The Definition of Pain

The Definition of Pain

The following definition of pain was established in 2017 by a taxonomy task force of the International Association for the Study of Pain: “Pain is an unpleasant sensory and emotional experience that is associated with actual or potential tissue damage or described in such terms.” If it is read carefully it is clear that pain is both a physical and emotional experience, and it is not only associated with tissue damage, but the potential for, or fear of, tissue damage. Fear is a very important aspect to be aware of. When you recognize that our fight or flight system, which is centered in our amygdala (often referred to as our “lizard brain”) cannot differentiate between a physical and an emotional threat, our understanding of pain expands.

While this definition seems to give equal weight to both emotional and physical experiences, the overwhelmingly physical focus of the medical system tends to blind people to what the definition seems to state so clearly; namely that pain is both physical and emotional. One cannot experience pain without one’s brain, and without a brain there can be no pain. So, by definition pain is firmly rooted in our brain.

This week The Guardian ran a science article with the headline, “Sufferers of chronic pain have long been told it’s all in their head. We now know that’s wrong.”  The article begins with the following passages.

It started with headaches and neck pain, but no sooner had Tricia Kalinowski’s physiotherapist come up with a strategy to tackle these problems, then another area of her body would start to hurt: her lower back, her hip or her jaw.

“The physio was chasing the pain up and down my body,” says Kalinowski, 60, from Minneapolis, US. Eventually, she was referred to an oral surgeon, who believed the root cause of these issues was a problem with one of the joints in her jaw, so she underwent surgery to replace a thumbnail-sized disc.

Unfortunately, the replacement was defective, triggering an immune reaction that resulted in the loss of several inches of jawbone. It took 13 rounds of surgery to fix the damage – the last of which was performed in 2015. “The irony to all the surgeries is that I still have headaches, I still have neck pain, and nobody really knows quite what to do about it,” she says.

The headline is provocative, and while it’s easy to understand why it is frustrating to be told that the pain is “all in one’s head”, this is clearly not what happened to the individual that the article begins with. In fact, it sounds like only physical approaches to dealing with the pain were taken, and that these approaches not only didn’t solve the problem, they seemingly led to more pervasive problems. However, if pain is both a physical and emotional response, then from a scientific perspective it would make the most sense to address both the physical and emotional aspects of it. Unfortunately, when it is suggested to people that their pain might have an emotional basis what they hear is, “it’s all in your head”. The problem seems to have more to do with the way in which words trigger emotional defenses than in a non emotional approach to science. In fact, there is so much resistance to looking towards the emotions that there seems to be all kinds of linguist contortions when discussing pain. The next paragraph reads,

Increasingly though, experts are waking up to the idea that chronic pain can occur without any obvious physical injury, or in a completely separate area of the body from the original site of tissue damage. There’s also mounting evidence that seemingly very different pain conditions – chronic headaches, low back pain and jaw pain, say – may share common underlying mechanisms, and that once a person develops one chronic pain condition, they’re predisposed to develop others.

The first line of that paragraph makes it clear that experts are waking up to the idea that the pain isn’t always connected any clear physical cause. Further, the same person may get many different chronic pain syndromes, “that may share common underlying mechanisms” and move all throughout the body without a clear understanding of how or why it is happening. At this point you might think that a scientist would check back in with that definition to seek clues. If they can’t find a physical cause then you might imagine they would examine the possibility of an emotional connection. However, the headline made it clear, “We now know that’s wrong.” What’s most surprising is that the article never addresses the idea that scientists have now proven that emotions are unrelated to pain. Instead there are several references to pain being connected to childhood trauma as well as depression. However, the article, and the other articles in the series, take an approach that borders on rage at the suggestion that of developing treatments that deal with the emotional aspects in order to address some of that trauma.

Here is a clip of Ashok Gupta from the UK making a great point about how the mind and body interact and the problem that sperating the mind (psychology) and the body (medicine) leads to a disconnection from understanding how the whole system works.

I am writing about this because I, and my partners, made a film about Dr John Sarno, who saw this problem of pain moving all over the body even though people came in with diagnoses of physical abnormalities that rarely aligned with where the pain was manifesting. Through careful attention and research he made the connection between pain and emotional trauma in the late 60’s. He studied medicine before the bio-technical approach that took hold in the 50’s pushed all discussion of the emotions to the edges of medicine, so it wasn’t a big leap for him. In the 1950’s he was reading journal article from the 30’s and 40’s that made the connection between stress and rheumatoid arthritis and other ailments. He had the insight that the pain he was seeing was often connected to suppressed rage. His theory, that small trauma’s from childhood like not getting needed emotional support, or being punished for emotional expression in early childhood, could lead to a learned repression of expressing one’s feelings. The young psyche learns to repress these emotions in order to stay safe. So, later in life the brain tries to keep us safe by making sure that these terrifying emotions don’t rise to conscious awareness. When our capacity to handle the stresses and strains of life begin to overwhelm us, limiting our ability to contain those emotions, he believed the brain created the pain to distract us from the this threat.

His prescription was knowledge. Learning to feel the emotions so that one might respond to them, and make the less terrifying, often helped his patients get out of pain. Still, many of his patients benefited from therapy that focused on increasing awareness of our emotions.

At the time none of his colleagues took him seriously and his work was dismissed. However, he kept seeing patients, and found great success in helping them heal. He wrote several books and had dozens of wildly famous clients who sang his praises. However, he was dismissed as not being rooted in science. Now, the definition of pain has expanded to include the emotional aspects, but that hasn’t changed practice in significant ways in regards to treatment that uses emotional awareness. In fact, as this article points out, even though pain is defined as being rooted in the emotions, very few people are willing to explore that idea. In fact, it’s met with some sense of horror in both patients and most doctors.

Still, in the last decade the idea of trauma informed treatment has begun to gain some footing. This approach asks clinicians to look at a patients whole story, to tease out what kind of trauma’s, big and small, might be affecting their health. Science and medicine move forward just like politics and history; in the form of a dialectic. The pendulum swings back and forth, seeking balance. However, things often get so out of balance that they create a build up of rage. The suggestion that our emotional history might affect our physical present will likely be met with great rage for some time to come.

I have a long family history of pain and illness that Dr Sarno was able to help heal. He helped my father, my brother, and me. That is how I came to make the film. In the past 15 year of working on, and distributing the film, I have gained a lot of insight into how these situations play out. I recently spoke with a science editor who acknowledged that much of what Sarno talked about has become accepted knowledge, but faulted him for not doing randomized controlled trials to prove his theories. Still, more people are doing those studies, and they will start to come out.

To be clear, I am not arguing that pain is all in anyone’s head even if I believe it is connected to emotional processes, often ones that we are less conscious of. Instead I am making the argument that when we separate the mind from the body we create a kind of willful blindness that makes it almost impossible for us to understand how the system works. If medicine refuses to look at the brain, especially the emotional aspects of consciousness and unconsciousness, even though the brain is codified in the definition of pain, then we are making it almost impossible to solve problems related to mind and body.



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