Bias: Is pain all the same?

The topic of how we define pain, and how humans respond to pain has come up for me as I mull over the IASP definition of pain. The current (new) definition is this:

An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.

Six key notes:

  • Pain is always a personal experience that is influenced to varying degrees by biological, psychological, and social factors.
  • Pain and nociception are different phenomena. Pain cannot be inferred solely from activity in sensory neurons.
  • Through their life experiences, individuals learn the concept of pain.
  • A person’s report of an experience as pain should be respected.
  • Although pain usually serves an adaptive role, it may have adverse effects on function and social and psychological well-being.
  • Verbal description is only one of several behaviors to express pain; inability to communicate does not negate the possibility that a human or a nonhuman animal experiences pain.

Now, for me the definition works fine – definitions describe and establish boundaries around what is being defined. Definitions don’t have to include all the uses of the term but instead just have to be distinct and clear, to “express the essential nature of something” as Merriam-Webster puts it.

Alongside this definition are notes about the function of pain – in other words, the notes (but not the definition) attempt to indicate why we experience pain. ‘An adaptive role‘ – in other words, pain serves a purpose in most cases and it may have adverse effects.

The question that leaps out to me now is what is the adaptive purpose of pain? This is the question that vexes many commentators who really don’t like the idea of what one author has called “maldynia“. Maldynia is thought to be “bad pain” that is severe, disabling and long-lived. I’m not fond of the word, but I do think there are pains that are not “adaptive” and these are amongst the ones that puzzle us the most in clinical practice. Things like phantom limb pain, nonspecific low back pain, complex regional pain syndrome and dear old fibromyalgia.

Back to the adaptive purpose of pain. Right now I have a cracked area on my heel. It’s quite a deep crack and it hurts every time I put my foot down. The way I’m using that information (the ‘ouch’) is to notice that yep, the crack is deep and there is tissue damage. And I am doing something about it by looking for urea-based cream and covering it while I work in the garden. I’ve (1) noticed tissue damage; (2) recognised that I need to do something about it; and (3) from experience, know that it will settle down and no longer be painful once the tissues have healed. I’ll also take care in the future to treat my heels so they remain soft as a baby’s bottom.

The metaphor of pain as an alert and action prompt serves quite well for me at the moment. And in most cases this is how we experience pain. Another example: I burned my thumb and finger on a soldering iron recently – you bet that hurt! I let go of the soldering iron PDQ, soaked my thumb and finger in cold water, then covered them until they had healed. The pain I experienced settled down after a day or so (unless I held a hot coffee cup!), and the new skin was a little tender for a couple of weeks. Again – pain served a purpose to alert me to stop doing dumb stuff, to protect the area, and to learn not to grab hold of the wrong end of the soldering iron! The metaphor of pain as an alert, call to action and learning experience again worked pretty well.

Now over the last few years I’ve had shoulder pain, imaging showed a bit of an enlarged bursa, a tiny fragment of calcification. This pain hasn’t settled down, even after I had cortisone injection AND did all the movement stuff including strength (yes – I did strength stuff!). Where oh where is the purpose or function of pain in this instance? Pain is not serving me well – I’ve been alerted, I’ve acted on that alert, nothing has changed and the metaphor breaks down.

But let’s take a look at the notes from IASP again – “Although pain usually serves an adaptive role” – usually. Usually. So there are times when pain does not serve an adaptive role. I think my shoulder pain, my groin pain, and my neck and back pain (yep, good old fibromyalgia) does not serve a function. I can’t think of any utility in having a grumpy body that really gripes about doing everyday movements like getting dressed, standing up from a chair, turning to look our the rear window of my car while I reverse down the driveway or aches in different parts of my body on different days then moves somewhere else at random.

A hidden assumption of the pain definition notes is that the “adaptive role” is reserved for those with a normally functioning nervous system, and where pain is associated with nociceptive activity, or inflammation. What if a nerve itself is damaged? What if the spinal cord is diseased or traumatised? What if there are changes to the way the nervous system processes information (we have that in every other sensory process, and in every other body system)? The experience of pain remains the same – still the same old aching, burning, gnawing, stinging sensations and the “ew”, “I don’t want this”, frustrating, totally unpleasant sensory and emotional experience as defined. The adaptive function, however? Not present.

The thing is, while I focus on persistent pain, most pain by far is not ongoing. I expect my heel crack to heal and the pain to go, and my now-slightly scarred finger and thumb are fine now.

Yes, the epidemiology of persistent pain shows that the prevalence of pain that goes on for more than three months is between 13–50% of adults in the UK. Of those who live with chronic pain, 10.4–14.3% were found to have moderate-to-severe disabling chronic pain (Fayaz, Croft, Langford, Donaldson & Jones, 2016). Similar findings for New Zealand – 16% of NZers live with pain lasting three months or more.

But given I think most of us will hurt ourselves at least once this year (especially with the lockdowns and stress of COVID19 and the economy and elections…), this means that more often than not, our experiences of pain are the acute kind. The ones that do alert us to notice what’s happening in our body, to take some kind of action, and to learn something useful from this experience.

So, while the metaphor of an alarm, alert, “danger signal” or “bear” or “beast” doesn’t hold up for all of our pain experiences, on the whole, it works. And the purpose of metaphor is “a way of conceiving of one thing in terms of another, and its primary function is understanding” (Lakoff and Johnson, 2003). Ultimately, we use metaphors like these to generate a sense of purpose for an experience that is commonplace, and the most common pain we have is a short-term, temporary one. Let’s not let my bias towards persistent pain lead me astray.

Fayaz A., Croft P., Langford R., Donaldson J., Jones G. Prevalence of chronic pain in the UK: a systematic review and meta-analysis of population studies. BMJ Open. 2016;6

Lakoff G, Johnson M. Metaphors we live by. Chicago: University of Chicago Press, 2003:36.

Merskey H., Bogduk N., editors. IASP task force on taxonomy, Part III: Pain Terms, A Current List with Definitions and Notes on Usage. IASP Press; Seattle, WA: 1994. pp. 209–214.

Musings on new learning

Over the past week I’ve been reading a book on embodied cognition, Intelligence in the Flesh: Why your mind needs your body, written by Guy Claxton. In this book, Claxton argues that we place far too much emphasis on abstract ideas of language and intelligence, and fail to recognise how intertwined our body and brain systems really are. It’s fascinating and raises many ideas and questions for me when I think of our pain experience.

To add to my musing, I had the great pleasure of attending the Australia and New Zealand Association for Contextual Behavioural Science conference in Wellington where I had the opportunity to have my mind blown by Steven Hayes and colleagues talking about a way of viewing language and behaviour from a functional contextual perspective (lots of links in this post because I can’t hope to do justice to the topics and I hope you’ll take the opportunity to click through to read more).

The truly weird thing is the links between these two aspects of being human: the one in which language is viewed in the context of whole body systems, and the one in which language (and thought) is viewed as a behaviour that develops as we grow and make connections between what is “out there” and what is “in here” – and all the abstract things in between.

I have no idea where this post will lead to, but here goes!

Let’s begin by thinking about how a baby experiences pain. Not that long ago it was believed that because babies can’t remember early life experiences and don’t have language to represent their experience, they didn’t feel pain. This, despite all of us knowing that when a baby is surprised by something external to them, when they want or need something, and times when they respond dramatically to an injection or being bumped, they react! And they react loud and clear.

Babies grow up into toddlers, and as they do we notice they develop associations between symbols and objects and experiences they interact with. Kids without hearing, in an environment where they’re surrounded by people using sign language, quickly develop the capability to represent experiences and objects with movements that mean something both to them and to those around them. Embodied cognition approach argues that the network of physiological responses flows in cycles between body and multiple parts of the brain to stamp “expected” patterns that begin to represent the world around us, and inside us. And we develop associations between internal and external objects that ultimately loop around many bits of the brain to ultimately be represented by symbols – words either spoken or gestured. Actually, according to Guy Claxton, these initial representations unfurl like ferns as a welling-up of associations and actions with multiple potential associations and actions that are either dampened down by past experience or allowed to develop dependent on intentions.

So, for example, a baby has a bunch of signals from his or her belly that flow and cycle around to various parts of the brain and endocrine system that represent what we know as “hunger”. Maybe initially it’s an urge to recapture that warm, safe, satisfied experience of having a full belly, but over time these signals develop more complex associations, with some representing “hunger”, others “milk”, “food”, “mummy”, “give me”, “want” and so on. As the baby develops, the associations between experiences and representations become far more complex and largely out of our “conscious” awareness, and these representations begin to develop a life of their own, so that as a two-year old, around dinner time, all those associations of “hungry”, “milk”, “food”, “mummy”, “give me”, “want” clamour for attention and the toddler has a melt-down! Seriously, perhaps for a toddler, being given a carrot which doesn’t fit with all those associations of  “hungry”, “milk”, “food”, “mummy”, “give me”, “want” actually doesn’t fit with the representations the toddler is trying to achieve at dinner time.

Let’s think about pain then. When a baby experiences the “yukkiness” of an empty belly – or the absence of “warm”, “mummy”, “food”, “safety” – he or she responds by crying. A baby’s whole body gets in on the act (you go watch one cry!) – and we respond. We use a bunch of words to talk to a baby when they fall down or get hurt – and they quickly learn that falling down or getting hurt isn’t nice – and that someone will come get them when they cry. Over time these experiences accumulate and the words we use for pain become associated with lots of unpleasant experiences like – cold, hungry, sad, tired, afraid, ouch, scratch, sore, comfort, abandonment, worry and so on. Soon enough any time we hear the word “ouch” or “pain”, or see a scratch or someone falling or ourselves falling, this constellation of associations are all activated, some more than others! Given how long we’ve been pairing all these associations together, it’s no wonder that pain, any pain, holds a whole bunch of meaning for us, many of which are deeply physical but also psychosocial.

At the same time as we make these connections, we’re also beginning to view “me” or “I” as somehow separate from what happens to us, and we’re all familiar with our internal narrative. This narrative contains not only the words we use to describe or narrate what’s happening, but also all those experiences and associations that go along with them. In contextual behavioural science, the representations of words, concepts, and all the associations between where, when, and how we connect these things are viewed as just as important as the words themselves.  This matters when we begin to believe that the representations (words, language) actually ARE what they “stand in for”. So, for example, if the word “pain” links with a whole bunch of experiences body processes, including perhaps not being helped to feel secure, or of fearing the worst, or of bad things happening to others around us (in life or TV even), it’s likely we’ll be experiencing those things as if they were happening in real life now. Pair that word with body experience which brings the whole to life again (in ways we can’t always express in language), and it’s no wonder many people are truly afraid of what’s going on – and act accordingly, perhaps without not really realising that this is happening. It’s like the unfurling of associations and actions occur independently of what we call “conscious thought”.

I know this is a fairly simplistic account of what I’ve been reading and learning about – and I have much more to learn and explore! But it strikes me that if our bodies are so comprehensively intertwined with the “what it is like” to be living in our world, it’s no wonder that only providing education about pain may not always be as powerful as we’d like. It helps me understand why experiencing our bodies doing things in different contexts while feeling safe/secure is so necessary. It also gives me more confidence that using metaphors (which represent our world or situations in symbols that straight words may not elicit) helps draw on these embodied representations and may elicit change more quickly than trying to “convince” or “tell” someone what’s going on.

I’d love to hear your thoughts – join in the conversation and let’s help each other make sense of this very groovy neuroscientific approach that integrates the social into our biopsychosocial framework.

The language of pain
Have you ever wondered about the ways we communicate our pain? Pain behaviour doesn’t just include nonverbal communication – one of the main ways we communicate our pain is through speech. Words are an incredibly powerful aspect of pain behaviour that strikes me as something we haven’t really studied much. When I was searching for the article to refer to in this post, I looked in PsychInfo under the terms “linguistics” and “pain” – and out of the tens of thousands of articles under each term, and total of 16 included both words. Sixteen!

The stimulus for this post comes from someone who said the term “catastrophising” is a misnomer – a way for health professionals to dismiss or minimise the suffering and distress someone who has pain is experiencing. In this person’s words “Now its no longer just a buzzword but a label that pain docs like to attach to everyone in chronic pain who indicates they are suffering. And of course as most pain docs dont particularly care for hearing about suffering of those in pain they then attempt to get them to go for some cbt or psychotropics.”

Now, I preface this next section with the notice that I’m no linguist (although it’s something I’d love to learn about!).  But in a paper by Elena Semino, it’s absolutely fascinating to read about the ways in which people describe pain – she starts by saying “sensations conveyed by the English word pain tend to be described via expressions that refer to potential causes of bodily damage.”  Note the word “causes”.  She gives the example of someone describing their pain as “sharp“, “like a rake over my eyes and head, digging in and scraping away”, noting that “expressions such as “sharp pain” function metonymically when they describe pain that directly results from physical damage, and metaphorically when no such damage is involved”.  (BTW Metonyms are figures of speech that replace a word with a word that is intimately associated with that thing or concept.  For example, in New Zealand “the Beehive” refers to Parliament, because that is the name of the building in which Parliament is housed.)

The reason we use terms like “sharp” or “stabbing”, argues Semino, is that “that these uses of metaphor may facilitate some form of internal embodied simulation of pain experiences on the part of listeners/readers, which may in turn provide the basis for an empathic response.”

Pain behaviour of all types functions in the same way – evolutionary psychologists suggest that they are remnants of early signalling behaviour designed to elicit a response from those around the individual.  It makes sense that if a group of prehistoric people are hunting, someone who has pain can signal to others through crying or groaning that “something’s wrong”, hopefully eliciting some sort of caring behaviour from the rest of the troup, with the withdrawal response later helping the individual remain still and quiet in the back of the cave so as to minimise the potential for sabretooth snacking!

What Semino and others postulate is that the language we use when describing pain draws upon the neurophysiological aspects of shared experience or empathy – the “mirror neurones”.   fMRI studies of the anterior cingulate cortex, the bilateral anterior insula, rostral anterior cingulate cortex and the sensorimotor areas of the neuromatrix (aka “pain” matrix – but this is probably a misnomer) show these are activated when individuals observe another person experiencing a painful procedure or hear words describing these procedures. 

Semino quotes Avenanti et al., (2005) who suggests that there are “two forms of empathy linked to one another in an evolutionary and developmental perspective.  A comparatively simple form of empathy, based on somatic resonance, may be primarily concerned with mapping external stimuli onto one’s body.  A more complex form of empathy, based on affective resonance, may deal with emotional sharing and with the evaluation of social bonds and interpersonal relations. p.958”.

Semino therefore proposes that metaphorical descriptions of pain that allude to causes of physical damage may trigger embodied simulations of similar experiences – and that both types of empathy are enacted when we use descriptive metaphors when talking about pain.

OK, where does this leave us when thinking about “catastrophising”? Catastrophising is the tendency to “think the worst” in a situation.  An example might be saying “my headache is killing me”.  Catastrophising influences an individuals appraisal of their situation.  Although this way of describing their situation does convey an individuals level of distress, catastrophic interpretations actually impede effective problem solving and active coping.  Catastrophising is associated with increased disability, high distress, low mood and high helplessness.

Is it normal to catastrophise?  At times, yes.  Most of us will do a little catastrophising from time to time, if we’re honest with ourselves.  But even if it’s normal, catastrophising isn’t helpful.  Again, most of us will catastrophise for a short while, then change our thinking and begin to speak differently and approach our situation differently – usually with a view to taking steps to exert some level of control over our situation.

I think it’s important to consider our use of language as health professionals, and it’s one reason for thinking about how we write reports, for example.  While we have our own technical language and use it amongst ourselves (and the term catastrophising is one of them) we need to be aware that people who don’t know the meaning of these terms can misconstrue them.  And in the case of some patients, feel misunderstood and sometimes offended.  We need to think about this and avoid using jargon where practicable.

More importantly, we need to be incredibly careful not to use terms in a pejorative or dismissive way.  We’ve moved a long way from describing a woman with pain as being “hysterical” – but terms like “functional pain” or “supratentorial” or “malingering” can still be found in some reports.

I think the best thing we can do when we’ve been talking with someone who does “catastrophise” is make it clear that we are not dismissing their pain as less than what they say it is, but instead to be sensitive to their language and reflect that their pain is very distressing and difficult to deal with.  Because in the end, that’s what the language used when sone tends to catastrophise is intended to elicit from us. 

Descriptions of Pain, Metaphor, and Embodied Simulation Metaphor and Symbol, 25 (4), 205-226 DOI: 10.1080/10926488.2010.510926

Avenanti, A., Bueti, D., Galati, G., & Aglioti, S. (2005). Transcranial magnetic stimulation highlights the sensorimotor side of empathy for pain. Nature Neuroscience, 8, 955-960.

Did you find him?

The man in the beans…

If you’re still looking – congratulations for your determination!!

Really, it’s not that hard, you just have to change your outlook – and perspective.

Go to the bottom third of the picture, and look between the beans…

Found him? Oh yes, he’s there!!

He’s really a metaphor for a bunch of concepts – like persistence, immersing yourself into data, changing your point of view, looking beyond the obvious, investigating, perception.

I find metaphors are great when working with people. I use them a lot.

Some of my metaphors for pain: pain sits on your lap when you’re driving, and what you want to be able to do is throw pain out of the car. You can’t, but you might be able to confine pain to the back seat, or even the boot (trunk for people from the US!).

Another metaphor is the squatter. Pain moves on in to your life, and takes over the kitchen, sitting at your dining table, eating your food, even sleeping in your bed! Sometimes pain comes and sits on your lap while you watch TV or read a book! You might never be able to completely evict your pain, but you can banish it to the garden shed (but watch out, if you’re not vigilant, your pain may well move in again…!).

The metaphor of diabetes management as similar to pain management: with diabetes we don’t think twice about using medication (insulin or whatever) to help control blood sugar levels. But at the same time, we don’t depend only on medications, we also need to consider lifestyle factors like exercise, eating healthy food, managing stress, and monitoring. Pain is similar – we can’t rely on any single thing to manage pain, we need everything we’ve got.

Do you have any metaphors that you use when working with people experiencing chronic ill health? Drop me a line – put in a comment, it’ll be great to share.

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