The Start to Solving the Problem of Chronic Pain Begins by Discovering Where It Lives
This X-ray shows two recording devices implanted in the shoulders and recording electrodes placed in the brain. Prasad Shirvalkar, M.D., Ph.D., UCSF. Permission pending from the National Institutes of Health.
Of all the somatic dysmorphic dysfunctions there are few others more malignly disabling to body, mind, and spirit than that of chronic pain.
Pain is a symptom and not a disease, but it takes on aspects of a disease state when it becomes chronic and intractable to treatment. Chronic pain has two very serious aspects. First, it is unusually resistant to traditional forms of treatment and, second, the emotional suffering becomes worse than the cause at some point. When the coping attempts become dysfunctional then the condition is termed chronic pain syndrome. Chronic back pain is the most common form of chronic pain with the expectation that 80 percent of all Americans will be affected by back pain at some point in their lives (Aronoff & Dupuy, 1999).
An estimated 86 million Americans suffer from some form of chronic pain. Forty percent of all medical patients seek treatment because of pain and 45 percent of will experience chronic pain sometime during our lifetimes. Pain, while it causes discomfort, often very severe suffering, and it is unwanted and inconvenient at best, is essential for the survival of the organism. It is our first-line alarm system for danger to the organism.
Pain is a holistic event involving the bodymind. Healthcare practitioners usually view pain as a symptom of something else that needs treatment. Yet pain that lingers long after the cause has been healed is extremely mysterious and problematic. Knowing the cause of a pain gives meaning to the experience and makes it slightly easier to bear, but unceasing pain without meaning is pure suffering. It is the quintessential symbol of disorder; of a body become anarchically sadistic. This condition is known as chronic pain. The effects of chronic pain are widespread and profound. First, unending pain cannot be tolerated by the physical organism beyond an unknown point and so that raises a variety of psycho-emotional and interpersonal issues. Next, society does not support persons in chronic pain as it is commonly believed that at a certain point the pain is not that bad and the person his or her self is perpetuating the problem or, worse, making it up. Chronic pain also indicates to the sufferer that something has gone wrong; that there has been a failure of some kind on the part of the healthcare treatment protocols. Also, patients with chronic pain are difficult for healthcare providers to help and manage and so slowly achieve the state of pariah after a certain point in time. Lastly, comes the paradox of pain itself. Pain is a purely subjective experience and its presence cannot be communicated to others or fully understood or appreciated by them. This makes it difficult for loved ones to continually support the pain sufferers and, over time, it diminishes the sick role status of the patient (Jackson, 2011).
Acute pain changes into chronic pain by two neural avenues of peripheral and central pathways. Peripheral pain is a product of damaged tissue. Pain then changes over time into a subacute state that lasts for a variable amount of time. A person could feel pain, depending on the severity of the injury, for hours, days, or weeks. This is the first phase of the development of chronic pain. The second phase is the sensitization of the central nervous system from the pain generated by an abnormal amplification of pain signals coming into the CNS. This begins at the spinal cord level and is when a person first begins to think that the pain is lasting longer than the healing. The chronic nature may be increased by a person’s behavioral responses to the pain. For example, a person may compensate for the discomfort by changing their posture or gait which in turn causes a joint or muscular problem. Pain, as its presence continues unabated, propagates further problems in the spheres of emotional, social, and economic functioning which then create more life stressors. Typical emotional responses to chronic suffering are anger, depression, helplessness, hopelessness, and dependency on other people and medications (Niv & Devor, 1999). Many chronic pain patients have the following characteristics: obsession with the pain, dependency needs, feeling isolated and alone, mild masochism (putting the needs of others before their own), poor coping skills, passive attitude, poor self-awareness about their own self-defeating behaviors, and inappropriate expressions of anger (Aronoff, 1999b).
Pain and Body Distortion
One issue regarding pain of interest here at the CBE site is how pain changes somatic perception and identity. It had been long presumed that a person with chronic pain in a specific body area would be overly attentive to caring for that body part, but this is not the case of persons with Complex Regional Pain Syndrome (CRPS). CRPS is the excessive and prolonged pain and inflammation from an injury to an arm or leg. It begins as an acute state, but can become chronic. Symptoms include pain, skin color changes, change in tissue temperature, and swelling. Other symptoms include changes in skin color, temperature, and/or swelling.
Chronic pain disturbs the body schema resulting in experiential distortions of body areas in pain. A good example is Complex Regional Pain Syndrome (CRPS) which results in autonomic, sensory, and motor dysfunctions. One study of persons with CRPS of the hands routinely reported that their hands felt larger than they actually were. The experiential distortions are most likely occurring in primary somatosensory cortex and the posterior parietal lobes (Peltz et al., 2011).
These people exhibit neglect behaviors similar to those with neurological deficits such as hemineglect. They often ignore their afflicted limbs by positioning them outside of their visual field. Others with chronic hand pain experience their hand as being larger than what it is or see it as a foreign entity. They often experience anger or hatred for their damaged limbs while others dissociate from owning the body part. When CRPS subjects envision their bodies, they see the painful area as grossly distorted in size and shape. Brain scans reveal that those with CRPS have disrupted cortical maps governing the afflicted body parts (Lewis et al., 2007).
People in chronic pain exist on a range of acceptance to rejection of their bodies. At one end of the spectrum, persons with chronic pain have come to unconditionally accept their suffering; that is, one surrenders to one’s fate. Next, other persons accept the pain, but only in the process of being able to manage it. This type of person experiences heightened body awareness which allows some control over the pain. Another kind of person finds his or herself swinging between hope to overcome the pain and the despair of being helpless against it. Finally, there is the person who rejects their own body as being defective, untrustworthy, and traitorous; the body for them is a prison and life is a living hell (Afrell, Beguet, & Rudebeck, 2007).
Finding the Cortical Lair of Chronic Pain
The attempts to understand and treat chronic pain it remains a mystery. Treatment strategies have been divided between the physical and the psychological. Chronic pain should be approached holistically as a complex somatopsychic process with negative emotional aspects such as rage, denial, inadequate coping choices, and poor support systems addressed along with the treatment protocol to relieve the physical suffering (Aronoff, 1999a).
The problem of certain types of chronic pain has remained intractable to treatment because of its nature. The pain occurs within the brain in areas previously unknown to science which means the most needed treatments cannot be developed.
Until today.
Past research of chronic pain was mainly based on subjective reports of pain levels. Typical tools were questionnaire scales of pain intensity and emotional response. Now, with the application of advanced brain scanning technology, the neural dynamics of chronic pain states have been located and mapped. A new study viewed at changes in brain activity in two regions where pain responses have been hypothesized to always occur: the anterior cingulate cortex (ACC) and the orbitofrontal cortex (OFC).
Researchers monitored the brain activity of three test subjects suffering from cerebral vascular accident (stroke) and one subject with phantom limb syndrome by inserting electrodes into their brains and telemetry packs under their skin. Subjects were asked several times a day to rate their pain level and emotional states while monitoring information was collected. This provided months of “snapshots” of brain state and pain level. Researchers were then able to predict pain level based on neural activity patterns.
Closing Thoughts
What does this mean. Well, first it is the first step to really getting a handle on the brain patterns of chronic pain. The next step is to develop new methods to modulate and control that previously uncontrollable activity.
Chronic pain is a horrible condition and it is hard to imagine it without being in that state. I witnessed a close friend and colleague die from cancer that had metastasized and entered his bones. The pain was horrendous, relentless, and non-stop. There were no means of dulling it or stopping it. This condition went on for several years with the pain increasing and spreading. It was an ungodly way to die and a terrible thing to see.
I find this research finding very heartening and hope that it leads to some viable treatment methods. Pain has been the eternal scourge of humanity since we developed nervous systems and it would be a miraculous thing indeed to see its uncontrollable nature reined in once and for all.
Paul Shane, Ph.D., LMT
Director, Academic Content
References
Afrell, M., Beguet, G., & Rudebeck, C. (2007). Living with a body in pain: Between acceptance and denial. Scandinavian Journal of Caring Sciences 21, p. 291-296.
Aronoff, G. (1999a). Psychodynamics and psychotherapy of the chronic pain syndrome. In G. Aronoff (Ed.), Evaluation and Treatment of Chronic Pain, Third Edition, Baltimore, MD: Williams & Wilkins, pp. 283-289.
Aronoff, G. (1999b). Psychiatric aspects of nonmalignant chronic pain: A new nosology. In G. Aronoff (Ed.), Evaluation and Treatment of Chronic Pain, Third Edition, Baltimore, MD: Williams & Wilkins, pp. 291-300.
Aronoff, G. & Dupuy, D. (1999). Evaluation and management of back pain: Preventing disability. In G. Aronoff (Ed.), Evaluation and Treatment of Chronic Pain, Third Edition, Baltimore, MD: Williams & Wilkins, pp. 217-224.
Jackson, J. (2011). Pain and bodies. In F. Mascia-Lees (Ed.), A Companion to the Anthropology of the Body and Embodiment, West Sussex, UK: John Wiley & Sons.
Lewis, J., Kersten, P., McCabe, C., McPherson, K., & Blake, D. (2007). Body perception disturbance: A contribution to pain in complex regional pain syndrome (CRPS). Pain 133, p. 111-119.
Niv, D. & Devor, M. (1999). Transition from acute to chronic pain. In G. Aronoff (Ed.), Evaluation and Treatment of Chronic Pain, Third Edition, Baltimore, MD: Williams & Wilkins, pp. 27-45.
Peltz, E., Seifert, F., Lanz, S., Müller, R., & Maihöfner, C. (2011). Impaired hand size estimation in CRPS. The Journal of Pain 12(10), p. 1095-1101.
Shirvalkar P., Prosky J., Chin G., Ahmadiopour, P., Sani, O., Desai, M., Schmitgen, A., Dawes, H., Shanechi, M., Starr, P., & Chang, E. (2023). Prediction of chronic pain state using intracranial neural biomarkers. Nature Neuroscience, p. 1090-1099.