same way that our experiences of seeing a vivid color or smelling our family’s cooking cannot be accurately conveyed to a third party.

I would argue that Levinas’s claim that pain exists in an “non-conscious” domain, however, is misleading. While rationalization, analysis, and interpretation of our experiences comprise an aspect of human consciousness, awareness is another key component which is dually integral to the pain experience. Without an awareness of pain’s sensation (as indescribable as this may be), it is hard to argue that a person is experiencing pain. Except in cases of shock, a person does not lose consciousness during a painful event. In fact, pain appears to insistently capture and sharpen a person’s attention so that he or she cannot focus on any other environmental signals; the victim’s conscious perception becomes limited to only the pain itself. I would argue that while this hyper-fixation of conscious attention limits a person’s choice (i.e., the choices to ignore the pain or actively fight against the antagonist) and ability to rationalize or explain what he or she is feeling, it ultimately leads to a hyperconscious, versus non-conscious perceptual state.

I realize that my argument may be semantic, according to a psychological (rather than philosophical) definition of human consciousness. Like you mention in your post, the ideas involving free agency and self-perspective become diminished by pain; the sensation is pervasive, immediate, and overwhelming, and in short is difficult to be placed into a greater perceptual context. It is important to point out, however, that the experience of pain is not possible without conscious experience.

 

~Alex Tuttle

Haverford '08

Felicia's picture

pain

It's really interesting to me to think about pain perception and differences in pain sensitivity. We seem to have generally agreed that there are many factors (bio, social, cultural) involved, and I wonder to what extent each of those play a role. In relation, the physiology of pain is also fascinating - and just how little we really know about how to measure pain. If we could figure out the factors, could we really come up with some kind of equation to determine the actual vs. perceived "level" of pain? Would that even do any good? In thinking about physicians and prescribing medicine, if someone's perceived level of pain is much higher than their actual level, should that doctor prescribe less? If the main concern is patients exaggerating their pain level, would a lie detector do the trick? These are clearly not all things I agree with and think should happen, but I’m concerned with the applicability of my own curiosity. I think it would be really cool to be able to have some quantitative measure for pain, but I’m not sure how it could be of use. In addition, going off our discussion about animal models, there would be a lot of moral issues with doing these studies (I’m talking about serious, debilitating pain, not minor pain studies done presently). What may be more important, as people have hinted at, is changing cultural/social perception of pain (at least minor pain), because I strongly believe there’s a large psychosomatic component.

Amelia's picture

Culture, SIA, Pain Medicine

I wonder that in our talk about the social and culture influence on pain, if the influence is on the reporting of pain or the actual experience of it. This also seems to get at the idea of personal state on pain. If you are told that something is really going to hurt and the pain is focus on you are going to be more aware of the pain as a central aspect. Maybe if the pain is not focus upon as such a major aspect a person may simple focus on other parts of the experience (or not focus on any part of it). An example I thought of from my own experience is with allergy shots—when the nurse simply gives me a shot without warning while we’re chatting, I don’t notice it. However, if she says something like ‘just a little prick’, I’m much more aware of the pain of a shot. The same nociceptors should be activated, but my state is different. With culture influence on pain, I wonder if it is also a case that the state of the person’s thoughts about the pain are different based on both the context and what other people tell them. I am sure there are also reporting differences, but it doesn’t seem like that would be the only explanation for differences.

A person’s state and its influence on pain is particularly interesting in the sense of Stress-Induced Analgesia (basically in extremely stressful/traumatic situation, people don’t feel the pain until later). While it makes sense that this happens through downward regulation, it is still just a really interesting concept to think about. I’ve seen people with severed limbs experiencing pain, but not nearly at the level that you would expect them to be at. Your body is in so much shock that the pain just isn’t real. My point in saying this, I guess, is that as people have pointed out earlier, it is important to realize that pain is not just nociception and that there is no 1-to-1 correlation between stimuli and the experience of pain. I am studying pain in animal models now (and will be continuing to in the future) and this lack of direct correlation is always on my mind.

People also touched on earlier about the reading about when the man said he didn’t have pain when the doctors thought that he should (and dispensing the pain medicine based on what they thought he should be experiencing). While, as I’ve said, it is certainly possible that he is not feeling the pain because of stress-induced analgesia or other reasons (though his bodily responses suggest otherwise), your body can still feel the pain even if your mind does not. In this case I think it was right for the doctors to dispense a higher dose of medicine, because even if he doesn’t feel it, the negative effects on your body from going through the trauma should be protected against. Physicians now often used localized anesthetic during procedures as well as generalized anesthesia because of this possibility. If you body feels the pain, regardless of what your mind remembers/experiences, it can be harder to recover from injuries and cause a decreased pain threshold for you. If his reporting of no pain was simply a reporting difference, the body should still be protected against. In this case the physician should know how much pain the patient should be experiencing and how much damage that could do to his body, and because of this, I find that the physician and nurse were correct in dispensing higher pain medicine for this man.

Elliot Rabinowitz's picture

Pain and Medicine

Many points were brought up on Tuesday night that I found particularly difficult to wrap my mind (and/or brain?) around. I found myself bouncing back and forth, agreeing with one suggestion and then changing to the opposite side of the argument. My difficulty in making conclusions may be mostly due to the incredibly number of factors that go into "pain" - the sensation truly depends on the setting, one’s reaction to the context, and one’s personal biological, psychological, and socio-cultural inner dialogue.

 

The subject of “treating pain” especially caught my attention. I can’t decide how recent the idea of treating pain as “pain” truly is in our world today. I partially agree with the statement based on my limited knowledge of the history of medicine. However, people have been treating symptoms of diseases forever. Now, whether we would like to actually include pain as a symptom or rather as a result of a symptom (e.g. pain due to inflammation), I’m not sure. But whatever the case, it seems like the goal for a long time has been to actually reduce pain, the physical and mental interpretation experienced by the individual. Maybe a drug given actually does cause a decrease in viral load by some specific effect (whether placebo or not), but the ultimate goal has been to reduce pain, not decrease viral load. Therefore, maybe the treatment of pain in and of itself in our current society is based on the idea that we always try to have answers and explanations for everything. For example, what if someone goes to his/her doctor with some unexplainable pain and then takes some random drug that has been shown to sometimes help in similar situations. Since we don’t know what the caused the pain (if there even was a cause), we also can’t know whether this was simply a treatment of the pain itself or of some underlying factor(s).

 

The best ways of treating people in pain closely relates to all of this. As someone interested in entering the art of practicing medicine, I found this subject particularly interesting. There seems to be an increasing desire to have explanations, charts, reasoning, and numbers to rationalize what pain is and how people feel it. Money is pouring into inventing new technology to make our hospitals even more state-of-the-art. However, as the posted Time article (“How Real is Your Pain?”) eloquently articulates, the real art may be in trusting our physicians experience and interpretation:

 

“Medical technology has yet to invent a machine that can look into another's mind to see what he's feeling, or thinking… There is, however, a mind-reading machine that certain doctors and nurses can use in cases like Charlene's and Jacob's. Its use is frowned upon by many in administrative positions and specific measures to render these machines useless, most notably long forms, committee meetings and menu-driven care algorithms, are being implemented with increasing ferocity. It is only this machine that can make rational and humane treatment decisions for the suffering though. It is, in fact, only this machine which suffers. See past the ones that beep and blink; the mind remains our most important machine in medicine.”

 

Maybe our medical education system needs to change its approach and focus more on training people to interact and treat individual patients. I don’t know how likely this is, but it’s definitely something I’m going to think about a lot over the coming years…

Mawrtyr2008's picture

The comments about assisted

The comments about assisted suicide and those about medicine creating a pain-free world started me thinking about pain and its ability to affect other areas of experience besides the senses and perception. The line of thinking that the experience of extreme pain can impair consent or even make informed consent impossible has long been used to justify prohibiting physician assisted suicide. I think there's a lot of merit in this argument. I also think it's interesting that pain is clearly not an objective, encapsulated physical phenomenon. Its effects branch out into a variety of other cognitive capacities.

 

I'd also like to return to a comment made in class about pain as it is seen as a rite of passage. In many cultures, extreme physical endurance and scarification practices mark a boy or a girl for adulthood. In class, I struggled to think of an example in Western culture, but perhaps I've stumbled off of one. I'm sure many of us, male and female alike, are familiar with the natural birth dilemma that many pregnant women face. I once learned in Anthro 101 that it's anthropology's job to make "the strange familiar and the familiar strange" and I think that a study of pain really gets that message across. I can't help wondering what's behind these rituals that, in a sense, glorify pain and especially the body's ability to withstand pain. This subject is departing from many of the more central questions discussed in the forum and in class, but I would welcome any comments!

tlogan's picture

Pain/Suffering Dilemmas

Hey guys,

I wanted to thank you again for coming to our discussion on Tuesday; I thought it was very interesting and enlightening, especially in the case of acupuncture. I wanted to ask you guys what you thought of the article “Spinal Irritation and Fibromyalgia: A surgeon general and the Three Graces.” I must concede that upon first read, it does seem somewhat unrelated, but when further reading is performed, one notices that many of the ideas in the paper relate to our class discussion, namely perception of pain. The bio-socio-cultural aspect of pain is particularly on display here, as the shifting perceptions of pain coincide with the shifting perceptions of body type, as the suggestion is made that body image and unhappiness could be linked with spinal irritation. For me, it is interesting that the shifting body types of the Three Graces depicted in artwork is used as a basis of a hypothesis for the role of social construct in “spinal irritation.” One then must wonder, if a longitudinal study were conducted in a way that cross-cut the shifting of beauty paradigms, would there be fluctuations in “spinal irritation” rates as well? That brings me to another point. Would assisted suicide because of pain be more acceptable in countries in which suicide is more acceptable already?

On another note, I agree that the goal of medicine should not be to eliminate pain completely, but I think the goal should be to eliminate suffering as much as possible, which I believe to be an entirely different animal. I should also say that not all kinds of suffering can be eliminated medically, such as heartache, loneliness, etc. I am merely saying that if someone is in pain or impaired in someway that makes a normal life much too difficult, medicine and should seek to aid them. I think we can all agree on this, as it is not too controversial; however, what if that person cannot be treated to an extent that will allow them to continue on without being crippled by pain, etc.? In this case, in response to Alex, then I do not believe the central goal of medicine should be abandoned. If the patient undergoes psychiatric evaluation and is judged to be mentally competent, I feel that the patient should have the right end their life. If physician assisted suicide is the only option that will eliminate the suffering (note: not pain), then it should fall under the scope of acceptable courses of action. I say this, but it would most likely be considered on a case by case basis.

krosania's picture

It seems like people for

It seems like people for some reason are always looking to assign blame for the origin of pain. Either you blame a physical underlying cause that is apparent in some way, or you blame the person for making it up or being too weak to handle what others think should be a tiny amount of pain. The purpose of pain med protocols in hospitals is to prevent doctors from having the power of assigning that blame to the person and punishes them by giving them little pain meds when they cannot find a physical origin, or like the doctor who wrote that one article, believe the person is just making it up. I understand that it’s really important hospitals don’t assist drug addicts by subscribing them pain medication, but I also think it’s probably better to err on the side of caution, at least initially. Just because pain does not seem real doesn’t mean that it isn’t, and if there’s anything that’s come up as a theme in our discussion, it’s that no one can determine what kind of pain a person is experiencing besides that person. The other interesting thing about the scale they use is that someone who has never experienced that much pain in their life (no broken bones, etc.) is probably not going to have the same scale for how intense pain is than someone who has gone through childbirth. I can imagine that when one is in intense pain, it is probably difficult to think about anything that could be worse and acknowledge that they pain they feel is only really a five, when it is the worst thing that they have ever experienced.

Another thing I wanted to touch upon as that I think the goal of medicine should not be to create a pain-free world. Most pain is there for a reason, and serves as a means of keeping us in touch with our bodies. It is a warning signal that tells us that our bodies need us to stop whatever it is that we are doing. Chronic pain typically does not fall under this category, as someone can be lying down perfectly still and still be in incredible pain, but sometimes it might. I wonder what kind of information people who are chronically medicated for pain are missing out on by having their neural pathways for pain blocked off. Is it possible that paying attention to the pain and working through it in a more naturalistic way would be more likely to resolve it permanently, rather than simply covering it up again and again? I don’t have any idea whether this is true, but I thought it was interesting to think about.

Marissa Patterson's picture

Chronic back pain

I was reading some articles on the internet and I came across one entitled "TV Commercials can literally be a pain..." which highlighted a study done in Germany after the wall of the Berlin Wall, when East Germany began to see TV commercials for pain relievers that had previously only been seen in West Germany.

Before unification the chronic back pain rate was less than 70% in East Germany, and 85% in West, but by 2003 the rates were nearly identical. The researchers say this is because "in the absence of injury or trigger, the mind is tricked into thinking the body is in pain when reading about the problem or hearing others complain about their pain"such as on tv shows or commercials.

They also say that only 15% of chronic back pain has an underlying physical problem (that is apparent using our current diagnostic techniques). It is an interesting way to look at and think about the origins of pain. How much of it comes from suggestion?

 

Jenna's picture

I think the study Marissa

I think the study Marissa brought up about the long term effects of circumcision on pain perception brings up some interesting issues.  First, I am not sure about the conditions of the study but I assume the parents of the child were able to choose whether or not to give their children anesthesia.  Therefore I think it is probably likely that the parent’s philosophy of pain influenced the child’s pain tolerance much more than the actual surgery.  This once again brings up the importance of the “beetle in the box” theory about pain.  I think someone’s perception of pain is composed from a variety of biological and environmental factors and is unique to each person.  I agree that the pain scales are then pretty much irrelevant except to protect the health care professionals from being accused of inadequately prescribing pain medicine.  However, I don’t have a better alternative except to explain the effects and strengths of the pain medicine available and then allow them to choose which best fits their desire for pain relief.  This brings me to another problem I have with the circumcision study and that is why does it matter whether someone’s pain tolerance is higher or lower?  It seems they are placing a value on higher pain tolerance which would be feeding into the common view in society that men should have a high pain tolerance and appear tough.  I don’t think someone’s tolerance to pain is really important, instead it is important to help them get relief from whatever intensity of pain they are feeling.  Whether someone’s tolerance is high or low, the pain is due to a physical injury or psychosomatic, the amount of pain someone feels should be treated as the person describes it because the pain is real to them and nobody else can really understand or judge their pain.  

Marissa Patterson's picture

Pain and Circumcision

I wanted to comment a little bit on the question of something being painful (or in what way) if it is forgotten, such as with circumcision. I know that studies were mentioned in class about boys who had been circumcised having a lower threshold to pain as compared to those who had not, a few questions pop into my head.

The first is what exactly they were measuring when they say "pain threshold." I looked up the study (Effect of neonatal circumcision on pain response during subsequent routine vaccination, Taddio et al 1996). This study (the one that was frequently cited online) looked at pain response during vaccination for infants who had been circumcised with or without a lidocaine cream prior as well as uncircimcised infants. Key here, though, is that they are looking at 4-6 month old babies and at "percentage facial action, percentage cry time, and visual analogue scale pain scores."

Can these things actually provide an accurate measure of pain for an infant? We were talking alot in class about how relative pain is, and how specific it is for each person. I wonder if "facial action" can actually highlight pain sensitivity very well. Furthermore, how applicable is this study to adults? These studies were being done at most about 23 weeks after circumcision has taken place. What happens 23 YEARS later? Are these men still having differential pain tolerance to vaccination? What about to other types of pain? It is very difficult for me to look at a study such as this one and come out with the conclusion that "circumcision reduces pain threshold" as it simply appears far too specific.

aamen's picture

I was thinking about some

I was thinking about some of the questions that Emily brought up in her post during our discussion last week.  I’ve always been interested by the fact that different people experience different levels of pain in response to the same stimulus.  Is this because the intensity of stimulation that is necessary for peripheral activation of neurons is higher in some people than others, or because people’s brains process information from pain transmission neurons in different ways?  Or is it something else all together?  In the pain lab that some of us were in last semester, part of our experiment involved having participants rate when a heating device reached a painfully hot temperature.  I was interested by the fairly wide range of responses.  Although there are of course different psychological factors that could come into play, it seemed like temperatures that some people perceived as highly unpleasant and painful didn’t bother others, which implies (to me) actual neural differences and not some sort of “mental toughness”.  In terms of the question of whether we can change our neural environment when we decide to “tough out” pain, I could definitely believe that if we subject ourselves to the same originally painful stimulus repeatedly the way in which nociceptors or t-cells fire in response to this stimulus will change as well (causing less or more pain, I don’t know).

 

On a totally different note, I thought the part of our discussion on doctor assisted suicide was very interesting as well.  I’m from Oregon, where physician assisted suicide is legal (I think it’s the only state where this is the case?).  I admittedly don’t know a lot about it, but I was trying to remember after class what I’ve learned in the past about the “Death with Dignity Act”.  I believe that approving a patient under the act requires multiple physicians to confirm that the patient is in high levels of discomfort and has an incurable illness that will cause death in (I think) 6 months.  The patient is also required to undergo a psychological examination, because they have to be shown to be a mental state in which they are capable of making such a serious decision.  For example, we talked in class about how depression could affect a patient’s decision to end their lives, but under this act if a patient were evaluated as depressed they wouldn’t be given approval to go through with it.  I wanted to bring this up because it seems like all the rules and regulations involved in the act address a lot of the issues and concerns that people had in class with doctor assisted suicide, but on the other hand I know that there is a lot of controversy around it because the regulations make it difficult and time-consuming for patients to get approval, and to some degree this seems to almost defeat the purpose.  I’d be curious to know what other people think.

ebitler's picture

mental state & neural state

I also unfortunately was not able to come to class last week (but since I had a bad migraine all day I like to pretend that I was "studying" pain first hand.) What really interested me from the above posts was Emily's question: what if the individual differences in pain perception reflect neural differences rather than emotional differences?

I personally think that it's probably some combination of the two. It sounds like there was a good bit of evidence in class that altered mental states can alter pain perception. But I also think that changing your mental state with respect to pain does in fact change your neural state as well. I know from Wendy's pain class (and I don't know how much of this was talked about the other night) that there's some evidence that a person can exert top-down control to change the neural state. For example, if a person is in a mild amount of pain and they really need to direct their attention elsewhere, then a certain pattern of neural firing in specific brain structures will lead to activation of the endogenous opioid system. This seems to make sense to me given the knowledge that simply believing you're getting an active pain medication can lead to activation of the endogenous opioid system. So even changing your mental states can change your neural states. And since mental state varies from individual to individual, it makes sense that the neural state would vary across individuals just to reflect the mental states.

In thinking about individual differences about pain, I also keep thinking back to one of our lab projects over the summer (Kara's, actually) that used human participants. She was looking at pain in empathetic situations, and for each subject we ran a couple different pain tests. Each subject did a threshold test, a suprathreshold test, and an ice water bucket test. The threshold test consists of putting a probe on the subject's arm that heats up. The point where the temperature goes from just "hot" to "painful" was recorded. The suprathreshold test involved the probe heating up to a predetermined temperature (some were supposed to be very painful) and having the subject rate their pain. The ice water bucket was just that; subjects had to put their arm in ice water for 90 seconds and rate the intensity (physiological aspect) and unpleasantness (emotional aspect) on a scale every 20 seconds. My only point here is that we had to do all of these different tests because they all get at different aspects of pain that vary from individual to individual. One person isn't just sensitive or insensitive to all of the tests; it varies from test to test. The ice water bucket wasn't very painful at all for me, but I yelled at the experimenter who put the hot probe on my arm. This leads me to believe that there is something neural going on to account for individual difference, rather than just a state of mental toughness.

ehinchcl's picture

As I was unable to attend

As I was unable to attend class last week, I found some of the above comments particularly interesting. I don’t know what was said exactly, but the whole concept of ‘context’ of pain is a complex one that I would like to address. The example for me that comes to mind is athletics. Athletes have been known to suffer extreme injury and “play through” intense pain; even without injury we are told to work through the pain and pain is perceived as a good thing because it is a means to getting stronger/faster/better. Some of this ability to work through pain is ascribed to the effects of adrenaline—but I would argue that this is the CAUSE of situational/contextual differences for pain. It’s a compelling argument, for me anyway, to think that any differences in pain level due to situation must be due to the other bodily factors that are associated with that situation. To used the examples above: someone said that in a depressed state pain can be more intense and less bearable. Could this simply be due to the fact that other chemicals may be out of whack and therefore make the pain worse? We simply don’t know enough about the effects a certain situation has on the body, and what their relationship to the pain pathway might be.

 

To extend this idea further, also discussed above is the idea that we all may experience pain differently. Could this also be due to differences in our body states--- we always seem to consider these differences as mental/emotional differences, rather than attributing them to our bodies themselves. We say that someone is a “baby” when they “cant take the pain,” as if it is somehow a choice or something that can be overcome with increased mental toughness. What if its just due to differences in hormonal levels? Or neural circuitry? It is also interesting to consider this in the reverse—do we change our neural environment when we decide to tough it out? We’ve always stressed that the brain is an incredibly powerful tool, so this doesn’t seem too far fetched to me. I’d be interested to know what you all think…

kbrown's picture

Top down pain alteration

Hi everyone,

   I thought our discussion of pain measurement and pain processes were really interesting on Tuesday.  One thing that really caught my attention, like it seems to have caught some others in posts before this one, is our discussion on acupuncture as a possible means of pain treatment.  I thought this was particularly interesting in leu of our discussion the week previous about phantom pain and the placebo affect.  When discussing the results of acupuncture, and whether we can actually take any effectiveness as truly an effect of the treatment or a purely a placebo affect, I brought up the fact that my dog has had successful results from acupuncture treatment for hip dyslpasia as support for the opinion that acupuncture does treat pain through processes other than that of the placebo effect.  My thought process was that because presumably dogs, cats and other types of domestic animals are unaware that they are being treated, they do not have any expectations to get better, and therefore any effect of this type of alternative treatment is most likely due to the treatment itself.  However, I realized later that there are other factors that could be effecting alternative treatment on these animals.  For instance, it is possible that the stress involved in such treatment, or simply involved in a visit to the vet, could be triggoring a type of stress induced analgesia which may mimick a true effect of the treatment. 

Also in more broad terms, another question came to me when we were discussing top down processes for pain inhibition and intensification.  The types of psychological and social variables which qualify for this category seem to be things like catastrophizing and stress, however, I was jsut wondering where the placebo effect itself fits in.  My initial reaction is that the placebo effect is not a top down process because in my understanding it does not effectively "close" melzack and wall's pain gate but instead by encouraging the release of endogenous opioids (as Alex A. pointed out in the last discussion).  However, like catastrophizing the placebo effect seems to be based in a psychological state of mind, namely in the expectation of getting better.  So then, is there a qualitative difference between the way the placebo effect works and the way top down processes effect pain, or are they interconnected?

Emily Alspector's picture

The Beetle

I, like Stephanie, enjoyed the Beetle analogy. What disturbed me about the reading was that the doctors gave the older gentleman a higher dose of painkiller than he requested (or thought he needed). While it was somewhat heroic when I first read it, after I thought more about it, I felt the nurse and doctor had crossed some boundary by upping the dosage when the patient claimed he didn't need it. Whether the man truly did not feel the pain, wanted to look tough, or just didn't want to be given medication, that is not up to the doctor to decide. However, regarding the second patient who seemingly just wanted a fix, it was definitely necessary for the doctor to decide to ignore the patient's requests. I'm not exacty sure how a doctor is supposed to deal with a patient whos self-report is seemingly false (maybe that's where that cool new computer gadget can come in handy), but aside from my expertise in hospital drama tv shows, I'm not sure what the protocol is.

I'd like to briefly address the "all symptoms are psychosomatic" argument. Psychosomatic has a negative connotation behind it with the sense that it isn't actually real. However, as we discussed in our presentation, I'm not sure how much that matters. If I think hard enough that my ibuprofen is going to give me a stomach ache and then I get one, does that mean it isn't real? Is that psychosomatic? We don't know enough about the power of the innerworkings of our brains, and therefore cannot dismiss anything as merely "in the head". From another standpoint, if my ibuprofen bottle warns: may get stomach ache, and I get one, can I automatically attribute it to my ibuprofen? Even if it was caused by the medication, there is a psychosomatic element to all symptoms, but that doesn't mean that is all there is to them.

I also enjoyed our discussion about expectations of pain and which "hurts more". The fact that one person can have the same pain stimulus but in different situations can perceieve it differently is fascinating. If anyone has more information they can share on the current research trends of this topic I would love to learn more.

Someone also mentioned language of pain and how we don't have many ways of expressing ourselves (besides sharp, dull, etcetc). Being interested in language development, is anyone proficient in another language who may know if this is a universal phenomenon or if other languages have more explicit expressions of pain?

Danielle's picture

Describing pain is a challenge

     I think it is interesting to explore expectations of pain. Someone mentioned in class last week that if we are expect to be in pain it makes the pain less, less intense, and noticeable. While I think this is true, another component is also what emotional state a person is in when they feel the pain or when their actions lead to pain. If someone is in a very depressed state, as we discussed in class, pain can be more intense and the body is more susceptible to pain. My question is how do our perceptions of what pain is define how we rate the intensity of pain? Pain is a very independent and personal bodily expression, as proposed by the "beetle in the box" model. Since pain is so individual, pain scales are just irrelevant. I think these scales while they ultimately try to give a patient a sense of their pain, are primarily available to offer legal administration of opiates during severe pain. I think that these scales exist for legal purposes to ensure proper use and treatment using narcotic pain medications, but also to protect the health care provider.

            I also think Professor Grobstein brought up an interesting point, that we have a very hard time describing our pain. I think it’s hard to describe pain because there are so many emotional and social factors that influence our description of pain, including a limited pain vocabulary. While I think pain scales attempt to make a standard pain vocabulary, it is impossible that the select vocabulary would accurately gauge someone’s pain. The pain vocabulary is limited and is bias to one type of pain terminology and language. Pain is so personal that I think that a person has a hard time describing pain because they feel they are expected to use the pre-determined pain vocabulary that does not accurately describe what they are feeling. Like emotion, pain varies from person to person and the vocabulary used to describe pain varies according a person’s perception of pain.

            Another point that was not mentioned in the class discussion was hypochondriacs. Although this relates to somatoform disorders, discussed last week, I think it is very relevant to the discussion of pain, especially pain perception. Hypochondriacs believe that they are seriously ill, and experience a variety of physical symptoms, including severe pain. Perhaps these severe sensations of pain are related to distorted pain receptor pathways that cannot be identified by physicians. So it could be that these individuals are in extreme pain but there are no techniques or procedures to accurately diagnose a dysfunctional or distorted pain system. Since pain is a private and individual perception, perhaps people who are hypochondriacs are more sensitive to what some people might call small insignificant pains. It could be that a hypochondriac’s pain is the body’s form of announcing or flagging a problem within the brain.

 
natsu's picture

What makes the difference

I am glad that I have the opportunity to post right after Stephanie, because the comment she made about her experience with acupuncture really intrigued me.  I found it very interesting that she felt that at least part of the reason why her pain was relieved from acupuncture which is generally thought of as being at least some what "unscientific", was because she got  a scientific explanation for it.  This made me think back to the discussion we had on the placebo effect and how the way in which medication and care is offered from the physician to the patient might have a significant effect on how well the patient feels after treatment.  If Stephanie had received acupuncture with a ying-yang explanation, would she have felt better?  I also wonder if this is a cultural thing.  That is, would an Asian person feel relief from pain if the person received treatment from the same acupuncturist who offers the scientific muscle tension explanation?  I find it interesting that East World forms of treatment are being imported into western culture with some modifications so that they are easier to accept for westerners.  This seems to be something very important for health care providers to keep in mind when they leave the country to offer care to people in other parts of the world, or when American physicians must treat foreign patients who live in the US. 

Stephanie's picture

some points on pain

Our discussion of pain brought up some interesting and important points for me.

1) Pain still seems somewhat like a mystery- although we have theories and have mapped pain pathways and found neurons responsible for creating the pain sensation, it still seems like there is more going on that we just don't know about, and maybe we can't know about it- I enjoyed the "beetle in the box" analogy of pain- we can never fully know about another's pain- they can characterize it for us, but ultimately we can't completely know another's pain- only our own pain.  

2) I thought the definition of pain was interesting because it included both a "sensory" and "emotional" component- I would be interested to find out more about what this "emotional" component is made up of and possibly how our emotions can influence our pain, for better or for worse.

3) I think the idea of the "context" in which you experience pain is an interesting one.  I definitely believe where you are when you are in pain and what you are doing can have a significant impact on the pain you feel.  In class, the example of getting a bullet wound on the battle field versus getting a bullet wound sitting in your house.  I think both contexts will influence the pain in different ways.  We should also consider how context can help and influence our treatment of pain.

4) I also enjoyed our discussion of alternative treatments of pain- such as acupuncture.  I have personally had acupuncture and the philosophy of how it works was described much differently to me- I received  much more scientific explanation (no ying or yang)- I was told that for my tightened muscles, the needle is inserted into the knots and tight muscles, then the muscles, tighten around the needle, and when the needle is removed, the muscle in turn relaxes- creating more relaxed muscles, which takes away any muscular-derived pain.  I personally connect more with this explanation- it just makes more concrete, logical sense to me.  But, no matter what the explanation is for how acupuncture works- I think acupuncture has proved successful for treating the pain of many individuals.  

Paul Grobstein's picture

pain: nociception or something more?

As per our discussion, pain brings neuroscience importantly into the realm of a number of number of social/political controversies. It is indeed interesting, for example, that both doctors and scientists take pain in and of itself more seriously now than twent years ago. Once taken primarily as a signal of something else wrong and otherwise largely ignored as basically "subjective", pain is increasingly regarded (in the west at least) having "health" or other important significance in its own right. 

In this context, though, its interesting that most textbooks and other "scientific" sources (see Society for Neuroscience Brain Briefings) still tend to talk about pain in terms of nociceptors and specific brain pathways for pain. While significant work has certainly emerged from this emphasis, it retains the perspective that the origin of pain is in well-defined peripheral disturbances. A number of phenomena, including peristent pain, phantom limb pain, referred pain, neuropathic pain, and psychogenic pain, are not well accouted for from this perspective, suggesting that there is significant work yet to be done starting with the principle that "all symptoms are psychosomatic". New understandings from research with this starting point (cf "abnormal painful sensations might be related to the incongruence of motor intention and senory feedback") might not only yield improved therapies in many cases but also new understandings that could be significant in regard to social and political controversies. Among other things, it might encourage a useful blurring of the dichotomy between "physical" and "mental" and so encourage greater investment in both research and therpeutic approaches to what is actually going on inside the brain.