0. Introduction – Pain, Personality and Psychotherapy
The topic of pain arose from a conversation with a friend recently back from
Margaret Lock’s book, Encounters with Aging: mythologies of menopause in
The patients in Freud and Breuer’s Studies in Hysteria complained of an array of physical as well as emotional symptoms, and were treated with a range of therapies, including massage, hypnosis and talk therapy. It was only later that Freud’s methods centered on the talking cure alone, and linked both physical and emotional symptoms in such patients to shameful early childhood experiences and fantasies. Freud’s talking cure, on which modern psychotherapy rests, was undoubtedly successful. But perhaps there is also room for the patient, attentive listening of the Japanese traditional doctor.
0.1. The Physiology of Pain
Pain is the sense that signals damage to the integrity of the body. It is essential for our survival, and without pain patients with congenital analgesia and leprosy do serious damage to their skin and joints that can ultimately be lethal in the absence of medical treatment. Pain tells us to move our finger away from the fire, to see a doctor when we are ill, or to rest our limbs when we recover from surgery. Yet most pain is useless. The death pains of cancer and other illnesses come too late to serve any useful function. Without powerful painkillers, most animals and humans would probably die in pain. Many headaches, backaches, and chronic aches and pains are associated with no lesions or damage to bodily tissues. Sometimes pains are caused by damage to the nervous system, as in neuropathic pain, post-herpetic neuralgia, or phantom limb syndrome. Sometimes there is no medical explanation at all. Conversely, studies by Patrick Wall and others have shown that most wartime amputees experienced no pain on the battlefield in the moment they lost their limb, although almost all of them experienced phantom limb pain within weeks of the injury that persisted 15 years later. Pain is a clunky warning system, and both false alarms and misses abound. It is a bad scientist who often brings us erroneous knowledge about our own body. Yet it is all we have, and at times we ignore it at our peril, insofar as we can ignore it at all.
Pain was defined by the International Association for the Study of Pain in the 1970’s as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage, or both.” What we know about the physiology of pain comes from relatively recent discoveries in the past 30-40 years (Usanoff, 2006).
There are no specific sensory receptors for pain, only free nerve-endings distributed throughout the body, including the skin and the linings of the internal organs, and the bones. These nerve endings contain clusters of small, clear vesicles as well as strands of endoplasmic reticulum, concentrations of mitochondria, and sometimes glycogen granules, suggesting that they interact chemically with the surrounding tissue in an energy-intensive fashion. These ‘sensory beads’ were first described by Ramon Y Cajal (1909), who also observed that the density of nerve endings in the cornea was 300-600 times that of the skin. The nerve endings release peptide molecules when they are stimulated, and these are thought to modulate the pain response, enhancing it and making the membrane more likely to depolarize again. Stimulation at the tip or anywhere along the nerve fiber gives the same pain sensations, resulting from a depolarization of the cell membrane that travels as an electrical impulse along the nerve fiber and reaches the central nervous system (CNS, the spinal cord and the brain).
Several different kinds of pain-fibers or nociceptors exist. Some rapidly conduct ‘first pain’, equivalent to a sharp, pricking sensation, whereas others slowly conduct ‘second pain’, a dull burning sensation. This distinction between first and second pain was proposed by Goldschneider as early as 1881. Most nociceptors fall into two classes, the thinly myelinated A-delta fibers that carry impulses at around 5-30 m/s, and the unmyelinated C-fibers whose conduction velocity is 0.5-2 m/s. The latter do not discriminate between different kinds of noxious (unpleasant) stimuli, and respond to mechanical, chemical and temperature changes, whereas the A-delta fibers respond mostly to mechanical pressure. According to Wall (2000), the C-fibers carry chemical messengers as well as electrical impulses.
Where they synapse within the CNS the nociceptors release the fast-acting excitatory neurotransmitter glutamate. Several other chemicals are released by nociceptors, at both ends, when they are activated. These include various peptides, enkephalin, brain-derived neurotrophic factor, and nitric oxide. These are thought to serve various neuromodulatory functions, enhancing or inhibiting neural activation and the transmission of pain, and possibly mediating background somatic sensations including awareness of the body.
The free nerve endings are found close to small blood vessels (capillaries) and mast cells in most bodily tissues, such as connective tissue capsules, the periosteum lining the bones, inside skeletal muscle fibers, the intestines, the lungs and the heart, the dental pulp, and the peritoneum that lines the abdominal cavity. Free nerve endings are generously distributed in avascular tissue not supplied directly by small blood vessels, such as the skin, the cornea, and the mucosa epithelia. They are most densely arrayed in the cornea, the dental pulp, the skin and mucosa of the head, the skin of the fingers, the parietal pleura and in the peritoneum.
The pain response is just one part of an inflammatory reaction to tissue damage, whether this is caused by external, mechanical stimulation or by an internal invasion of bacteria, viruses or cancerous cell growth. Patrick Wall, in his book Pain: The Science of Suffering, describes the “three act-opera” of tissue damage. In the immediate stage, stimuli such as sudden mechanical pressure, heat or cold, chemicals like mustard, chili or CS spray used by police, cause the firing of nociceptors. During the secondary stage, the stimulated fibers emit peptides that in turn cause nearby blood vessels to dilate, and cause more pain. When cells are smashed, their contents are released into the body’s tissues, and some of these chemicals in turn stimulate certain nociceptors to fire. Enzymes break down the debris into smaller molecules that stimulate pain. During the tertiary phase, these chemicals attract white blood cells, as hot blood rushes through the dilated vessels. Pain is now produced by gentle pressure that would previously have caused only the sensation of touch. Some nociceptors that were formerly silent, or sleeping, awaken and become sensitive to peripheral stimulation. These nociceptors were first discovered by Schaible and Schmidt (1983) in the knee joint, and later found in skin and visceral nerves (cited in Usanoff, 2006). Fibroblasts eventually move in and pack together to form a scar, sometimes accompanied by the growth of blood vessels and nerve fibers. According to Wall, the C-fibers transport chemicals from the site of tissue damage toward the CNS to modulate central excitability.
Pain sensors differ markedly from the sensory receptors for other sensations such as vision, audition and taste or smell by firing increasingly often the more they are stimulated, instead of adapting to background levels of stimulation and reducing their firing rate to repeated stimulation.
The cell bodies of the nociceptors lie in the dorsal root ganglia (or bundles) of the spinal cord and, in the case of nociceptors serving the face and head, in the trigeminal nerve ganglion inside the hindbrain at the base of the skull. Nociceptors, the primary afferent neurons for pain, have a single, central process called the crux communae that terminates in a T-junction. One arm goes down into the tissues of the body to form peripheral free nerve-endings, sometimes as far away as the base of the spine to the big toe and sometimes as close as the base of the skull to the teeth. Generally each nociceptor grows out to innervate a particular location, but it is possible there is some branching of the fibers that might be important in understanding referred pain. The other arm grows up into the spinal cord and the lower reaches of the brain. It is not known if this upward arm gives rise to further branching. It was once thought that this growth of the fibers occurred mostly in the embryo, but Coppes et al. (1990, 1997) found ingrowth of nociceptive fibers into the vertebral disc itself in many cases of chronic back pain, where in normal backs only the outer third of the disc is innervated.
There is no pain center in the brain, and instead pain processing is distributed throughout many parts of the cortex and the subcortical regions of the brain. The sensation of pain is modulated both through the actions of the nervous system and by means of neurochemical modulators such as peptides, endorphins, and certain hormones. Neuropathic pain, such as the pain of post-herpetic neuralgia (after infection by the herpes virus that causes shingles), chronic back pain, and diabetic neuropathy, can result from physical changes in the structure of the neural tissue, for example the growth of nociceptive fibers around an affected disc of the spinal cord. While surgery can help with a few such conditions, and more is being discovered all the time concerning effective surgical treatments for pain, it is hindered by the body’s tendency to become locked in a state of feeling pain or increased sensitivity in affected regions wherever there is damage to the nervous system itself. Conversely, the brain has in certain circumstances the almost miraculous ability to modulate the sensations of pain by changing the mind’s beliefs about the body, the emotional meaning and significance of the pain and the attention it deserves. By calming the inflammatory response through the interlinked stress reaction, we can sometimes learn to reduce the sensations of pain ourselves, or they can be reduced through the intervention and influence of caring others.
0.2. Pain and Personality
In his outstanding book on the neuro-philosophy of pain, Feeling Pain and Being in Pain, Nikola Grahek demonstrates that there can be a complete dissociation between these two experiences when the nervous system is damaged in particular ways. Patients with the rare condition of pain asymbolia sense the hurt of physical pain, but it has no emotional significance to them, in fact they often seek painful stimuli and laugh about them. This condition is usually caused by damage to a particular part of the brain called the insular cortex. Such patients my try and excuse their peculiar responses by reference to their personality, “I am not a man who cannot stand pain” (from Hemphill and Stengel, 1940). Conversely, patients with causalgia, from a high-velocity injury such as a bullet wound, sense intolerable burning pains spreading all over the affected limb when subjected to irrelevant emotional stimuli such as a crying child. Damage to the parietal cortex, another area of the brain, can cause hypersensitivity and sensations of pain in response to visual stimuli approaching the affected side of the body. Grahek suggests that chronic pain patients might experience the emotional sequalia of pain, being in pain, long after the peripheral stimulation that led to them has ended.
Our personalities, the set of beliefs that we have about ourselves and that others have about us, both influence and are influenced by experiences of pain and illness and, as the above examples indicate, by the organic conditions of our bodies and brains. Several studies suggest high rates of personality disorders among chronic pain patients (Gatchel and Dersh, 2002), and this has been modeled by Weisberg and Keefe’s (1997, 1999) diathesis-stress model in which ‘marginally adaptive’ coping styles associated with certain personality patterns become exacerbated during pain and illness, resulting in the expression of a personality disorder. In common parlance, we are used to people becoming irritable, even to the degree of becoming a different person, when they are in pain. Yet we admire someone who, in spite of excruciating toothache, is able to care patiently for her young children, saying “I am not my pain”.
Such attitudes toward pain are common in Anglo-American culture, which promotes the idea of pain as a warning signal, serving a useful function only insofar as it indicates underlying conditions that carry future consequences and call for action by authorized medical professionals. In contrast, according to Zborowski’s (1969) book People in Pain, Jewish patients reserved the authority and expertise over their own pain, seeking comfort and reassurance from trusted family members over the prescriptions of doctors. Italian patients focused on the present emotional experiences of pain, and the significance of cultural factors such as food and caring rather than the potential causes and future consequences of pain and treatments. Irish patients expressed guilt over their own suffering, and dreaded its future consequences, but they were unable to share their feelings with others. The Baghvad Gita, a central scripture of the Hindu religion, calls life “the place of pain”, and Buddha asserts that “Birth is suffering; Decay is suffering; Death is suffering; … in short: the Five Groups of Existence are suffering.” Frank Vertosick Jr., in his book Why We Hurt: the Natural History of Pain, argues against these Eastern philosophies, suggesting instead that intelligence not life causes human pain. The meaning and emotional significance of pain, perhaps even the sensory experience of pain itself, is modulated by the cultures of our upbringing which are an expression of human intelligence, and by the person they have shaped us into becoming. Conversely, pain changes us and when we change we can change it.
0.3. Chronic Pain and Illness
Chronic illnesses have always been a part of the human condition, and as certain illnesses like cancer become increasingly well understood and treatable, there remain many more chronic illnesses whose causes are not yet explained by medical science. Seventy percent of patients visiting a primary care doctor leave without a diagnosis or treatment plan (Johnson, 2008). Medical science is fairly recent, not so the human desire to categorize illnesses and make meaning out of them.
Historically, the causes of chronic pain and illness were thought to depend on gender. Women (as documented since Ancient Greek and Egyptian times) suffered from hysteria, a shifting array of symptoms including pains caused, it was thought, by the wandering of their womb, which needed to be fixed in place through its proper usage in procreation. Similarly, Freud’s thought that hysteria resulted from women’s unexpressed sexual desires. His earlier theory, that sexual trauma caused some of these symptoms, was probably more accurate, according to recent studies cited in Susan Johnson’s excellent book Medically Unexplained Illness: Gender and Biopsychosocial Implications. Men, on the other hand, were more likely to experience hypochondria or, popularly around the turn of the 20th Century, neurasthenia. An earlier condition, intriguingly called railroad spine, caused similar symptoms in male business travelers who had been in a crash or a holdup, as described in Eric Caplan’s book Mind Games: American Culture and the Birth of Psychotherapy. Railroad spine may have its modern offshoots in shell shock, post-traumatic stress disorder, and gulf war syndrome. We now know that a common consequence of trauma, especially sexual trauma, is dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis, resulting most commonly in reduced levels of cortisol (but sometimes higher levels). This occurs in up to 25% of patients with “stress-related” disorders, who have double the population prevalence of having been sexually abused, and in many otherwise healthy rape survivors.
In the ever-shifting landscape of medically unexplained illness (MUI), the so-called functional somatic syndromes are currently categorized as follows. Irritable bowel syndrome (IBS) is a complex combination of abdominal pain and discomfort, diarrhea (more common in men) or constipation and bloating (more common in women). The prevalence of IBS is 10% to 20% of the population, and the gender ratio is 4 women: 1 man. Fibromyalgia syndrome (FMS) is characterized by pain and tenderness in a number of specific locations distributed throughout the body. The prevalence is 3.4% of women and 0.5% of men, but about 10% of women aged 50-60 are affected. Chronic fatigue syndrome (CFS) is characterized by severe, disabling fatigue present for at least 6 months. The prevalence, according to population-based studies, is about 2.5%, of whom 80% are women. Multiple chemical sensitivity (MCS) is a condition in which many disabling symptoms are reported in response to low-level chemical exposure. The prevalence is as high as 12%, of whom 60%-80% are women. The above definitions are from Susan Johnson (2008). The following are from Peter Manu’s book The Psychopathology of Functional Somatic Syndromes. Pre-menstrual syndrome (PMS) is characterized by affective lability, tension, anger, irritability, tenderness, headaches and pains in the last luteal phase. Gulf war syndrome (GWS) was characterized by unexplained fatigue, musculoskeletal pain, and cognitive or psychological symptoms. These were not very different from the reasons for disability claims after earlier wars, such as British veterans of the Boer war.
There is considerable overlap among the above MUIs (about 15% to 80% depending on gender, particular illness, and study). There is overlap between MUIs and psychiatric diagnoses such as major depression, generalized anxiety disorder, post-traumatic stress disorder, and abnormal personality disorders. In particular, a history of depression and anxiety is common among patients with MUIs, even more so than meeting diagnostic criteria at the time of illness. Peter Manu, a psychiatrist, in his book The Psychopathology of Functional Somatic Syndromes, suggests that somatic descriptors of chronic musculoskeletal or abdominal pain, persistent fatigue, sleep disturbance and cognitive deficits are common among people with abnormal personality features, a history of sexual and physical abuse, a tendency to attribute their illness to a physical cause, and a catastrophic coping style. These conditions are exacerbated by unsatisfactory doctor-patient relationships, leading to the increased complaints, persistent illness, and resistance to treatment characteristic of these patients.
Chronic illness can be frustrating for both patients and clinicians. Patricia Fennell’s 2003 book Managing Chronic Illness: Using the Four-Phase Treatment Approach outlines a vision of chronic illness based on Kubler-Ross’ Four-Stage model of mourning. The four phases are Crisis, Stabilization, Resolution and Integration. During Crisis individuals experience an emergency state triggered by the onset of illness, in which the task of the individual and caregivers, including clinicians if present, is to cope with the hurt, loss, and potential trauma of the new illness. Stabilization is when symptoms plateau, while patients continue to experience chaos and dissembling about their illness. The patients’ struggle is to fit the illness into their lives, and the clinicians’ task is to help the individual restructure life patterns and perceptions in order to do so. Patients can feel a false sense of relief and security at this stage, and still need to get used to possible ups and downs in the illness which may be triggered by a return to their former way of life. The third phase, Resolution, is characterized by patients learning the patterns of the illness and how the world responds to it, while making meaning in their lives and creating a new self. The clinician can help the patient work towards accepting the chronicity and ambiguity of the illness experience in this phase. Finally, Integration involves incorporating elements of the new self and illness together with the old pre-illness self, within a larger philosophy or framework, in order to experience “a complete life in which illness is only one aspect” (Fennell, 2003).
Fennell stresses the importance for the clinician of identifying the phase at which the patient is presently at, in order to help in ways appropriate for the tasks of that phase. As with Kubler-Ross’ model, the progression from one phase to the next in the patient’s life is not necessarily linear. He or she may cycle around the phases, slowly over the years spending more and more time in Phase 4. Fennell emphasizes the importance of Caritas, Veritas, and Fortitudo, words she found carved in marble on a building scheduled for demolition that mean love (or compassion), truth (or authenticity), and strength (or courage), both for the clinicians working with the chronically ill patients and as a goal for the patients themselves in order to achieve better, more meaningful lives.
0.4. Outline
I begin this literature review with a reading of Thomas Dormandy’s The Worst of Evils, a History of Pain Relief, a book that outlines the amazing breakthroughs in the medical treatment of pain. While drugs have enabled modern medicine to flourish, particularly with the advent of surgical anesthesia, Dormandy gives attention to ancient methods of pain relief by faith healing and other mental transformations which can under certain circumstances be as effective. This history makes clear that both drugs and techniques such as hypnosis were validated pragmatically, and the physiological actions of neither were or are fully understood. The politics of medicine have shaped the scientific segregation between mind and body, and informed the emergence of modern Western cultural attitudes toward pain and its treatment.
In the second chapter, I summarize and discuss Elaine Scarry’s thoughtful essay The Body in Pain: The Making and Unmaking of the World, where she considers the role of subjectivity in the experience of pain, particularly in the contexts of torture and war, and its remediation by means of the human imagination and the creation of cultural artifacts. These philosophical aspects of pain impact its role as a symptom and influence the power dynamics of the doctor-patient encounter. As the next two chapters suggest, perhaps there is more scientific validity to Scarry’s fanciful, creative leap in proposing that products of the human imagination can be of assistance in the eradication of pain.
The third chapter outlines a particular method for working with pain and other stress-related conditions, from Jon Kabat-Zinn’s book Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain and Illness. The efficacy of this psychological method, based on the teaching and practice of mindfulness meditation, has been demonstrated repeatedly in the treatment of pain. This result highlights both the amazing powers of the human mind and imagination, and the gap between what we really understand about the body and its ailments and what the public thinks we understand.
In the fourth chapter, I give voice to a patient’s account of her personal experiences with pain and illness, summarizing Dorothy Wall’s book Encounters with the Invisible: Unseen Illness, Controversy, and Chronic Fatigue Syndrome. Wall’s story illustrates the significance of empowerment through learning and self-advocacy in the personal transformation that often takes place when patients get better, while at the same time returning to the problems of being ill in modern Western society. Her personal account lays bare the effects that caring and compassion had on her day-to-day experiences with pain, chronic illness, and the uncertainty that entails.
The fifth chapter summarizes Carol Leppanen Montgomery’s amazing and innovative book Healing Through Communication: the Practice of Caring. Montgomery is a psychiatric nurse and nursing professor who has examined and analyzed the ways in which caring about our patients, and communicating that caring to them, contrary to the strictures of medical and particularly psychiatric models of practice, are in fact cornerstones in the art of helping the patients heal.
This literature review concludes with a personal consideration of these diverse readings, bringing them together to formulate some hypotheses concerning the role psychotherapy can play in the transformation of personality associated with the healing process in conditions of chronic illness and pain. Women and men still experience the pains of menopause and aging, just as they do in
