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.

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?

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.

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…

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.

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?

 

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.

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.

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?

     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.

 

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.