Pain: How much of it is just in your head?

Dear Writer,
Our team of researchers have gathered what we believe to be an excellent source of materials for your essay on how much of pain is in your head. We introduce the topic with definitions, case studies on fibromyalgia and capgras syndrome, along with differentiating between the mind and body with emotions and feelings.
In addition, we illustrated the biology of pain along with figures and videos to help you understand more clearly. We would like to thank you for giving us this opportunity to provide information in helping you write this essay and wish you luck during the process.
All the best,
Celine Davoudy, Gali Cohen, Murtuza Mohammed

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Introduction


Pain is defined as “subjective, multidimensional, and associated with social factors, behavioural states, affective responses, and cognitive responses”(Murphy, Tosi, & Pariser, 1989, p. 1343). The biopsychosocial (biological, psychological, and social) model of pain recognizes that pain experienced by individuals can be shaped by the overall interactions between biological, psychological, and sociocultural factors. Experiencing pain may be due to cognitive, emotional disturbance, which focuses on the "ABC" model - it expands “B” and adds "D" (physiological-biochemical responses) and “E” (behavioural responses). In the past, there has been a variety of research and outlooks towards treating pain. There was great importance in aiming for individuals’ rights, which progressively enhanced attitudes.

Fibromyalgia is an illness with extensive musculoskeletal pain along with tenderness in specific areas. Majority of individuals with this condition obtain psychiatric symptoms through the result of chronic pain, this is where the comorbid disorders come in; these include: depression/anxiety, sleep disorders, PTSD (Post-traumatic stress disorder), and pain. To understand more clearly, below, there is an image of an impact questionnaire for individuals who might be diagnosed with fibromyalgia. In understanding individuals’ pain perception, it is vital to explore their pain processing pathways and neurotransmitters.
In terms of the biological factor, the phenomena of pain is broken down into: inputs to body-self and outputs to brain areas; these are elaborated more in detail below. Generally, pain is identified by nociception, perception of pain, suffering, and pain behaviours. These can be played out in: transient pain, acute pain, or even chronic pain.

Head injuries such as Capgras syndrome are caused by damage in a certain area of the brain, also known as the “face area” of the brain. In these cases, people are incapable of recognizing faces, however, they can identify others (even themselves) by their voices as opposed to physical characteristics. There is a case introduced about a 44-year-old man who had developed this syndrome.

Finally, the phantom limb is introduced – when an individual’s arm or leg is amputated, they continue to feel the presence of their missing arm, even though they are fully mindful of the fact that their arm is not there. These individuals would have vivid sensations (e.g. waving their hands or petting a dog).

Murphy, M.A., Tosi, D.J., & Pariser, R.F. (1989). Psychological coping and the management of pain with cognitive restructuring and biofeedback: a case study and variation of cognitive experiential therapy. Psychological Reports, 64, 1343-1350.

Definitions


Somatic Depression: Individuals meeting the criteria for major depression associated with sleep, appetite, and sleep disturbances.
Post-Traumatic Stress Disorder (PTSD): Individuals experiencing stress that has reached its extreme, full extent.
Fibromyalgia: Individuals experiencing chronic pain, which involves tenderness and fatigue in multiple areas.
Homeostasis: Refers to our internal state or well being. When our bodies are lacking balance it can progress to many health problems so the body naturally fixes itself to maintain equilibrium of our internal body state.
Periaqueductal gray: An important site in ascending pain transmission. It receives sensory from nociceptive neurons in the spinal cord and sends projections to thalamic nuclei that process nociception. It is also a major component of a descending pain inhibitory system. "Activation of this system inhibits nociceptive neurons in the dorsal horn of the spinal cord" (Behbehani, 1995 p. 570).
Dorsal periaqueductal gray: A major site for processing of fear and anxiety. It interacts with the amygdala and its lesion alters fear and anxiety produced by stimulation of amygdala. "The stimulation produces vocalization and its lesion produces mutism" (Behbehani, 1995 p. 570).

Behbehani, M.M. (1995). Functional characteristics of the midbrain periaqueductal gray. Elseiver. 46, p. 570-575.

History of Pain


Treating pain has been a significant problem for years, however since 1945 new therapeutic alternatives have developed through research and theoretical perspectives. Pain is the oldest medical problem for mankind itself, however it has not been understood until today. Pain is considered to be the suffering affliction for humans throughout history. Pain was not only considered religious and political, but was also a major medical problem. Most often European physicians would relieve their patients’ pain through the judicious use of opium or laudanum (which is a mixture of opium in sherry) (Meldrum, 2003). They inflicted it to relieve evil humors or to amputate diseased limbs. To the physicians, pain was a sign of the patients' vitality. In the early 1800’s, the philosophy of pain changed. It had a greater focus on individuals’ rights, which gradually changed attitudes. To exemplify, a surgeon would put his skills to work and take pride in his ability to minimize pain by operating quickly. There was a realization with possibilities of minimizing pain through sedative gases. For example, ether was introduced to relieve toothache (Meldrum, 2003). With the attempt of relieving pain, surgical anesthesia was introduced. It was one of the great breakthroughs of modern medicine. However, a controversy arose on operating on unconscious patients both in Europe and the United States. This is because there was a possibility that the anesthesia might retard the healing process (Meldrum, 2003). The story of anesthesia determines the intricacy of pain as a phenomenon and the way in which societal meanings have complicated its treatment. It was concluded that the relief of physical pain was an advantage. By the mid 1800s, pain had become the focus of three known medical topics: The symptomatic relief of acute pain, the alleviation of severe pain from those suffering and dying of ongoing diseases such as cancer, and the relief of unbearable pain from disorders such as tension and migraine headaches (Meldrum, 2003). These three medical topics will be discussed more briefly throughout the biology of pain.

Meldrum, M. (2003). A Capsule History of Pain Management. JAMA: The Journal of the American Medical Association, 290(18), 2470-2475.

Emotion and feelings


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Before getting into the conversation of pain – where it actually is, or where it emerges from? Is it in the brain? Or brain is not involved in this process; before indulging in any of these questions let’s analyze the concept of pain through evolutionary processes.
So what is evolution? Evolution is a concept that is introduced by Charles Darwin. In simple words, evolution can be defined as simple organisms are getting better and more complex as time passes. (Evolution By Natural Selection, 2013). For example, life began with the single cellular organisms, and became more complex over time. For instance, amoeba and paramecium are the unicellular organisms that appear first in the world; later, multicellular organisms appear such as dinosaurs, birds, humans, etc.
The purpose of explaining evolution in this paragraph is that all living beings share some common basic principles with the single cellular organisms. To understand this explanation, let’s consider one example that is explained by Damasio in his book “Looking for Spinoza”. He says “All living organisms from the humble amoeba to the human are born with devices designed to solve automatically, no proper reasoning required, the basic problem of life. (Damasio, 2003, p. 30). In this statement Damasio is trying to explain, that even simple organisms have the capability to solve issues as they experience them. Furthermore, he clearly explains the challenges that simple organisms faces is similar to all living beings, which includes “finding sources of energy, incorporating and transforming energy, maintaining chemical balance, maintaining the organism’s structure etc.” (Damasio, 2003, p. 30). Through these quotes we could consider that the simple organisms do not possess brain, but their wants and needs are very common to all living species.
Based on the above evolutionary explanations, we could conclude that emotions occur first then feelings come after. Damasio argues that “emotions precede feelings” because “we have emotions first and feelings after. Evolution came up with emotions first and feelings later. Emotions are built from simple reactions that easily promote the survival of an organism and thus could easily prevail in evolution” (Damasio, 2003, pp. 29-30). To prove the argument of emotions precede feelings, Damasio proposed a very simple experiment in which he says “think of a lone paramecium, a simple unicellular organism, all body, no brain, no mind, swimming speedily away from a possible danger in a certain sector of its bath – maybe poking needle, or too many vibrations, or too much heat, or too little” would cause this organism to move to a safer place, because “these simple organism is designed to detect the signs of danger” (Damasio, 2003, pp. 40-41). With these explanations we could understand that “these brainless creatures already contain the essence of the process of emotion that we human have – detection of the presence of an object or event that recommends avoidance and evasion or endorsement and approach. The ability to react in this manner was not taught” to these unicellular organisms (Damasio, 2003, p. 41). Hence, it is true that feelings are the shadow of emotions – always after the emotions.

Damasio, A. (2003). Looking for Spinoza. Orlando: A Harvest Book Harcourt, Inc.
Evolution By Natural Selection. (2013). In The Pearson Custom Library for the Biological Sciences (pp. 55 -58). Pearson Learning Solutions.

Mind And Body


After understanding the concept of emotions and feelings, let’s consider how the mind and body react to feelings and emotions. From the above paragraph of emotion and feelings, it was clearly explained that these unicellular organisms do not possess a brain, but they could still detect the signs of danger, and try to find peace; this is the common behavior of all living beings. When we pin the paramecium, it feels uncomfortable, and it would move out of the way. They do not have a brain like us that would send signals of danger to tell them to move out of the way, but they have the emotions that cause it to move out of the way. So evolutionary speaking, body came first and then mind develops. Thus, emotions are experienced in the body and the feelings are experienced in the brain. Damasio also supports this idea, as he says “First came the machinery for producing reactions to an object or event, directed at the object or at the circumstances – the machinery of emotion. Second came the machinery for producing a brain map and then mental images, an idea for the reactions and for the resulting state of the organisms – the machinery of feeling" (Damasio, 2003, p. 80).

Every psychologist has different concepts of explaining mind and body. Some take a dualist approach that say mind and body are two different things. But some take an aspect dualist approach, which says that mind and body are two ASPECTS of the SAME THING. Similarly, Jonathan Haidt reported in his article that a French philosopher Michel de Montaigne went a step further and suggested that each part of the body has its own emotions and its own agenda. He explained this by giving an example of independence of penis where he says “We are right to note the license and disobedience of this member which thrusts itself forward so inopportunely when we do not want it to, and which so inopportunely lets us down when we most need it. It imperiously contests for authority with our will" (Haidt, 2005, pp. 5-10). He further explains that sometimes “our facial expressions betray our secret thoughts; our hair stands on end; our hearts race; our tongues fail to speak; and our bowels and anal sphincters undergo dilations and contractions proper to themselves, independent of our wishes or even opposed to them.” All these effects are caused by the autonomic nervous system which is a network of nerves that controls the organs and glands of our bodies, which is completely independent of voluntary or intentional control.
Based on the above discussion from Montaigne, Haidt took this mind and body concept a bit further and says that mind is the region of the "head brain and the body is the region of the gut brain. He says the gut brain possesses a high degree of autonomy, and it continues to function well even if the vagus nerve is severed – a nerve that connects the two brains together (right brain and left brain)" (Haidt, 2005, p. 6). Overall, when someone has infection in their intestine, the gut brain triggers anxiety in the head brain, which forces the sick person to act in the most cautious way, during his sickness (Haidt, 2005).

Damasio, A. (2003). Looking for Spinoza. Orlando: A Harvest Book Harcourt, Inc.
Haidt, J. (2005, May 11). The Divided Self. First Division: Mind vs. Body, pp. 5-10.

Experiment

The study by Sandner et.al explains the structures of brain that are active during emotion. They suggested that stimulation of either the dorsal periaqueductal gray or the medial hypothalamus induces aversive effects of resembling fear. Humans when stimulated in either the periaqueductal gray or the hypothalamus feel frightened and experience uncomfortable sensations (Sandne, et al., 1993). The study provides some examples that show that dorsal periaqueductal gray or medial hypothalamus stimulation elicits aversion in the rat.
The first example concerns the effect of electrical brain stimulation. Rats that were stimulated in dorsal periaqueductal gray or medial hypothalamus region, they learn an action that allows them to put an end to the stimulation, i.e. switch-off behavior. Once a rat has been trained to switch off the brain stimulation, the rat can calmly switch off the stimulation which reduces the aggressive/flight behavior. The switch-off behavior can be modulated by administration of drugs that is known to alter the state of anxiety (Sandne, et al., 1993).
The second example concerns the effects of chemical microinjections. Blocking the inhibitory GABAergic transmission within the dorsal periaqueductal gray (an anatomical and pharmacological target for the anxiolytic action of benzodiazepines) elicits place aversion.
When the rat was first injected with 6 micrograms of semicarbazide, the rat would spend most of its time in the cage. After a total of four injections, the rat spends less time in the cage, it spends most of its time outside the cage, and the rats were also observed to behave aggressively (Sandne, et al., 1993).
Thus, based on this experiment, it is clearly seen that emotions are performed by body, but it gets stimulation from the brain. Stimulating different regions of the brain of rats, with different test shows the different changes in the emotional state of the rat.

Sandne, G., Oberling, P., Silveira, M. C., Scala, G. D., Rocha, B., Abdallah, B., et al. (1993). What brain structures are active during emotions? Effects of brain stimulation elicited aversion on c-fos immunoreactivity and behavior. ElsevierScience Publishers B.V., 58(1-2), 9-18.

Pain and Cognitive Restructuring

In general, pain can be influenced by multiple psychological factors. A therapy model, which addresses multiple psychological factors in emotional or psychophysiological conditions, could collaborate with the management of pain. The Cognitive Experiential Therapy (CET) is based on the use of cognitive restructuring; it is an escape from the “ABC” theory of emotional disturbance (p. 1343, 1989). That said, CET “greatly expands “B” and adds “D” (physiological biochemical responses) and “E” (behavioural responses)” (Murphy, Tosi, & Pariser, 1989, p.1343).
In CET, cognitive restructuring takes place when an individual is relaxed or in a hypnotic state and proceeds through six developmental stages: awareness, exploration, commitment, implementation, internalization, and behavioural stabilization. The time span (past/present) and level of awareness (consciousness/unconsciousness) provide a core for the therapist to shift the client’s focus of attention to networks of A, B, C, D, E elements and towards their organization in time and awareness. That being said, “hypnosis and imagery have been shown to facilitate the rational restructuring of negative cognitive, emotional, physiological, and behavioural states” (Murphy, Tosi, & Pariser, 1989, p.1344), (which can also be known as “pain”) add a developmental dimension to the system.

There has been sufficient case studies introduced which include these following disorders: "migraine headache, depression with a schizophrenic male, anxiety, and pathological nonassertion when the treatment model has used behavioural rehearsal" (Murphy, Tosi, & Pariser, 1989, p. 1344).
Biofeedback is defined as “an intervention, which monitors the regulation of voluntary or autonomic functioning” (Murphy, Tosi, & Pariser, 1989, pp.1344). In the case study below, biofeedback (similar to hypnosis and imagery) was speculated to improve relaxation and interact with cognitive restructuring.

Murphy, M.A., Tosi, D.J., & Pariser, R.F. (1989). Psychological coping and the management of pain with cognitive restructuring and biofeedback: a case study and variation of cognitive experiential therapy. Psychological Reports, 64, 1343-1350.

Case Study

A client who was a 33-year-old woman was in a psychiatric setting; it was a structured therapeutic environment. She was hospitalized for major depression along with chronic muscular headache pain. In the course of the referral, the client reported abuse of Demerol prescribed for her headache pain. Murphy determined four-analyzed responses to the inventory, acquiring a four-factor solution: “health index, affective stability, repressed frustration, and anger & somatic anxiety” (Murphy, Tosi, & Pariser, 1989, pp.1345). The client disclosed that she had started experiencing headaches from age 11. At the beginning of treatment, she was divorcing her husband.

Prior to treatment, there was a collection of a 2-month history for the frequency, duration, and the level of intensity for her headache pain. The data revealed that the client experienced headaches on a regular basis. Generally, the pain lasted with a rating of 8 out of 10 on an intensity scale. There was self-report data collected on a weekly basis.

Treatment was initially aimed on the monitoring and management of the physical responses towards stress, which are correlated with autonomic arousal (Murphy, Tosi, & Pariser, 1989). Throughout the treatment sessions, the developmental stages were integrated. In the first session, the treatment included: deep breathing, counting as a technique, suggestions of warmth, imagining a relaxing scene, and passive concentration – all to improve the physiological management of pain (Murphy, M.A., p.1346, 1989).

In the “exploration stage” of treatment, the client was capable of identifying the event that triggered the headache pain. The pain began when her mother blamed her for the marriage conflicts and divorce of her parents. Her mother was unsympathetic when blaming her for the divorce. Once the client withdrew from this event, she experience headache pain (Murphy, Tosi, & Pariser, 1989). Her mother indicated sexual relations between the father and the client. Nonetheless, when the client experienced headache pain, her mother was more sympathetic. The client distinguished her beliefs as: “I am inferior, and to blame for my parents’ divorce, I am a failure with my present marriage” (Murphy, Tosi, & Pariser, 1989, p. 1346). Throughout several sessions, the therapist aimed her attention to the beliefs she held about herself and her present divorce.

In the “commitment stage”, the client was using biofeedback and cognitive restructuring skills concerning her present stressors and when headache pain was experienced in the past. Throughout this stage, the therapist “confronted the irrational and perfectionistic tendencies about the past and present, and reinforced more rational constructive tendencies" (Murphy, Tosi, & Pariser, 1989, p.1346). The client then began to manage negative affect, behave more accordingly, and reduce the intensity of her chronic headache pain (Murphy, Tosi, & Pariser, 1989).

In conclusion, following the ABCDE model, “her situation improved, cognitive processes were more rational, affect was more stable and manageable, physiological responses improved, and behaviour was stabilized” (Murphy, Tosi, & Pariser, 1989 p.1348). Her chronic headache pain was reduced and her coping with stress was improved.

Murphy, M.A., Tosi, D.J., & Pariser, R.F. (1989). Psychological coping and the management of pain with cognitive restructuring and biofeedback: a case study and variation of cognitive experiential therapy. Psychological Reports, 64, 1343-1350.

Fibromyalgia

Fibromyalgia is a disease of the soft tissue, muscles, and tendons. Individuals experiencing fibromyalgia take part in a history of pain for a minimum of 3 months, along with pain at 11 of 18 tender points. With fibromyalgia, symptoms like inflammation are not very visible, and point tenderness can be altered in location and number of points over a certain amount of time. It is very hard to detect the diagnosis, however, self-assessment tools may help. Physicians must confide on the physical examination and the history of the patient. The symptoms a patient with fibromyalgia experiences are “sleep disturbances, fatigue, depression, anxiety, poor concentration, irritable bowel, obesity” ( Thompson, Lettich, and Takeshita, 2003, p.211).

Critics identify fibromyalgia as a “psychosomatic disorder” mainly because over half of the patients meet the criteria for a psychiatric disorder. That said; majority of patients obtain psychiatric symptoms through the result of chronic pain.

Thompson, D., Lettich, L., & Takeshita, J. (2003). Fibromyalgia: An overview. Current Psychiatry Reports, 5(3), 211-217.

Comorbid Disorders

1. Depression and Anxiety
These are the consequences of chronic illness and pain associated with fibromyalgia disease. It is important for the diagnosis of depression to be considered, even though mood systems are a direct consequence of chronic pain (Thompson, 2003).

2. Sleep Disorders
In fibromyalgia, a lack of sleep is common and involves interference of alpha-waves into deep sleep. Considering that sleep disturbance in common in chronic syndromes including depression, it is vital to revoke other potential causes when encountered with dyssomnias (Thompson, 2003).

3. Stress Disorders and Post-Traumatic Stress Disorders (PTSD)
Stress intensifies fibromyalgia's symptoms: PTSD is triggered when stress has reached its climax. The most common cause in women is sexual trauma (15%), experiencing childhood sexual abuse (38%), adult rape (13%-20%), and a minimum of 20% are battered (Thompson, 2003). However, patients with fibromyalgia who have experienced sexual trauma will most probably account for somatic symptoms as opposed to identifying their abuse in the past. Sherman stated that “56% of patients with fibromyalgia had symptoms of PTSD” (Thompson, 2003, p.213).

4. Pain
Individuals experiencing pain along with their comorbid depression encounter a deeper extent of discomfort and poor quality of life as opposed to individuals who are not depressed. Pain affects women and men who are diagnosed with somatic depression more often in relation to those who are not diagnosed; however, they are still likely to experience pain.

Thompson, D., Lettich, L., & Takeshita, J. (2003). Fibromyalgia: An overview. Current Psychiatry Reports, 5(3), 211-217.

Fibromyalgia Impact Questionnaire

Click the image for magnification.

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Pathophysiology

Pain Pathways and Neurotransmitters

Fibromyalgia is correlated with “allodynia (pain from nonpainful stimulus) and hyperalgesia (magnified pain response)” ( Thompson, Lettich, & Takeshita, 2003, p. 214). Exploring individuals’ pain processing pathways is an important factor in understanding their pain perception clearly. There are two pathways that stimulate within the process: fibers in the ascending and descending pathways. “The descending pathways employ serotonin via the rostral venomedial medulla and norepinephrine via dorsolateral pontine catecholamine cell groups” (Thompson, Lettich, & Takeshita, 2003, p. 217).

Researchers have been looking for physiologic links; they found two studies. These studies were focused on individuals with the roles of serotonin and norepinephrine. In one study, patients with fibromyalgia were matched to patients with rheumatoid arthritis and control individuals; the patients with fibromyalgia had lower serotonin levels. Another study indicated these particular individuals with lower levels of central spinal fluid in norepinephrine (Thompson, Lettich, & Takeshita, 2003).

Neurokinin receptors are responsible for substance P induction – these are responsible for pain transmission. Serotonin has an effect on releasing substance P, which then leads to increasing the transmission of painful stimuli (Thompson, 2003).

“Altered serotonin metabolism was more common in 62 patients with fibromyalgia than in control individuals. The promoter region of the serotonin transport gene was analyzed, and patients with fibromyalgia were more likely to carry the S/S genotype, which was also associated with higher rates of depressive symptoms” (Thompson, 2003, p. 217).

Thompson, D., Lettich, L., & Takeshita, J. (2003). Fibromyalgia: An overview. Current Psychiatry Reports, 5(3), 211-217.

Hypothalamic-Pituitary-Adrenal axis and Neurotransmitters

There are two factors that play key roles in fibromyalgia: dysregulation of the HPA axis and its key mediator, and the corticotrophin-releasing hormone. Serotonin and norepinephrine stimulate CRH neurons can stimulate and result to the release of adrenocorticotropic hormone (ACTH), which leads to secretion of glucocorticoids at the level of the adrenal gland. A lack of hormonal levels may have intense effects on the HPA axis by preventing appropriate feedback (Thompson, 2003).
Adrenocorticotropin hormone and cortisol levels are uplifted in patients with fibromyalgia - this is usually associated with hyper arousal or depression. "A recent study demonstrated a disconnection between cortisol and psychosocial or lifestyle-related issues" (Thompson, 2003, p. 217).

Uplifted cortisol levels in 21 patients with fibromyalgia could not be affiliated to any ongoing or acute stressors. In the HPA axis, there was a delayed (but exaggerated) ACTH response to CRH with fibromyalgia patients “versus control individuals and a bunted cortisol response to CRH challenge” (Thompson, 2003, p. 217).

Thompson, D., Lettich, L., & Takeshita, J. (2003). Fibromyalgia: An overview. Current Psychiatry Reports, 5(3), 211-217.

Hypothalamic-Pituitary-Adrenal axis and Estrogen

There is a relationship between fibromyalgia and estrogen, specifically within the female preponderance of the disorder.
Estrogen is defined as “one of the several substances that upregulates neurotransmitters, such as serotonin and norepinephrine” (Thompson, Lettich, & Takeshita, 2003, p. 217). Considering the fact that these have significant relationships to mood and pain, lower levels of estrogen (e.g. menopause), can impair the neurotransmitter-HPA axis feedback loops (Thompson, 2003).

Thompson, D., Lettich, L., & Takeshita, J. (2003). Fibromyalgia: An overview. Current Psychiatry Reports, 5(3), 211-217.

Biology of Pain

This image below breaks down the phenomena of pain. On the left side it shows the input to the neuromatrix (a word that describes the brain), and on the right side it shows the output of the brain, which is based on the input (shown on the left side).

bodyselfneuromatrix.gif

“Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage” (Loeser & Melzack, 1999, p. 1607).
Pain can be identified in 4 categories, these subsets of pain are anatomical, physiological, and psychological substrates:
Nociception – this subset of pain detects tissue damage because it has specialized transducers attached to A delta and C fibers. These transducers can be flawed by inflammatory and neural changes in their immediate environment (Loeser & Melzack, 1999). Medicinal drugs such as aspirin and acetaminophen act to attack the inflammation and produce pain relief mainly by restoring nociceptive sensitivity to it’s resting state (Loeser & Melzack, 1999). As well as Anesthesia can also prohibit nociception from becoming pain, along with downstream modulation.
Perception of pain- is often triggered by injury or disease that often promotes a noxious stimulus. Perception of pain can often be seen in patients who have experienced diabetic neuropathy, spinal-cord injury or stroke when the lesions in the peripheral and central nervous system are being detected (Loeser & Melzack, 1999). Autonomic and somatic reflexes are associated when acute pain occurs, however with patients who suffer from chronic pain these effects disappear. When relating injury and pain, nerve injury does not respond to analgesics (such as morphine) as efficiently as it does to tissue damage(Loeser & Melzack, 1999).
Suffering-creates a negative response that is brought by pain along with psychological states such as fear, anxiety and stress. Language is used to describe pain alternatively from suffering itself, no matter what the cause is, which ultimately confuses both the doctor and the patient as to the level of the suffering (Loeser & Melzack, 1999). When the patient endures suffering, their physical and psychological integrity are defenseless. Finally suffering is not always caused by pain but in our culture we label suffering with pain.
Pain behaviors – is the outcome of pain and suffering along with what a person’s actions may be, which may lead to tissue damage. Examples of these behaviors include expressing pain verbally (e.g. saying “ouch”) limping, lying down, resorting to health care, and refusing to work (Loeser & Melzack, 1999). These behaviors are influenced by anticipated environmental consequences. Through pain behaviors and the history of physical information, we interpret the existence of nociception, pain and suffering.

Loeser, D. J., & Melzack, R. (1999). Pain: an overview. The Lancet, 353, 1608-1609.

Types of pain:

Transient Pain : is evoked by the initial activation of the nociceptive transducers in the skin or other tissues in the body, when tissue damage is not present. After stimulation is applied, the function of transient pain has two relations: its speed of onset and its speed of offset (Loeser & Melzack, 1999). The speed of offset indicates that the physical disturbance is no longer intruding the body. This type of pain had evolved to protect individuals from stress within the body tissues along with physical damage from the environment. In terms of the clinical setting, transient pain is seen strictly in incidental and procedural pain (e.g. injection for immunization) (Loeser & Melzack, 1999). It remains the common conceptual model in health care.
Acute Pain: is provoked by injury of body tissue and the activation of nociceptive transducers, where local tissue damage is present. The local injury shifts the response characteristics of the nociceptors, central connections and autonomic nervous systems (Loeser & Melzack, 1999). The local injury does not overpower the body’s healing mechanism (homeostasis), it can occur without medical intervention. However this intervention can be useful in two ways, to prevent/reduce pain and to speed up the healing process. This type of pain is most often in effect after trauma, surgical interventions, and certain diseases (Loeser & Melzack, 1999). Considering the healing process takes place only a few days or weeks, pain that lasts months or years, does not identify as acute.
Chronic Pain: includes low back pain and fibromyalgia, which are triggered by an injury or disease along with influences apart from the cause of pain. The injury may surpass the body’s ability to heal due to the loss of the body part, the range of the trauma and scarring or the partaking of the nervous system within the injury (Loeser & Melzack, 1999). All types of chronic pain lead individuals to pursue health care, but are not treated adequately. Considering chronic pain being ceaseless, it is likely that stress, environmental and effective aspects may overlap on the damage tissue and contribute to the severity and the ongoing of the pain (Loeser & Melzack, 1999).
Chronic Pain will continue when treatment stops, since the cause of individuals’ perception of pain disregards medical treatments, psychological forms of therapy (cognitive and behavioral treatments can shift the effect of the pain in an individual’s life). As the brain is modified by experience (specifically in early life the brain can have the capacity change the way pain producing information is processed to decrease its impact (Loeser & Melzack, 1999). It is not the duration of pain that differentiates acute from chronic pain, but specifically not being able to reinforce its physiological functions to normal homeostatic levels (Loeser & Melzack, 1999).

Loeser, D. J., & Melzack, R. (1999). Pain: an overview. The Lancet, 353, 1608-1609.

Examples of Pain due to Head Injuries


Capgras syndrome

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It is the syndrome that is caused by the damage in the gyrus (the area in the brain, can be seen in the picture). It is also called as the face area in the brain, because when it is damaged people are incapable of recognizing faces; they cannot even recognize their own face. However, they can still recognize themselves, and others by their voices, but they cannot point them out as “ohh that’s you” (Weston & Whitlock, 1971).

Weston, M. J., & Whitlock, F. A. (1971). The Capgras Syndrome Following Head Injury. The British Journal of Psychiatry, 119(25), 25-31.

Capgras Syndrome Case Study

The case study by Alexander et.al (1979) states that there was one individual who was 44 years old and he had developed capgras syndrome. He was a very healthy individual, but due to recession and unemployment he was very much worried about his life, and he was not able to bear the stress. He slept less than two hours a day, which caused him to develop grandiose, paranoid delusions, and had auditory hallucinations, which was related to his job. Auditory hallucination is an experience that involves the apparent perception of something that is not present (Nayania & Davida, 2009). For example in this case study, the patient would hear someone calling him, or talking to him, but in reality nobody would call him nor talk to him.
Later, the patient got in an accident, where he thought someone called him so he jumped out of the car, and got struck by another vehicle. This caused him to go into a coma. The doctors were trying their best to cure him, but they noticed that at this time (four weeks after the accident) the patient was inattentive, forgetful, incontinent, and unable to stand. After nine months of the accident, the patient came out of the coma, but he did not fully recover; he developed capgras syndrome. His behaviour was very normal, as if nothing had happened to him, but when he sees their relatives, friends, or any other person that he may know; he would identify them as imposters. After ten months of the accident when he was brought back to his home, he said “I live with a second family, virtually identical with the first family and they lived in a house just like the one I had lived in previously” (Alexander, Stuss, & Benson, 1979, p. 334). "He remained forgetful, apathetic, and slovenly. Although he seemed to recognize his friends, the “reduplication” of his family persisted. At this time the hallucination was not noticed, and besides that he never displayed agitation or anger to anyone, including his wife" (Alexander, Stuss, & Benson, 1979, p. 334).
Later he was scanned with EEG, and the results were normal. But the Computerized tomography (CT) scan revealed a surgical bony defect, atrophy of the right frontal and temporal regions, considerable patchy decrease in density in the left inferomedial frontal lobe, and generalized ventricular enlargement in the frontal horns, greater on the right (please refer to the figure A and B on the right).

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When people talked to him about his relatives he insisted that he had two families of identical composition. The wives of both families had the same given name, the same maiden name, very similar appearance and manner. She came from the same town, and had brothers with the same names. There were five children in each family, with the same names and the same sex distribution, although he believed the children of his original family were about 1 year younger than those in the second family. Although he insisted that they were distinct and that he could tell them apart, he could provide no details by which they could be differentiated. He described positive feelings towards “both wives”, showed no anger or distress about his first wife’s desertion, and specifically expressed thankfulness that she had located a substitute. He insisted that he had not seen the first family since that time, nor had he attempted to see them. When direct questions were asked, such as how both families had been separated, responses became vague and evasive, and he says “You’re asking difficult questions!” (Alexander, Stuss, & Benson, 1979, p. 335).
He was repeatedly told that his perception of two separate families was incorrect, and he could accept both of them as one since he cannot provide rational reason of how he got separated from the first family. When he was re-interviewed a couple months later, he recalled discussing the implausibility of his story, but still insisted that he had two families.
The neurological evaluation of the patient showed disturbance of emotions in the frontal dysfunction. Language testing was generally within normal limits, and assessment of cognitive functions revealed normal performance in many areas, especially when previously learned material was involved. His Wechsler Adult Intelligence Scale (WAIS) results had improved.
On tests of recognition of verbal and nonverbal recurring figures, there was much difficulty with nonverbal figures, as a result suggesting that right temporal lobe dysfunction. Verbal interference resulted in impaired performance in recall of three consonants, and recall for consonants presented visually was significantly lower than for the consonants presented orally.
The analysis from the neuropsychological strongly suggests frontal pathology, with indications of right hemisphere dysfunction, particularly frontal and temporal regions.
This patient had a serious head injury with prolonged coma, suggesting deep diencephalic damage, and surgically seen severe right frontal damage. The initial confusion and amnesia improved throughout several months. At the time of improving but still impaired memory function, a trivial change in his wife’s routine apparently precipitated a lasting delusion of reduplication. Later, he had minimal memory dysfunction and could rationally discuss the preposterous nature of his reduplication, but could not be swayed from the strong feeling that he was correct. In addition, he remained euphoric, apathetic, and tangential. Neuropsychologicalal and neuroradiologic data confirmed bilateral frontal and extensive right hemisphere abnormality.

Alexander, M. P., Stuss, D. T., & Benson, D. F. (1979). Capgras syndrome:A reduplicative phenomenon. NEUROLOGY, 29(3), 334 339.
Nayania, T. H., & Davida, A. S. (2009). The auditory hallucination: a phenomenological survey. Psychological Medicine, 177-189.

Capgras delusion

Explained by Ramachandran, V in a Ted Talk Video

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This is very rare syndrome and it occurs due to head injury. When this patient sees his relatives, friends, parents, spouse, pet or any person (that he knows before his head injury), he is able to recognise them, however he thinks that they are pretending. For example, when this patient sees his mother, he would say “This woman looks exactly like my mother, but she's an impostor. She's some other woman pretending to be my mother”. They are intelligent in all other aspects, but they are not able to recognise people due to injury in the fusiform gyrus (area of the brain responsible to recognise faces). If the patient’s mom talk to him on a phone he could recognise the voice, and he could picture his mom, but if his mom come face to face he would again say “you pretending to be like my mother”.
The reason behind this scenario is that there is a wire (not shown in the picture) that goes from the amygdala to the limbic system, the emotional core of the brain. This wire is cut by accident but the other parts are not disturbed, the patient could recognise his mother, but cannot confidently say that she is his mother. The patient can fully recognise the voice of her mother because there is a separate pathway going from the hearing centers in the brain to the emotional centers, and that has not been cut by an accident. So this explains why through the phone he recognizes his mother, without any difficulty, but when he sees her in person, he says she is an impostor.

Ramachandran, V. (2007, March 27). 3 clues to understanding your brain. (V. Ramachandran, Performer) Ted Talk.

Phantom Limb

Explained by Ramachandran, V in a Ted Talk Video

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When a patient’s arm or leg is amputated, from infection, or it got cut in war, they continue to feel the presence of that missing arm, and that's called a phantom limb. Patients are fully aware that the arm is not there but they have very vivid sensations, such as they can wave their hand to say good bye or they could pat someone.
Some patients have a paralyzed phantom arm, this paralysis in the arm is not due to injury but it was originally there prior to the phantom surgery. The nerve in the actual arm was damaged (may be due to an accident). Therefore, the patient has a painful arm, and to cure it, the surgeon amputates the arm, now this has become the phantom paralyzed arm.
This is very painful to the patients because the brain orders them to move their phantom arm, but the hand says no. Through this confusion, pain is not released as he could not follow brain’s command. This also indicates that the body performs its functions on its own, not always relying on the signals from the brain.
To cure these patients with their paralyzed phantom arm, Dr. Ramachandran develops a mirror box, in which he advises his patients to place the paralyzed arm in the box, when the patient places his phantom arm in the mirror box, he/she experiences that their phantom arm has been resurrected, because they would be looking at the reflection of the full arm in the mirror. Then he told them to move the full arm, looking at the mirror. When the patient wiggles his full arm looking in the mirror, he says “Oh my God, my phantom is moving again, and the pain, the clenching spasm, is relieved”.
The biology behind this process is that the brain is faced with tremendous sensory conflict. It's getting messages from vision saying the phantom is back. On the other hand, muscle signals saying that there is no arm. The motor command saying there is an arm, because of these conflicts, the brain says, there is no phantom, it goes into a sort of denial, and it gates the signals, which removes the pain.

Ramachandran, V. (2007, March 27). 3 clues to understanding your brain. (V. Ramachandran, Performer) Ted Talk.

Following this Ted Talk by Vilayanur Ramachandran, in which he explain Capgras Syndrome, Capgras Syndrome Delusion, and the Phantom Limb.

Vilayanur Ramachandran tells us what brain damage can reveal about the connection between celebral tissue and the mind, in Ted Talk.


Conclusion


Neural networks are extensively spread out throughout the brain in order to create an image of self through genetic programs and memories of past experiences. Pain is produced through the afferent inputs that act on the neuromatrix (in relation to the brain and pain) that produce output patterns, leading an individual experiencing the feeling of pain (Loeser and Melzack, 1999). The cause of stress however can cause the relationship between the neuromatrix and the peripheral stimuli to alter, as well as other factors like learned experiences and expectations. Serious significant acute pain usually always involves tissue damage. The peripheral and central nervous system work together and are regulated by tissue damage (Loeser and Melzack, 1999). When damage is detected both the central nervous system and the stress regulation systems work correspondingly to create a response to such damage. This is also called homeostasis. Now however, we are quickly starting to gain more information that can potentially be effective to find better care for those who suffer from pain.

Loeser, D. J., & Melzack, R. (1999). Pain: an overview. The Lancet, 353, 1608-1609.

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