City limits

FROM:   Existential Depression in Gifted Individuals

"Existential depression is a depression that arises when an individual confronts certain basic issues of existence. Yalom (1980) describes four such issues (or "ultimate concerns")--death, freedom, isolation and meaninglessness. Death is an inevitable occurrence. Freedom, in an existential sense, refers to the absence of external structure. That is, humans do not enter a world which is inherently structured. We must give the world a structure which we ourselves create. Isolation recognizes that no matter how close we become to another person, a gap always remains, and we are nonetheless alone. Meaninglessness stems from the first three. If we must die, if we construct our own world, and if each of us is ultimately alone, then what meaning does life have?"

Freedom, isolation, death, meaninglessness.
Ignore "gifted individuals" in the title. The author is discussing children in this blogpost, and everyone gifted or not, has to pass through the gate of childhood to reach adulthood. Everyone. No one can stay a child forever, except maybe my mother, whose emotional age seems to always hover around two and a half, or three. That sunny disposition she carries around like a flag in the wind has never varied other than to become cranky and snappy at times. 

I don't agree that only gifted individuals experience existential depression - my personal experience is of being spectacularly ungifted, yet saddled with more awareness than I knew what to do with, most of the time. 
Scene: driving along a prairie highway, age 9 or 10, in the backseat of the car, parents in front seat, no seat belts in those days, brother and sister in the back with me, age 6-ish and 3-ish.  Some sort of conversation transpiring, details of which I can't remember, but I am grumpy about something, maybe not wanting to go to whatever boring event we were traveling to. I announce to my parents "I never asked to be born". Their shocked silence pierces me as I register that my dad has taken quite a bit of offense; my mother is simply too stunned to find anything pleasant or trivial to segue to, for several minutes.

If life were a town, all the jolly communal cultural and life-passage celebration stuff in the center, those four aspects would be its city limits, its edges. Everyone has to grapple with awareness of those four frontiers of the human primate troop - death, lack of or too much freedom, isolation, meaninglessness. Don't we? They? 

The majority seem to get through life simply ignoring the edges, choosing to focus in the middle, through whatever rose-colored glasses ordinary people carefully make and carefully keep taped together to focus on beauty, love, distractions and daily pleasures however fleeting, the busywork, the stuff they prefer to talk about, look at, share. Celebrate. I can remember checking out those human things, those culturally dusted and polished pride items displayed proudly in the center of this cage called human existence. They are nice, but something in me has always found them profoundly saddening, under that magpie-attracting glint. Sad that people try so hard and are doomed anyway;  brave but foolish, because don't they know it's all for naught? Then, another side of me says, no, they do it all because they like it and want to. It gives them joy. Give them a break. They know what they're doing. Stop judging. 

So, whatever sizzles their steak, I guess. But, no joy in any of that for me. Nothing lasting after the novelty has worn off, ever. I know this, because if I just sit and wait, it wears off rather soon. Whew. I would never have wanted to have my life become trapped in the middle of this hypothetical town. Too oppressive (expectations), too mechanical (culturally imposed behaviours), not enough psychological space (I need every bit of that I can find. Just to breathe in, and then out, and keep my body, my own unit of life, comfortable.)

The edges, even though there never seemed to be much I could do about them, even though they seem bleak, attracted me. At first it seemed I was there all alone. Little by little I have seen that the edges of human existence are quite busy, with activity, investigation, expansion into the unknown. It's not all bad, just not what ordinary 'happies' are attracted to thinking or talking about. Nothing to celebrate or organize a parade for, or a party, not an excuse to buy a new dress or shoes or a cake or invite people over.
 
Freedom
I also don't agree that meaningless is off in a space by itself: to me, death, isolation and meaningless seem to belong together, in a bucket, labelled "Topics to avoid at the dinner table".  Freedom seems odd, not equivalent to the other three. I totally get that transitioning from freedom of childhood to having to create adult, freedom-hampering structure, is stressful, and difficult, and angst-ridden - been there, felt it, became aware of how depressed I really could get. But structuring a life is the only way to deal with the other three edges. In my experience. It's a good edge to start from. Or, rather, structure is a good thing that can give you an edge. Most of the time. Managing freedom through structure. Not a bad idea at all. Using freedom to fashion a cage for yourself, then be in it a lot. Decorate it the way you want. Be able to wear it like a hoop skirt. Leave yourself free to move around if you want. Make sure you never forget how to take it off. Structure does not have to restrict you from exploring the other edges of town, or visiting the center of downtown to look at shiny human constructions - if you want. 


If these four aspects were four directions, freedom would be east, I think. Free to start a new day.

Death
In this small community where I've been for close to two years (although it feels like only 5 minutes) most of the people I know (including my 87-year-old, three-year-old mother) are independently-living,  over 80, see at least 4 or 5 of their own peer group die every year. If they aren't going to a funeral they are laughing and playing cards and eating each others' birthday cakes. They deliberately and carefully keep the social veneer very, very well-polished. They choose to enjoy each other and laugh about little things that aren't even funny, just tedious. According to me. But I don't say anything. 

They have to be aware of death, maybe even look forward to it, don't seem afraid of it, but still, don't like to talk about it, or explore it, or share how they've come to terms with it. Not to me at least. My mother did remark she wanted to be cremated, and I know she has her paperwork, will, etc. all organized and in a safety deposit box, to which I have a key, kept by itself in a special drawer along with power of attorney, when the inevitable day arrives. She's more organized about Death than I am. I'm more ruminative about it, probably. 

In my inner human town of human existential discomfort, death is the south edge of town, buried by distraction and busy-ness of keeping life full of action. Where I live these days, the town dump is on the south edge, just over a low hill. To me death is not scary or depressing - death just is. It's just entropy. That's all. Everything is entropy. It takes a lot of energy to be alive, for life to form itself, maintain itself - then it gets tired and can't. Bam, you're dead. That's it. I'm in no hurry to get there, but I will likely not care that much when I get to that point. My bits will disintegrate and become food for something microbial, or whatever... one idea I had was to donate myself to an anatomy lab to keep funeral costs non-existent.


Isolation
Isolation is a rather edgeless notion, I find. I grew up on a prairie farm with no playmates and a circular horizon that was always there, no matter how far you tried to walk or drive. A couple parents who I guess must have interacted with me, although they seemed awfully preoccupied keeping a farm going. A couple siblings who seemed like they were from another planet, so little did I feel sympatico with them, deep on the inside of myself. Scratch that - more it was like I was from the other planet, landed in a world completely foreign and alien - to me. Whatever, we get by. 


I lived in a big city with lots of people flowing around me. I connected to a few of them, to groups of them, but attachments were purposeful and inevitably, fleeting. I tried to be porous, let people in, let them know me. But it was painful, awkward, never smooth, never growthful. Too hard. Too sad. The closer I would get, the more they seemed to recede, just like the prairie horizon. The closer they would get to me, the more I would feel invaded. All that effort with nothing to show for it. Just further away from whoever it was that I was. So I gave up trying to connect or be connected with. I stuck to my work. Related to people through the bars of my work cage instead. The structure I had built. That sufficed for human contact. 


I let myself fall in love with a cat, finally, just under a year old. I brought her home from the SPCA; the adoption fee included spaying.
Kitty Scissorpaws. She clawed everything to death, including me, until our boundaries sorted themselves out and she had me trained. She was like me. She didn't let people get very close except on her own terms. She was just a tiny scrap of a cat, 6 pounds, but she could be all fury - could chase away cats twice her size, lacked cat manners of any sort. Next door lived a large female English bull terrier with weak eyes and a gibbly hip, named "Bill", who she befriended, and would visit every day, walking underneath and wrapping her long tail around and beside and over. Bill loved Kitty. Kitty would walk away from Bill, and Bill would hobble along to catch back up to her, trying to get close, trying to see her more clearly, but that big nose/forehead would just bump her instead. The cat had all kinds of patience for this dog. I could not fathom their friendship. Whatever the meaning of what went on between them, it was sweet to see.  

Bill eventually died. And we moved, Kitty and I, about halfway into our relationship; I got new furniture, had the cat's front claws removed. She became an indoor cat after that. We had a long relationship, 15 years. She became ill and I did what I had to do, put her down. It's been 7 years, and I still miss her. I can still feel a cat-shaped, 6-pound hole in my chest, when I check, although it doesn't intrude into whatever I happen to be doing anymore the way it did at first. 


I can't imagine what bonding to, then losing a person through death, must feel like, deep inside. Even my dad, who I did manage to bond to, a bit, when I was a baby, and who died a decade ago, didn't leave as huge a hole as my cat did, my cat who I freely chose and who I thought at the time chose me. My father was a parent, not someone I freely chose. Although I'm not even sure I know what I mean by that. I think I mean that losing a parent whose existence you had nothing to do with starting must feel a lot different from losing a child, whose existence you are entirely responsible for starting. All that work. Or a spouse who you chose from all those who exist alongside you, someone you click with and decide to love wholeheartedly, have kids with. I've avoided finding out what that feels like. I always knew I'd never in a million years be able to handle taking all that on, all that potential pain, because of being too aware of potential pain.

A woman I have known for most of my life lost both parents when she was barely into puberty. I met her when we were very young adults. We were close friends, went camping in Quebec, traveled a bit in California. She fell while mountain climbing and fractured her spine, both ankles, but survived and was able to walk after. She married. On the way home from her wedding, her brother, his wife, and her aunt were all killed in a bad car accident. The two children sleeping in the back seat lived, and other than some fractures, were fine. She became their new mother, a week after her own wedding. They were age 6 and 9 at the time. She had two more of her own after that. She never really got over the pain of all of it and has had chronic physical pain as well, ever since her injury. She exists between two pains. Two panes. Like a butterfly trapped inside a window.  Then she developed cancer. Finally it was successfully treated, as far as I know. She and I haven't had much contact in the last 3 or 4 years. She didn't want to talk to me anymore, it seemed. Sometimes things just change, all by themselves. I never knew how to help her anyway; I knew no way I could evolve that would refresh or continue the relationship. I have to keep doing whatever it is I need to do. It might be that she feels better without me, wants me and my particular depressing ways out of her life. I don't know. Just don't know. I have to wait and see. I'll never not consider her a friend, no matter how isolated/isolating I am. 

'Alone' was scary when I was a child, lonely when I was an adolescent, and gradually became peaceful contentment as an adult. 'Alone', and the lovely silence that swirls endlessly all round it, is now the companion preferred before all others.


Isolation is the west edge of town where the sun goes down and light dims and edges disappear and distances or closenesses can not even be seen, let alone judged.

Meaninglessness
This one is so hard. Of any, this one gives me the saddest feeling. (Maybe the author's right after all - maybe this one does deserve a bucket all its own.)
Meaningless is the side of town that no matter where I go or where I stay or where I face, there I am, always managing to be stuck on the wrong side of the emotional tracks. This is the one that prompted me to announce to my parents in the car at age 9 or 10 that I had never asked to be born. I fear, somewhere deep in my bones, that the only meaning there is is that it's all meaningless. I suspect, deep in my gut, that this is what drives people crazy and sends them all into religiosity. Which to me is even more meaningless than regular, generic, no name, existential meaninglessness.  
The north edge. 
The further north you go the less there is to compare, make meaning from.


We've made our way all around the edge of town, explored its sides, and now we're back to structure. Structure is the only way I've ever found to deal with meaninglessness. I won't say it's been successful. But at least I've not ever despaired to the point of cutting my own flesh or taking my own life or anything. I've never felt that bad. What might have happened: Very early in life, Meaningless appeared and creeped the absolute beheebus out of me - so much so that I could hardly wait to build myself my own little cage of structure to hide out in, like a turtle shell, until such time as I wouldn't need such a thing anymore. Deliberately constructed Meaning. From the article:

"A particular way of breaking through the sense of isolation is through touch. In the same way that infants need to be held and touched, so do persons who are experiencing existential aloneness. Touch seems to be a fundamental and instinctual aspect of existence, as evidenced by mother-infant bonding or "failure to thrive" syndrome."

I would concur. In fact, I might have instinctively realized that even as a child, even as I fled away from freedom and toward creating structure, toward developing a life as a human primate social groomer. It seems to me that life is bad enough to have to get through without doing whatever you can to help out when and where you see a way to do so. 


Some where along the way I learned how to make myself a bit useful, I think, treating pain in other people, in a structured manner, but not in the center of the town where societal human structures glint in the sun. Over here, on the edge of town, at the intersection of Meaninglessness Avenue and Structure Street. Is there anything on the planet more meaningless than persisting pain?

A modest dream, but one that eventually developed itself into a (relatively) comfortable life. One I've carefully shepherded in order to avoid piling unnecessary angst in on top of all the angst that to me, seems unavoidable. One that was self-reliant and rarely disappointed. One that by learning how to touch in a way that was useful, helpful, helped me too, by providing me with endless novel physical contact. Win win. The only gift I was ever born with may have been the gift of spotting, then avoiding, any unnecessary angst, and choosing, in the privacy of my own existence, to never fully connect with other humans, except through the structure I had built, and never to disguise ordinary (unavoidable, existential) angst with the usual human primate kinds of window dressing or distraction, including marriage, children, religion. I feel like a monk. Kind of a zen monk. Not wise, not gifted, not steeped in any sort of tradition. Just a self-styled cobbled-together zen monk. Someone who didn't strive very hard to get there, was sort of lazy, didn't really see the point of doing anything too hard or difficult or emotionally tiring, just sort of ended up never taking my eyes off the edges of human existence in order to gaze at or be dazzled by its center where all the emotional action is usually found. 

Again, from the blogpost: 

Dreams

Hold fast to dreams,
For if dreams die,
Life is a broken-winged bird
That cannot fly.

Hold fast to dreams.
For if dreams go,
Life is a barren field
Covered with snow.

- Langston Hughes

I would argue that Life IS a broken-winged bird, Life is ALREADY a barren field covered in snow, AND that dreams are nice, that life is but a dream, so row your boat down the stream, and it doesn't have to be 'merrily' if merrily does not feel congruent or honest or authentic. Be who you are. That's all there is - and you STILL have the right (as a humanantigravitysuit) to dream whatever you want - the only meaning of freedom accessible by everyone, anywhere in town, any time of day or night. Deeply deeply democratic.

Sapolsky the Brilliant

I have enjoyed reading this guy's books ever since I picked up his books, Why Zebras Don't get Ulcers, and A Primate's Memoire, in a second-hand store, ages ago.

I'm ecstatic to see that Stanford University has uploaded all 25 lectures of a class he taught last year on human behavioural biology, about 36 hours in total, plus a bunch of other videos in which he lectures. Such a pleasure. I could listen to /watch him teach all day long (and have been).

Very lucid guy. He makes life in a humanantigravitysuit start to make a lot more sense.

Here is a link to the whole list of his videos/lectures.

Four-part series on pain research and its problems

This is by Pain-Topics.org News/Research UPDATES, a blog by Stewart B Leavitt.
I've read several posts at this blog. This 4-part series is particularly insightful, I think. Excerpts provided:
1. How to Make Practical Sense of Pain Research

"Most presentations of research today are overflowing with data and statistics that often seem to defy sensible interpretation. The old saying, "There are three kinds of lies: lies, damned lies, and statistics," has never seemed more pertinent than in this era dominated by computerized data analysis programs. These can crank out sophisticated statistics to make even misguided or ill-conceived research appear to be the latest and greatest discovery in pain management. So, learning to interpret the often mysterious and complex language of research is a challenging but vital task."

2.  Pain Research: All That Glitters is Not Gold

"Just because a pain research study is published does not mean it is accurate, unbiased, valid, or useful for any clinical or decision making purpose. The truth is that much pain-related research literature is simply not worth reading, and sifting out the golden nuggets of worthwhile research from fool’s gold can be a challenging task for any healthcare provider or patient."

3.  Validity, Reliability, & Bias in Pain Research

"Critics of medical research have proposed that many wrong, or at least unreliable and invalid, therapeutic answers are being generated due to biased studies that are poorly designed and use inappropriate analyses. The pain field is no exception, even though the underlying research may seek answers to important clinical questions that are of value. Understanding potential sources of bias in pain research is vital for assessing reliability and validity of the outcomes."

4.  Pain Research: Insignificance of “Significance”

"As described in preceding articles in this series [here] many experts have warned through the years that medical researchers’ love of statistics has spawned countless faulty findings. And, as Albert Einstein pointed out long ago, “Not everything that counts can be counted, and not everything that can be counted counts.” Along those same lines we would add, “Not all that is statistically significant is significant.” Understanding this is key to becoming a more critical consumer of pain research."

Multi-sensory illusion for pain

I spoke to this a bit yesterday, in  Movement illusions and pain. Today I saw a tweet by one of my all-time favorite bloggers, Mo Costandi, of this piece by Candida McCabe, When illusion becomes reality.

She refers to this letter by Catherine Preston and Roger Newport, Analgesic effects of multisensory illusions in osteoarthritis, which sits lonely behind the paywall, alas, but has this extract available for public consumption. I looked it up and really, most of it is covered by McCabe's commentary, apart from a few photos, but the two linked videos in my earlier post are better anyway, so it's all OK.

I really like how this is all still coming together.

The reference list under McCabe's comment is really worth the bother of opening the link to her comment, quite apart from the fact that her comment is delicious in and of itself.

Movement illusions and pain

I enjoy days when the dots seem to connect all by themselves. 

Researchers in Nottingham stumbled upon an observation that a simple visual illusion, i.e., having people watch through the window of an optical machine, their own arthritic fingers being stretched out like Pinocchio's nose (even though their finger wasn't being pulled much at all), resulted in large amounts of decreased pain, replaced by pleasurable sensations.
See the following two news stories for more detail, and watch the short videos embedded inside.

Mind tricks may help arthritic pain

Illusion can halve the pain of osteoarthritis, scientists say

I've used skin stretch (I've called it dermoneuromodulation for the last 4 or 5 years) as a main treatment modality for a couple decades. What I'm starting to see is how, apart from any local effects, or any spinal descending modulating inhibitory effects, the patient's brain likely, automatically, provides him/her with a (internally generated) mental visual image of greater lengthening than is actually occurring. The ruffini endings are slow adapting type II, so they don't shut off until the practitioner lets go.

Cutaneous Receptors Contribute to Kinesthesia at the Index Finger, Elbow, and Knee

Whether the brain is supplied with exogenous visual illusion (as in Nottingham), or makes its own endogenous visual illusion (as per Collins and Gandevia, and in my own clinical experience), doesn't seem to matter. It would appear that a key piece here, and not mentioned in the news stories, is the operator's contact, and the patient's feeling of being stretched (in a comfortable way). Maybe the patient's brain takes the two inputs, the kinesthetic and the visual, compares them, finds a discrepancy, and defaults into the more painless of the two options. 

OPEN ACCESS: D. F. Collins, K. M. Refshauge, G. Todd and S. C. Gandevia; Cutaneous Receptors Contribute to Kinesthesia at the Index Finger, Elbow, and Knee. AJP - JN Physiol September 2005 vol. 94 no. 3 1699-1706

 

 

Altheimer's, livers, highway exhaust

I saw these two snippets, and present them here, together:

1. Freeway air pollution linked to brain damage in mice (Apr 7, Louis Sahagun, LA Times) Excerpt: 

"It is well known that air pollution from cars and trucks on Southern California freeways -- a combination of soot, pavement dust and other toxic substances -- can cause respiratory disease, heart attacks, cancer and premature death.

Now, exposure to pollution particles roughly one-thousandth the width of a human hair has been linked to brain damage in mice, including signs associated with memory loss and Alzheimer’s disease, according to a USC study in the journal Environmental Health Perspectives.

In a statement, senior author Caleb Finch, an expert on the effects of inflammation and holder of USC's ARCO/William F. Kieschnick Chair in the Neurobiology of Aging, said “You can’t see them, but they are inhaled and have an effect on brain neurons that raises the possibility of long-term brain health consequences of freeway air.”

Lead author, Todd Morgan. 


A lot of whatever the body takes in and can't use to sustain itself, gets dismantled in the liver, right?

2. Sutcliffe, J. G., Hedlund, P. B., Thomas, E. A., Bloom, F. E. and Hilbush, B. S. (2011), Peripheral reduction of β-amyloid is sufficient to reduce brain β-amyloid: Implications for Alzheimer's disease. Journal of Neuroscience Research, 89: n/a. doi: 10.1002/jnr.22603. (Open access for now) 

Abstract:  (my bold)

"Three loci that modify β-amyloid (Aβ) accumulation and deposition in the brains of a mouse model of Alzheimer's disease have been previously described. One encompasses the Psen2 gene encoding presenilin 2, a component of the γ-secretase activity responsible for generating Aβ by proteolysis. We show that the activity of mouse Psen2, as measured by levels of mRNA accumulation, unexpectedly is heritable in the liver but not the brain, suggesting liver as the origin of brain Aβ deposits. Administration of STI571, a cancer therapeutic that does not cross the blood–brain barrier, reduced accumulation of Aβ in both the blood and the brain, confirming brain Aβ's peripheral origin and suggesting that STI571 and related compounds might have therapeutic/prophylactic value in human Alzheimer's disease. The genes Cib1 and Zfhx1b reside within the other modifier loci and also exhibit heritable expression in the liver, suggesting that they too contribute to Aβ accumulation. © 2011 Wiley-Liss, Inc.

Alzheimer's disease (AD) is a neurodegenerative disorder characterized by the age-dependent deposition of β-amyloid (Aβ) within vulnerable regions of the brain, particularly the frontal cortex and hippocampus (Terry, 2006). Aβ has a pathogenic effect, leading to progressive neuronal loss that causes deterioration of the ability of those brain regions to orchestrate both higher order and basic neural processes. Some forms of human AD are highly heritable, caused by rare variations in genes that encode proteins that are associated with both familial and sporadic forms of this neurodegenerative disorder and play central roles in the initiation of the disease process. One of these encodes the amyloid precursor protein (APP; Tanzi, 1989), a membrane protein whose biochemical function is at present unknown. APP is a substrate for proteolysis by several endogenous proteases, liberating proteolytic fragments of various structures. Proteolysis of APP by β-secretase generates a fragment that can subsequently serve as a substrate for cleavage by γ-secretase at multiple adjacent positions within the precursor to form Aβ isoforms ranging from 37 to 43 amino acid residues. The 42-residue species is thought to be the most pathogenic (Wolfe, 2006) and forms oligomeric structures, which, in addition to depositing in plaques in the AD-affected brain, are thought to cause cognitive deficits (Barten and Albright, 2008). AD-predisposing variations in APP cluster in the vicinity of the proteolytic cleavage sites, affecting the rate at which pathogenic Aβ fragments are generated, their stability, and their ability to form oligomers (Selkoe, 2001). Individuals inheriting such APP variations usually show signs of AD in their 50s, whereas sporadic AD is not common until individuals reach their 70s (Waring and Rosenberg, 2008). Rare variations in two other genes, Presenilin 1 and Presenilin 2, also confer high risk for early-onset AD. These two genes encode independent proteins of similar structures that function as part of the γ-secretase protein complex (Wolfe, 2006). As a consequence of these genetic observations and considerable experimentation, the etiologic model that has emerged holds that biochemical events that increase the production and accumulation of Aβ, particularly Aβ1–42, accelerate the onset and progression of AD.

Transgenic mouse models have been developed that recapitulate critical features of human AD. In the R1.40 model, expression of a human APP transgene carrying the so-called Swedish mutations (K670N, M671L, variations that predispose those humans that inherit this mutant gene to develop early-onset AD) is driven from the natural human APP promoter (Kulnane and Lamb, 2001). Congenic lines were derived from the R1.40 model on the C57Bl/6 (B6) and DBA/2 (D2) backgrounds (Lehman et al., 2003). Although these two transgenic strains produced the same amount of APP precursor (indicating that the transgene was expressed comparably in the two strain backgrounds), B6s accumulated more Aβ than D2s, as measured by ELISA on brain homogenates and plasma at 21 and 60 days and developed amyloid deposits characteristic of human AD at 13.5 months, whereas the D2s were protected (no deposits at 2 years). This indicated that there were genetic differences that distinguish B6 and D2 mice and that modify the development of AD-like pathology, most likely by influencing the accumulation of the pathogenic substance Aβ (Lehman et al., 2003). The identities of the modifier genes might suggest therapeutic or prophylactic modalities that would mimic the modifier effect and delay or prevent the emergence of AD pathology.

To assign the modifying genes to chromosomal intervals (quantitative trait loci; QTLs), Ryman and colleagues (2008) analyzed Aβ accumulation in the brains of 516 F2 mice from a B6/D2 intercross population and mapped three modifying loci, assigned to broad regions centered on the following positions: chromosome 1, 182.049374 megabases (Mb); chromosome 2, 41.216315 Mb; and chromosome 7, 63.680922 Mb."

More about human delusional... I mean "metaphorical" capacity

 

 

Nice blogpost, The Perils of Metaphorical Thinking,  by Julia Galef, posted to Rationally Speaking blog.

There are plenty of topics covered, that have to do with body movement and somatosensing that operate below the level of conscious thought: Leaning back when discussing the past, or forward to discuss the future. Thermal influences. Cleanliness and morality. Rationalization after the insula has had a chance to register disgust. War metaphors for argument. Women as candy. (I guess the only subjectivity permitted is for men. Women must always and forever be objects, like candy.) 

"Meet the first beginnings" by Frank Forencich

I saw this today, and loved it. This guy is a good, good writer. Here is his post. Meet the first beginnings  by Frank Forencich at Exuberant Animal.

So, Frank is a fitness guy, loves to run around and push his body to its limits, because he loves the feelings and is convinced physical activity is healthy. It's kind of reassuring to learn that sometimes, even somebody Frank will experience pain:

"Like most active people, I occasionally get injured... Most of the time I’m pain-free, but sometimes things get a little out of hand and I go in search of a specialist.

One particular instance stands out in my mind. I’d been suffering with a nagging pain in my shoulder, so I made an appointment with ... an orthopod. The good doc ran me through a basic physical exam and took the afflicted limb through all the standard tests. He checked my range of motion and did a host of biomechanical assessments. And because he was either detail-oriented or living in fear of litigation, he sent me down the hall for X-rays and an MRI.

When the results came back, we reviewed the images in his office. “Well,” he said, taking on his best bedside manner, “It doesn’t look like much. You’ve got a bit of an arthritic change in the joint, but it’s pretty subtle. You’ve got basic function and you can mange your pain with NSAIDs. Beyond that, there’s really not much I can do for you at this point. I’d recommend that you wait until it gets really bad and then come back and see me. Then I’ll be able to help you.” With that, he fired off a prescription for an over-the-counter NSAID and disappeared.

I am not making this up."

As you read through the blogpost you will note a river metaphor runs through it. We each are at an upstream moment, capable of many potential acts which will reverberate further downstream. The medical system is downstream, waiting for us. It can deliver us from all sorts of suffering, but only suffering it has equipped itself to deal with. Any suffering we encounter while still upstream, tough darts. We're pretty much on our own. He got better by the way.

More from Frank:

"To my way of thinking, this [medical encounter] episode symbolizes everything that’s wrong, not only with the medical and health care system, but with so many other systems in the modern world, from education to agriculture to economics to international relations. That is, we apply the majority of our attention and resources to late-stage downstream problems while ignoring what’s happening upstream, at the source. Across a wide range of professional and social programs, we practice a strange and troubling variation of the Hippocratic oath. Instead of “First, do no harm,” our strategy now appears to  be “First, do nothing. Wait until the problem is monstrous in scale and scope, then implement some desperate counter-measures.” These counter-measures may or may not work, but they sure are lucrative."

My bold. How true is that? Nuclear reactors in the earthquake/ tsunami belt.. Libya.. the status of women all over the world...

"So what are the origins of this downstream orientation, this habitual foot dragging, this bias against prevention? Can we trace it to its source? Perhaps there’s an influential force in intellectual history that gave rise to our “wait-till-the-last-minute” orientation. Or maybe it’s just a quirk of the human mind, a malfunction in our brain wiring that inclines us towards cognitive laziness and procrastination.
In all probability, it’s our evolutionary psychology at work: our brains are wired to maximize survival in the present moment. Staying alive is the prime directive; the future is an abstraction that may not even come to pass. Only with the invention of agriculture and industry did people have the opportunity to think of abstract upstream causes and future downstream consequences. When you’re living on the wild grassland, you hunt, gather and scavenge, and let the consequences fall where they may. If you’re still alive in the morning, you’ve succeeded."

Yeah... well... maybe. I don't know. Seems to me we have enough history around by now we shouldn't have to repeat it.  However, because human primate political and social and religious systems have dammed up the river, it's pretty hard to get upstream. If you're on the downstream side, the dam is a barrier, and you might as well be a salmon. If you're on the upstream side, you have to swim around a whole lot in a huge artificial lake to even find the source of the creek.

Back to the medical angle on all this:

"Whatever the origins, today’s incentives are fundamentally perverse. There can be no getting around the fact that our prevailing downstream orientation keeps profits high. In fact, it keeps entire industries and professions afloat. Why should my doctor teach me how to keep my shoulder healthy when doing so would only hurt his bottom line? Even more to the point, why should medical and health insurance companies lift a finger to promote healthy living when doing so would destroy their gravy train of obesity, diabetes, heart disease and other lifestyle diseases? If we really started getting serious about upstream health and education, a lot of people would find their cash cows drying up; the profit party would be over."

About human procrastination:

"It’s an old story of course, this tragedy of the commons. Like the village grazing pasture or the local river, the future is a commons, a very handy dumping ground for today’s challenges and inconveniences. Just as we casually dump carbon into the atmosphere and plastics into the oceans, so too do we dump today’s difficulties into the days, years and decades of our futures. This “solution” ultimately fails of course, as it leads to vicious cycles of embedded problems, desperate action, frantic fixes, half measures and escalating chaos. Procrastination, whether personal, professional or institutional, is a recipe for disaster."

Couldn't agree more.

Solution in terms of health? fight from wherever your position is now. It could always be more downstream. Relative to where you could be, the present moment is upstream from there, and you still have a slight advantage.

"To the casual observer, a present-moment upstream action may not look like much. It might be something subtle, something having to do with attention, awareness or seemingly minor choices. It might be a simple change of language, a new choice of words. It might be a new orientation towards the body, with a fresh physical challenge. It might be eating, a little more real food and a little less refined carbohydrates. It might be spending a little more time with friends and family."

Same solution in terms of anything, I think.
Thank you, Frank Forencich, for a fabulous blogpost.

Human delusional capacity II

Yesterday I pondered for a long time on Human Delusional Capacity, specifically
1. the burning of the book in Fla., and events that supposedly hinged on that, in Afghanistan
2. an observation made by an author writing about the decline of rural culture - "Nothing gets handed down, passed on except the illusions."
3. a new blog (Revolutionology), eyes on the ground in Libya.

Today I'm still in that mood (although I have got to brag that I mostly have the income tax crap all sorted, organized, piled and whatever needed to be shredded from 2004, shredded. So, yay for me. )

Yesterday, after I pondered, I found something else that by rights belongs squarely in this section of ponderocity, The Military's Secret Shame, by Jesse Ellison, about rape of soldiers by other soldiers, or gangs of soldiers, in the military. Regardless of their gender. By males. Of course. The outies of the human primate species. Rape as a way to establish domination.

So, it makes me think that being in the army is not a lot different from being in prison. Don't bend down to pick up the soap.

What is it with men in groups? The vatican is full of pedophiles, the army is full of rapists, the world seems full of deluded religionists, who know that the most atrocious way to insult another equally deluded human primate social troop is to burn the most symbolic thing it possesses. Whereupon the offended troop rampages around killing actual/innocent/biological human-shaped life, outsiders who are convenient and not part of it. The thing the troop 'stands for' has completely eclipsed the troop itself or the individuals comprising it or human life itself.

From my own vantage point,  the world is clearly nuts; it's mostly a male world with male power structures, which it evolved to beat on and kill mostly other males but also any females it doesn't like. Then, I thought about Russell Williams. He is Canada's latest public military shame.. I wonder what motivated him and his antics that resulted in human death? I was particularly intrigued (and slightly horrified) to read the last sentence in this link:

"In what is believed to be a first, Williams' uniform was destroyed through burning by the Canadian Forces, as his name had been stitched into the fabric.^[54] His SUV and medals will likewise be destroyed.^[55]"]

Huh.

That's an overlap, right there. Can you see it?
The Canadian army is superstitious, and wants to "cleanse" itself, symbolically, by burning up clothes (clothes that are presumably free of lice or unpalatable biologic effluence... all that's wrong with them is that the owner's name was stitched into them).
The army, surprised at what a monster lurked within it, "purifies" itself, then closes ranks around itself, feels all spiritually "clean" and smug and invulnerable again. So its members can go back to being obtuse about the army's own culture.

Just like the catholic church. Although it looks like it might finally be starting to do something to change things institutionally.. at least in one country...

I want to yell, to the whole world, get a grip, silly human primates! We are biological flesh. No army or religion or any other cultural superstructure we build to contain, then charge with protecting us geographically or mentally or emotionally, is ever gonna change the fact that...
We are all gonna die.
Every single one of us.
The incidence of death is one per person. You can't leverage that. You can't average it out. It won't dilute statistically. The correlation of birth and death is a solid one to one relationship. It's the cleanest correlation there ever has been. There: Believe that!

Then get used to it and be a decent human being on the planet while you have breath in you. Relax - the human life span exceeds most other mammals by quite a bit. Which leads me to add, try not to die of boredom meanwhile. What it all means, is, don't confuse a book with whatever deity you have it conflated with. Don't have a deity. "Believe in yourself - you're all you've got."- Janis Joplin

Be helpful. Do your best to understand yourself and other people. Don't react instinctively by hurting them. Think about everything, all kinds of stuff (there's always plenty of stuff - too much at times). Stand up for yourself, but don't intimidate, bully, kill humans, or institutionalize human foibles.

The human brain is a marvelous biological gift. It can see forward in time and a long way backward. You have one. It came to you for free. Just for being born. If yours works normally, don't waste it, use it. Construct scenarios for yourself on how to be a decent person, test them in the privacy of your own imagination, fearlessly and dispassionately chuck any that don't measure up.

Don't rely too much on whatever human primate social troop you happen to be embedded within - it's made up of other individuals, each of whom may have a poorer 'moral compass' than whatever you can come up with on your own; it may only be interested in perpetuating the troop itself, with no interest whatsoever in the wellbeing of any of the people who inhabit it.

Don't burn other peoples' stuff to try to make a point. It doesn't matter what object it may be or how absurd. People are crazy; sometimes they believe their flag or their book or whatever the thing is, is more important than human life. Yes, that is crazy, and it is a default human craziness we all share (see "objectification" and "reification" for more about that). Burning their 'thing' is like throwing your feces at their face, from their POV. They will become mad at you and rampage around like enraged chimpanzees. So don't be a jerk. We are all just a couple strands of DNA away from being enrageable chimps and some human primate troops (due to culture) default to back to that behaviour easier than others. So try to be sane and try to get through life - all the way through - without getting sucked in to the 'crazy human' whirlpool.

Life gets dished enough disaster and sorrow via nature.  Celebrate small precious victories.

Seriously, what was the army thinking, burning those Russell Williams clothes? Did it think burning a murderer's shirt would make any difference to the level of insanity that pervades institutions and the deliberate obliviousness people cultivate about how much human primate mental ugliness inhabits said institutions? That they actually are building and maintaining scaffolding for human craziness? Like those lattice uprights people put in gardens to give the climbing plants something to climb on?

Here's what I would do if I were in charge of the .... ok, not the whole world, just the Canadian corner, like, let's say I were a Minister appointed to preserve Collective Sanity. I'd keep that clothing, and all the other stuff. I'd build a Museum. I'd call it, "The Sane Peoples' Museum of Examples of Human Primate Social Domination, Horror and Craziness."  Russell Williams' personal effects would occupy a small room, or alcove. They would serve as a cautionary tale to future generations to not allow their systems or structures or religions to develop greater importance in their own minds than themselves and each other. To stay internally integrated and protect that integration, not maintain a discrepancy between private self and public self. It makes for too large a gap, into which one might fall, into that bottomless human mental chasm between what is real and what is symbolic. 
There would be large spaces in my museum, rooms enough for all the religions that have ever been, and all their religious artifacts, and any books and flags that have ever been scorched or burned or ripped. It would be physical. It would be real. Maybe with a wax museum of the deluded leaders of all these socially constructed delusional human social systems. It would be a place for school tours to visit. It would be catalogued and documented. There would be well-labelled drawers to keep all the little crap bits organized. Hopefully anyone who toured it would come out, knowing who they were and what was important, and what was not. So they would go on to NOT replicate more nonsense and harm and rape and misery.

Human delusional capacity

If there is anything I've figured out over a lifetime of being a human primate social groomer, and atheist, it's that the depth of human capacity for self-delusion seems to be bottomless.

So much food for thought today. Maybe I'm just trying to escape having to round up all those horrid bits of paper and organize them for the annual income tax gouge. So this may be just displacement behaviour.

Anyway... so, some nutbar burns a Koran in Florida and a bunch of people feel so personally offended they rampage and kill innocent people in the UN, who weren't even American, so what the...? Is revenge that sweet? Is biological human life so cheap to these rampagers that they get it confused with some book? I mean, is the book more important? Evidently. To them. Same deal with flag burning. Get over it - it's just a piece of cloth for petesake.

The endless ways the human brain can confuse itself and conflate itself with a social group around it, or a symbol that is perceived to be more "pure" or "holy" or "sacred" than human life is endlessly ponderable. I wrote a bit about it while trying (and I hope, succeeding to a limited extent) to understand it in HuManual Therapy. It seems to be about substituting an idea for a thing, then treating the idea as if it were as real as a thing that is already real. I think it all started when we learned how to talk, and we've been completely confused about what is real and what isn't ever since. It's called "objectification" or "reification" or "hypostatisation". If beliefs are left unexposed, confusion results. Occasionally "reification" is deliberate, e.g., in math and science. In order to create symbolic entities with which to measure and count, you understand. Not kill. See a Pharyngula blog post about this whole sorry piece of nutbardom.
On Facebook people are wondering what the deal is, why it is that people would ever feel that impassioned about some book. I wrote,

"Maybe human life (messy, biological, full of unquenchable needs and wants, and those awful evil beings, aka females) *is* considered less important than the reified and objectified notion of perfection, i.e. a book that represents the deity... so precisely imagined, but of whom no images are allowed. I mean, let's face it - such a way of life has remained unchanged/unchangeable since ..whenever... Dawn of civilization 10,000 years ago? Patriarchy baby. It's had a long time to harden into all this. Since when have individual humans *ever* mattered to a system like this? (..or any other long entrenched male-dom[inated] system?) Since when has someone's own life mattered as much as the "cause", which always seems to be about trying to perfect human society (through whatever distorted lens is being peered through)? And make it more like something they imagine some perfect male deity imagining?"

Anyway, I've always preferred real, concrete, biologic to abstract, symbolic, idealized. I've always preferred to work with whatever I can touch with my hands to working with things only my mind can touch. And I'm female. So shoot me, I guess.

Speaking of working with hands, came across this interesting book review, White Underclass Crushed By Economy - A review of Joe Bageant's Rainbow Pie: A redneck Memoir , by William Bowles. It seems the book is about the erosion of rural life and culture, something that hasn't quite yet destroyed the community I now live in (in Canada).... Excerpt from the review:  

"... every generation that comes along seems to be doomed to have to relearn the lessons of the past. Nothing gets handed down, passed on except the illusions. There is no continuity between the generations, something that also now afflicts the UK. The past that we "consume" is an artifice, a sleight-of-hand, a concoction dreamed up in universities and media conglomerates' 'creative' departments."

I can feel it coming though. Most of the little towns of 100 or fewer are ghost towns now. Including the one I grew up near. Where we used to get mail. And groceries. And gas. And see movies when I was really young. And go to dances when I was a bit older.

At least I didn't ever have to put up with any war going on around me, though, just battles inside my own head sometimes. (See "objectification" etc., again.) Which brings me to the last link I want to put up - Revolutionology, a very nice new blog that I plan to follow and read every day until this Gaddafi nonsense (and all his particular capacity for self-aggrandizing delusion) is over. The blogger has decided to watch from inside the rebel line, and comment on the people involved themselves, report their opinions on what they think about the world, their country, about the guy who has kept his heel on their throats for over 40 years. They call him "Uncle Curly" and tag burnt out tanks with his graffiti image. Imagine that.

Interesting times.

A Lorimer classic: "Reconceptualising Pain According to Modern Pain Science"

I saw this retwittered today - an earlier blogpost from Body in Mind (summer 2010 I think); I decided to bring it here, for the exercise, and for anyone who might have missed it at Body in Mind: Research into the role of the brain and mind in chronic pain.
Reconceptualising Pain According to Modern Pain Science was originally published in Physical Therapy Reviews 2007; 12: 169–178.

Abstract
"This paper argues that the biology of pain is never really straightforward, even when it appears to be. It is proposed that understanding what is currently known about the biology of pain requires a reconceptualisation of what pain actually is, and how it serves our livelihood. There are four key points:

(i) that pain does not provide a measure of the state of the tissues;
(ii) that pain is modulated by many factors from across somatic, psychological and social domains;
(iii) that the relationship between pain and the state of the tissues becomes less predictable as painpersists; and
(iv) that pain can be conceptualised as a conscious correlate of the implicit perception that tissue is in danger.

These issues raise conceptual and clinical implications, which are discussed with particular relevance to persistent pain. Finally, this conceptualisation is used as a framework for one approach to understanding complex regional pain syndrome."

Introduction:  (abbrev.)

"At first glance, pain seems relatively straightforward – hitting one’s thumb with a hammer hurts one’s thumb. Such experiences are easily understood with a structural-pathology model, which supposes pain provides an accurate indication of the state of the tissues. However, on closer inspection, pain is less straightforward. Much of the pain we see clinically fits into this less straightforward category, where pain cannot be understood as a marker of the state of the tissues. This paper argues that the biology of pain is never really straightforward, even when it appears to be."

Pain does not provide a measure of the state of the tissues

"In 1965, the gate control theory[2] was proposed to explain the variable response of animals to noxious stimuli. The theory proposed that noxious input was modulated at the spinal cord by other non-noxious input from the periphery, and by descending input from higher centres. That theory was interrogated in many animal experiments (see Wall and McMahon[3] for a review). A typical experiment would involve the insertion of recording electrodes into the nociceptors of the study animal, applying a defined injury and recording nociceptor activity. Finally, experimenters would record behaviours of the animal that implied that the animal was in pain. These behaviours might be relatively simple; for example, the reaction time of a withdrawal reflex. They might be relatively complex; for example, the ratio between time spent in a non-preferred environment (e.g. illuminated box) with a cool floor, and time spent in a preferred environment (e.g. dark box) with a heated floor.[4]
Two findings consistently emerged from those studies. First, the injury, or noxious stimulation, initiates the change in behaviour. Second, neither pain behaviour nor nociceptor activity hold an isomorphic relationship with the state of the tissues. By clearly demonstrating these things, those studies provided the first experimental evidence that pain does not provide a measure of the state of the tissues.
One limitation of animal experiments is that they do not tell us about pain. Human experiments, however, can. Although it is difficult to justify injuring human volunteers, it is possible to deliver non-harmful noxious stimuli, for example brief thermal, electrical or mechanical stimuli (see Handwerker and Kobal[5] for a review of various methods of experimentally inducing pain). By recording activity in nociceptors while simultaneously recording subjects’ pain ratings, experimenters have been able to evaluate the relationship between the state of the tissues (in the absence of tissue damage), activity in nociceptors, and pain.[6]
Human pain experiments corroborated both findings from the animal data. Specifically, noxious stimulation is necessary for nociceptor activity, which usually reflects the intensity of the stimulus, and nociceptor activation does not provide an accurate measure of the state of the tissues.[6] The human experiments went further because they showed that the relationship between pain ratings and nociceptor activation is variable. In fact, some authors have proposed that the notion of nociceptors is misleading because small diameter fibres (Aδ and C fibres) respond to very small (non-harmful) changes in the internal state of the body.[7] That said, some small diameter fibres are not responsive to small changes (so-called high-threshold neurons) and this sub-class of small diameter fibres may reflect what we call nociceptors. Regardless, it is clear that experimental studies do not show an isomorphic relationship between pain and nociceptor activity, nor between pain and the state of the tissues. Rather, they show a variable relationship that is modulated by many factors."

 

Pain is modulated by many factors from across somatic, psychological and social domains

"Anecdotal evidence that somatic, psychological and social factors modulate pain is substantial – sportrelated and war-related stories are common (see Butler and Moseley[8] for several examples). However, numerous experimental findings corroborate the anecdotal evidence (see Fields et al.[9] for a review of central nervous system mechanisms of modulation). Other factors that are known to modulate the pain evoked by a standardised stimulus include inflammatory mediators (increase nociceptor activity), tissue temperature (increased temperature increases nociceptor activity via summation), and blood flow (decreased blood flow increases nociceptor activity via summation induced by H+ ions). See Meyer et al.[6] for a review of peripheral mechanisms of modulation.
Experiments that manipulate the psychological context of a noxious stimulus often demonstrate clear effects on pain, although the direction of these effects is not always consistent. For example, a large amount of literature concerns the effect of attention on pain, and of pain on attention.[10–22] Despite the wealth of data, consensus is lacking: some data suggest that attending to pain amplifies it and attending away from pain nullifies it, but others suggest the opposite.
Anxiety also seems to have variable effects on pain. Some reports link increased anxiety to increased pain during clinical procedures[23–26] and during experimentally induced pain,[27] but other reports suggest no effect.[28,29] Relevant reviews conclude that the influence of anxiety on pain is probably largely dependent on attention.[28,30]
Expectation also seems to have variable effects on pain. As a general rule, expectation of a noxious stimulus increases pain if the cue signals a more intense or more damaging stimulus[22,31–35] and decreases pain if the cue signals a less intense or less damaging stimulus (see Fields[34] and Wager[36] for reviews). Further, cues that signal an impending decrease in pain, for example the process of taking an analgesic, usually decrease pain. Thus, expectation is thought to play a major role in placebo analgesia.[37,38]
The common denominator of the effect of attention, anxiety and expectation on pain seems to be the underlying evaluative context, or meaning of the pain. That is demonstrated by the consistent effect that some cognitive states seem to have on pain. For example, catastrophic interpretations of pain are associated with higher pain ratings in both clinical and experimental studies (see Sullivan et al.[39] for a review). Believing pain to be an accurate indicator of the state of the tissues is associated with higher pain ratings,40 whereas believing that the nervous system amplifies noxious input in chronic pain states increases pain threshold during straight leg raise.[41]
The social context of a noxious stimulus also affects the pain it evokes. Initiation practices and sadomasochistic sexual practices are two examples that highlight the importance of social context. Overall, the effects of social context are again variable but again seem to be underpinned by the underlying evaluative context, or meaning (see Butler and Moseley[8] for a review of pain-related data and Moerman[42] for exhaustive coverage of the role of meaning in health and medicine).
To review the very large amount of literature on somatic, psychological and social influences on pain is beyond the scope of this paper. However, it is appropriate, and clinically meaningful, to reiterate the theme that emerges from that literature: that the influences are variable and seem to depend on the evaluative context of the noxious input."

The relationship between pain and the state of the tissues becomes weaker as pain persists

"The nervous system is dynamic. This means that the functional properties of individual neurones and of synergies of neurones change in response to activity. To review all the changes that have been identified is beyond the scope of this paper and the expertise of this author. However, the nature of the changes can be summarised thus: that the neurones that transmit nociceptive input to the brain become sensitised as nociception persists, and that the networks of neurons within the brain that evoke pain, become sensitised as pain persists. The molecular and systems biology of these changes have been discussed at several levels.[8,43,44] The clinical manifestations of these changes are: hyperalgesia (formerly painful stimuli become more painful) and allodynia (formerly nonpainful stimuli become painful). These terms are used widely, most often in reference to tactile stimuli, but also in reference to movement and to thermal stimuli.
One aspect of the changes that occur when pain persists is that the proprioceptive representation of the painful body part in primary sensory cortex changes.[45–47] This may have implications for motor control because these representations are the maps that the brain uses to plan and execute movement.[48] If the map of a body part becomes inaccurate, then motor control may be compromised – it is known that experimental disruption of cortical proprioceptive maps disrupts motor planning.[49] The notion of distorted proprioceptive representation has been discussed with regard to its impact on motor control[50,51] and, more recently, in a theoretical way with regard to pain.[52] Although exceptions exist,[53] there is mounting evidence that changes in cortical representation occur in association with chronic pain, and it is feasible that these changes may become part of the problem.[46]"

Conceptualising pain as a conscious correlate of the implicit perception that tissue is in danger

"The biology of pain is complex. One response to this complexity is to develop clinically viable conceptual paradigms that incorporate what is now known about that complexity. One such paradigm that is gaining support is the neuromatrix theory (see Melzack[55] for a contextual review),[54] which conceptualises pain as one output of the central nervous system that occurs when the organism perceives tissue to be under threat. There are two important components of this conceptualisation.  First, there are other central nervous system outputs that occur when tissue is perceived to be under threat, and second, that it is the implicit perception of threat that determines the outputs, not the state of the tissues, nor the actual threat to the tissues (Fig. 1).
When tissue is under threat, a range of local and segmental responses occur. For example, inflammatory mediators are released, the body part is usually withdrawn via short and long latency reflex loops, there are rapid changes in blood flow and in the excitability of peripheral nociceptors (so-called peripheral sensitisation).[56] The nociceptive system transforms this threat into electrical activity in peripheral neurones. If this message of threat is then transmitted by spinal neurones to higher centres, the responses become more complex. For example, immune mediators are released into the blood stream,[57] voluntary and postural muscle activity are altered[58] and conscious knowledge of the threat (i.e. pain) may emerge. Within this context, pain will not emerge until the nociceptive input to the brain has been evaluated, albeit at an unconscious level (see Moseley[59] and Gifford et al.[60] for further discussion).
The second important component of the neuromatrix theory is that pain depends on the perceived degree of threat. This means that pain can be conceptualised as the conscious correlate of the implicit perception of threat to body tissues.[8,59] That psychosocial factors are very important in most chronic pain states is well established.[61–65] This paper argues that the mass of data regarding psychosocial factors can be gathered within the proposed conceptualisation that pain is one output of the central nervous system that occurs when the organism perceives tissue to be under threat. The conceptualisation has limitations and strengths. One limitation is that it does not attempt to describe the biology of implicit evaluation of threat, nor of how this might emerge into consciousness. In this sense it adds little to theories first proposed decades ago (see, for example, Hebb[66]). However, a strength of this conceptualisation is that it can easily be integrated into a clinical context where making sense of the influence of factors from across somatic, psychological and social domains is valuable."

Implications for clinical practice

"That pain does not reflect the state of the tissues, but rather is a conscious driver of behaviour aimed at protecting those tissues, has implications for clinical practice. One implication is that to base clinical reasoning on what is currently known about the biology of pain requires that the skills and knowledge of the clinician are broader than those related to anatomy and biomechanics. That is, the clinician must have a sound knowledge of diagnostic tools, tissue dynamics, healing and remodelling, peripheral and central sensitisation, and psychological and social factors that might affect the implicit perception of threat to body tissues. This information is readily available and there is evidence that clinicians can understand modern concepts with relatively limited training.[67] That said, it may be unrealistic to expect clinicians to keep uptodate with progress in knowledge across these areas. This points to a strength of the conceptualisation of pain as the conscious correlate of the implicit perception threat to body tissues because the clinician can use the conceptual model to guide treatment. That is, rather than know and understand all the evidence about which somatic, psychological and social factors have been demonstrated to modulate pain, and the nature of their modulation, the clinician can consider each factor in terms of what effect it might have on the implicit perception of threat. This conceptual model seeks to synthesize that wide body of evidence into a principle.
Another implication that is worthy of special mention is that patients should be helped to base their reasoning, about their condition and their pain, on similar information. This is important because teaching patients about modern pain biology leads to altered beliefs and attitudes about pain[40] and increased pain thresholds during relevant tasks.[41] Moreover, when education about pain biology is incorporated into physiotherapy management of patients with chronic pain, pain and disability are reduced.[68,69] A key objective of such education is to encourage patients to apply the same principle as that advocated for clinicians, summarised here as ‘what effect might this (factor) have on the implicit perception of threat’, or in patient-appropriate language, ‘how does this affect the answer to the question, how dangerous is this really?’.[8]"

(my bold - DJ)

Using this conceptualisation to understand CRPS and guide new options for management

"Complex regional pain syndrome (CRPS) is a debilitating condition that can occur after minor trauma, and sometimes without peripheral trauma, for example, post-stroke.[70] Much is known about the pathophysiology of CRPS, including facilitated neurogenic inflammation[71,72] and tissue hypoxia[73] at the injury site,[74,75] autonomic,[76] immune,[77–79] motor,[80,81] tactile[82–85] and proprioceptive[86] dysfunction (Fig. 2).
The syndromic pattern of signs and symptoms includes pain, hyperalgesia, allodynia, dystonia, swelling, abnormal blood flow, abnormal sweating, hair and nail growth. The sensitivity to provocation can be remarkable, for example, elicitation of pain, swelling and (anecdotally) blood flow changes in response to imagined movements[87] or when the patient receives visual input that the limb is being touched, even though it is not in fact being touched (‘dysynchiria’).[88] The wide-spread and multisystemic nature of the pathophysiology of CRPS implies that, although CRPS is usually initiated by peripheral insult, it is a disorder of the central nervous system.[75]
When one tries to make sense of such a multisystemic and exaggerated response to minor injury, the conceptualisation that pain is a conscious correlate of the implicit perception of the threat to body tissue can be useful. That pain is just one output by which the brain might try to protect the tissues – one aspect of a homeostatic response[89] – lends itself to CRPS because the other responses are so patent. That pain is a correlate of implicitly perceived threat to body tissue, rather than the state of the tissues, or the actual threat to the tissues, is particularly relevant to CRPS in the absence of any tissue or neural injury, for example, as a stress response.[90]
Each of the pathological findings that have been documented in patients with CRPS might be considered a protective response, whether it be an immune, motor, sensory, vascular, autonomic or conscious response. consistent with attempts to protect the part in question, by utilising immune, motor, sensory, vascular and autonomic systems as well as consciousness. Reducing the threshold for activation of these protective responses would seem a particularly effective way to protect the body part in question, for example making it so sensitive that even looking at it being touched activates a protective response.[88]
The challenge for those trying to understand CRPS according to this paradigm is to identify why the implicit perception of threat to body tissues is so exaggerated in some patients and in some situations, but not in others. Fundamental to the paradigm is that anything that modulates implicitly perceived threat should be relevant. That means that psychosocial factors, including anxiety, depression, attitudes and beliefs, social context or work status may all play an important role. Although patients with CRPS do not demonstrate a ‘typical’ psychosocial profile, psychosocial contributors are probably relevant in the majority of cases. Finally, there is initial evidence for a genetic contribution to CRPS,[91] but more data are required to clarify that possibility."

Clinical response to CRPS according to this paradigm

"If CRPS is an exaggerated protective response, then it seems sensible to devise treatment that aims first to find a baseline that is sufficiently conservative to not elicit the unwanted protective responses (to ‘get under the radar’), and second to expose the limb gradually to threat while continuing to avoid elicitation of the unwanted responses. This approach underpins graded motor imagery for CRPS,[92,93] whereby patients begin training by making left/right judgements of pictured limbs. It is known that this task activates cortical networks that involve representation of the limb and preparation for movement,[94] but this task does not activate primary sensory and motor cortices.[95] Graded motor imagery progresses from left/right laterality judgements to imagined movements, which do activate primary sensory and motor cortices,[95,96] and then to mirror movements. The order of these compo nents seems to be important in the effect on pain and disability in patients with chronic CRPS (Fig. 3).[1] In patients with acute (or anecdotally less severe) CRPS, it may be sufficient to begin training (conceptualised here as exposure to threat) with mirror movements.[97]
One of the key issues outlined earlier is that the nervous system changes when nociception and pain persist. There is a large amount of evidence that the cortical representation of the affected limb undergoes substantial changes in patients with CRPS[47,74,75,83,98–100] and these changes have been implicated in the maintenance of pathological pain syndromes (although see Moseley[53] for a word of caution).[46] If distorted cortical representation contributes to CRPS, then it would seem sensible to attempt to normalise cortical representation of the limb. This has been done in patients with phantom limb pain,[101] which is associated with changes in primary sensory cortex that are probably similar to those observed in CRPS (see Acerra et al.[102] for a review of common findings in phantom limb pain, stroke and CRPS). In that study with amputees, sensory discrimination training evoked normalisation of cortical representation, improvement in tactile acuity on the stump and reduction/elimination of phantom limb pain.[101] Increase in tactile acuity, normalisation of cortical representation and reduction in pain were positively related.
Finally, if CRPS reflects an exaggerated implicit perception of threat to body tissue, then it would seem sensible to attempt to reduce the perception of threat. One approach that has been studied extensively in other populations is the explanation to the patient of the underlying biology of their pain. Preliminary data from patients with CRPS appear promising,[103] but clinical trials are required."

(my bold - DJ - Learning to tell right body parts from left body parts, visually)

Conclusions

"Extensive experimental data corroborate anecdotal evidence that pain does not provide a measure of the state of the tissues and that pain is modulated by many factors from across somatic, psychological and social domains. It is now known that as nociception and pain persist, the neuronal mechanisms involved in both become more sensitive, which means that the relationship between pain and the state of the tissues becomes weaker and less predictable. One paradigm, which considers the current thought in pain biology, conceptualises pain as the conscious correlate of the implicit perception of threat to body tissue. This conceptualisation can be applied clinically to identify factors from across somatic, psychological and social domains that may affect the perceived threat to tissue damage. Further, it suggests approaches to treatment that target those factors. Evidence from clinical trials suggests that clinical strategies based on this conceptualisation can be effective in patients with disabling complex and chronic pain."

 (my bold - DJ)


LINK TO ORIGINAL BLOGPOST:

Reconceptualising Pain According to Modern Pain Science

Please go look at it, as there are helpful diagrams, acknowledgments and references I didn't copy over to here. While you are there, check out all the other excellent blogposts others have contributed. Body in Mind is one of the most thoughtful and clinically useful blogs on chronic pain to ever have graced the web.

Here is a recently posted, short, one-minute youtube video by Matthias Weinberger, showing mirror therapy for CRPS.