‘The divided subject of chronic pain: I don’t want pain/am in danger’ – a contribution to our special edition collection of pain in the medical humanities, by Seamus Barker
Chronic pain is typically defined as pain that persists for longer than three months. In the previous post, ‘What is Pain?’, I suggested that pain corresponds to the brain’s calculation of present danger to the body, where the brain also calculates that such pain forms part of the most adaptive response available to the organism to the calculated danger. Can such a conceptual formulation, and its neuroscientific underpinnings, help us understand why chronic pain is so intractable?
In states of chronic pain a process known as ‘central sensitisation’ has generally occurred. Researchers Butler and Moseley note that central sensitisation involves changes to the structure and function of the brain and spinal cord, including increased production of excitatory neuro-transmitters, sprouting of extra axons and decreased threshold for depolarisation of action potentials (electrical impulses) in neurones, ‘smudging’ in the somatosensory cortex so that areas representing distinct body parts come to overlap, and many others. In such cases some peripheral nociception can continue, but it is the changes in brain and spinal cord function that create the vastly amplified and continuing pain experience.
Some of the biggest predictors for developing chronic pain are holding catastrophising beliefs relating to the body, pain, and injury (Sullivan 2009), as well as scoring highly on measures of fear and avoidance of painful activity (Wideman, Adams & Sullivan 2009; for further studies see Gheldof, Crombez et al; Jensen, Karpatschof et al 2010). This suggests that chronic pain is produced by the brain in response to a calculated ongoing danger, a calculation based as much or more on the strongly held beliefs and attitudes of the sufferer than on the nature of their original injury, even as this calculation seems to lead to the physiological and anatomical changes occurring throughout the nervous system in central sensitisation. Indeed, while the brain’s calculation of bodily danger typically leads to pain for most people, many chronic pain sufferers further interpret pain itself as a sign of ongoing danger. It is easy then to see how a positive feedback loop can be created in the experience of chronic pain, with intractable suffering often the result.
In my clinical experience with chronic pain patients, many are reluctant to consider that their own thoughts, beliefs, and emotions might contribute neuro-biologically to their body’s production of pain. Anecdotally, many feel that such a narrative of where their pain is coming from involves elements of blame, accusations of malingering, the suggestion that their pain could be consciously controlled, or that the pain is ‘all in their heads’. This reluctance is unsurprising as historically chronic pain sufferers have been – and continue to be – stigmatised. Many chronic pain sufferers hold strongly to a counter-narrative that emphasises somatic anatomical injury as the sole source of pain, as a discourse that would seem to offer validation of their pain experience, obviating the aforementioned concerns. Unfortunately, such patient narratives might actively contribute to the chronic pain state, since, in eliding psychological or social factors from the account, and instead maintaining a belief in ongoing somatic injury, the ongoing perception of danger to the body can be heightened.
It is widely noted that the individual has epistemic certainty as to their own pain but, while this is inarguable, I would further suggest that pain experiences also are always constituted by elements unknowable to the sufferer. Even the individual aware in an academic sense of the brain’s processes still cannot fully understand how his or her own brain calculates the precise level of danger to the body or calculates the most adaptive response to that danger – namely, in the case of chronic pain, a particular intensity of pain and the ‘need’ for its persistence. Freud’s notion of the unconscious seems quite pertinent here, and we might usefully think of the subject in chronic pain as a divided subject – divided by and against their pain. For it seems that the brain, the non-conscious mind, of the chronic pain sufferer believes with absolute certainty that to be kept safe the organism must remain in ongoing pain. This is a confronting thought, for to believe that our own brains, or minds, can act against our subjective, conscious wishes, to maintain us in a pain state that we find torturous and would do anything to be rid of, is to believe that we are not rational, autonomous, unified subjects, that we are at the mercy of parts of our brain that we cannot control, but that yet draw on our deepest fears.
For those with chronic pain, their beliefs about the world at large, their body, their injuries, and their pain can be absolutely central to and constitutive of their identity, but at the same time contribute to the ongoing pain state. How can a clinician or loved one ethically respond? If such patients are indeed divided against their pain, I would suggest that, even as their experiences should be acknowledged, their narratives should not be readily validated. For if transformation from a pain state is sought then beliefs must be challenged, behaviour must change. Ultimately, the brain needs to calculate that the danger has subsided, that the pain is not adaptive or necessary. Then, just as the nervous system’s plasticity once allowed it to change into a sensitised state, this nervous system has the potential to transform once more. This is not a case simply of willing oneself into a perception of safety, though. The intractability of chronic pain suggests just how difficult this is to achieve, and perhaps how vainly it is that we might struggle to unify ourselves.
This guest contribution was written by Seamus Barker, who has worked in Chronic Pain teams for over a decade as a Physiotherapist, and now coordinates the Persistent Pain Program for Ballarat Health Services in Australia. During that time Seamus has maintained a keen interest in the neuroscientific and behavioural bases of pain, and their philosophical consequences. Seamus completed a BA (Hons) at the University of Melbourne in 2012 and an MPhil in American Literature at the University of Cambridge in 2014. He plans to commence a PhD in 2015 in the Medical Humanities program at the University of Sydney, which will look at the consequences of the marked differences in the narratives provided by medical science, by the Medical Humanities, and by sufferers of chronic pain, as they answer the question: where is the pain is coming from?
Correspondence to Seamus Barker
You can follow Seamus on Twitter with @sbpainphysio
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