Claiming Multidimensionality of Pain: Part IV (Part A)
Claiming Multidimensionality of Pain: Part IVChronic pain is a disease and an illness (Part A)
by Ma'ayan Simon
The commonality of pain can be deceptive, often perpetuating misconceptions of what it is to be in chronic pain. All people experience acute pain, yet the biological mechanisms underlying chronic pain are dramatically different. To affect change, it is crucial to develop an accurate understanding of the basic disease processes propelling chronic pain, and the resulting illness.In an acute situation, anatomical pain is a warning signal or "alarm" that something within the body is wrong (Butler and Moseley 32). When the threat is resolved the perception of the potential for injury subsides. When pain is chronic, the perception of the potential for injury remains heightened as a protective measure. The body goes on high danger alert and the threshold for perception of an active threat is lowered, generating more frequent "flare-ups" or exacerbations of pain. I imagine it like a crime TV show or movie when a character says, “escalate the threat level and send out a jurisdiction-wide notice!”If chronic pain persists the perception of pain continues to escalate to a pain state even greater than the initial pain, becoming its own disease process (Thernstrom 128). The perception of threat persists, changing the sympathetic and parasympathetic divisions of the autonomic nervous system, endocrine, immune and motor systems, brain, and spinal cord (Thernstrom 6, 140). Wherein acute situations pain is temporary and localized, persistent pain causes systemic physiological changes (Thernstrom 138-139). As Thernstrom describes,
…chronic is not ordinary pain that endures, but a different condition, in the same way an alcoholic’s drinking differs from that of a social drinker. It is not the duration of pain that characterizes chronic pain, but the inability of the body to restore normal functioning. (6)
Interestingly, in chronic pain a feedback loop in the brain is created to continue increasing the pain signals much like the brain produces mounting cravings to satiate a need for an external substance when a person is addicted (Butler and Moseley 38, Thernstrom 180). The perception of pain increases and worsens over time, becoming even more difficult to modulate and decrease (Thernstrom 139; Butler and Moseley 78). Furthermore, because of the homunculus a person’s pain perceptions literally grow within the brain when pain signals are activated (Butler and Moseley 57, 77; Thernstrom 128, 139).I think of pain signals as "overachievers" and, apropos to this analogy, the compulsion to do more and more is, in essence, a positive biological impulse and survival intelligence that goes awry (Thernstrom 27, 286). What begins as the brain’s "good intention” to bring the nervous system back to equilibrium becomes a self-perpetuating cycle that, due to the plasticity of the brain, becomes more and more entrenched. Pain signals also co-opt nervous system pathways not normally used to transmit pain signals, which increases the likelihood of a person’s overall perception of pain expanding beyond a specific locale, becoming central sensitization (Butler and Moseley 38, Thernstrom 141).Inflammatory and autoimmune response also spreads and increases the longer that it persists. Most people experiencing chronic anatomical pain are predisposed to having a heightened inflammatory response and a more easily dysregulated nervous system. Mood-impairing depletion of serotonin is also a hallmark of chronic pain. Thernstrom asserts, "… anxiety and depression are not merely cognitive or affective responses to pain; they are physiologic consequences of it. Pain causes depression just as reliably as difficulty breathing triggers panic" (157). Though it is beyond my present scope to substantiate, it is my understanding that changes to the brain, neural pathways and nervous system dysregulation are evident in emotional, social, and spiritual pain, as well.Alongside an individual’s pain sensitivity and perception threshold, modulation is a key factor in processing pain: in people with chronic pain conditions "the brain’s ability to temporarily switch on pain inhibiting mechanisms" is impaired (Thernstrom 173, 180). As Thernstrom explains, "Much chronic pain is thought to involve either an over active pain-perception circuit or an under active pain-modulation circuit" (289). What's more, significant reduction in gray matter in the brain is seen in people with chronic pain (5 to 11% per year as compared to half a percent per year without chronic pain) and, even more telling, this loss of gray matter "specifically atrophies those parts of the brain whose job is to modulate pain," with neuropathic pain atrophying the brain even more than inflammatory pain (Thernstrom 186).There are an ever-increasing number of environmental and situational neurotoxins from pollution to pesticides and chemical exposures, which may contribute to chronic pain disease. "In fibromyalgia patients, for example, the pain caused by successive noxious stimuli increases much more rapidly than in normal individuals," writes Thernstrom (180). Like many other disease processes, pain can change and shift overtime, and there is no finite line at which a person's pain becomes a disease process. For instance, in an illness classified as "chronic" the pain of the illness will not necessarily escalate to becoming a disease process.Recurrent pain and chronic pain are not interchangeable; in fact, they are radically different. Recurrent pain—areas that occasionally flare-up and then resolve—is acute pain that then returns to "normal." Perhaps the spot is more vulnerable from an old injury or habits, but the neurophysiological process is not that of the disease process of chronic pain, sometimes distinguished as "pain syndrome" or “pain disorder,” in which there is no pain-free "normal." However, “syndrome” or “disorder” fails to account for the gravity of the impacts of protracted pain, which is why I believe in describing persistent chronic pain as what it is: chronic pain disease.A fundamental difference in chronic pain disease is that the pain is not necessarily in proportion to the activity or duration of the "inciting incident," whereas acute pain can be expected to more reliably and consistently respond to specific triggers and recovery aids. A person with pain disease cannot simply avoid triggers or rest the area and expect the same recovery as someone with an isolated injury. In pain disease, pain can be exacerbated even without a specific "cause"; a person can go from being in (relatively) little pain to a dramatic increase in a short period of time, which can significantly vary a person's level of functionality even when, from an outsider's point of view, nothing appears to have changed.This elemental feature of the disease of pain—that it is not simply acute pain that persists—is of paramount importance to grasp. Society and western medical scholarship condition us to think, respond to, and understand primarily acute conditions. It is precisely because pain is so feared that the failure to effectively treat chronic pain often results in the attitude that the people in pain are to blame (Edwards 11, Thernstrom 5). The widespread ineptitude of peoples' capacity and interest to acknowledge pain as a legitimate disease have led to generations of people in pain being stigmatized, accused of exaggerating, and being subject to discrimination. This prejudiced treatment of people in pain urgently needs to stop!Please, pause here and absorb this: reread the above if you need to or print it out to review again later. And again, if that's what it takes to "get" it.We cannot, and should not, judge or assume intensity of another person's experience (or our own, for that matter) based on a "category" or diagnosis. The mechanisms of pain are only one segment of the whole picture of pain, and do not account for the debilitating impacts of pain on an applicable level. This is critical to distinguish as we are all individual, and the severity and extent of how a person’s life is affected by pain cannot be assumed or generalized. This is why it is essential that we understand not only the disease of pain, but also pain as an illness.Click here to read Part B, the final installment of "Claiming Multidimensionality of Pain" about the illness of chronic pain and how you (yes, you!) can make a difference.