Friday, May 03, 2013

Playing pingpong with the diagnosis of chronic pain

I  spotted a tweet from PainBC a few minutes ago, and tracked down the Facebook post for it.
Here is what it says:

"On February 7th, Pain BC wrote a letter to the American Psychiatric Association urging them not to go ahead with the inclusion of Somatic Symptom Disorder (SSD) in their upcoming DSM-5 diagnostic manual. We believe the over-inclusive definition of SSD will potentially harm people in chronic pain who are medically ill, by mislabeling their medical problems as a mental disorder if they worry "too much" about their physical health. Some American doctors reached out to Pain BC board chair, Dr. Michael Negraeff as a result of our advocacy, and asked us to contribute to an article. Dr. Negraeff's comments were recently published in the Huffington Post. You can read them here: PLEASE SHARE THIS PIECE as widely as possible so that our collective voices will be heard and prevent these harmful changes to the DSM-5. Thank you!"

Here is the article in Huffington Post, written by Allen Frances, with the letter from Dr. Michael Negraeff, PainBC's board chair, embedded. While I agree with the main gist of the Frances article, that chronic pain should not be listed as a mental disorder, there are certain blanket statements made by him that I can't agree with.

"Chronic pain is part of the human condition."

Well, maybe it might seem that way from a medical perspective, an endless sea of suffering in the waiting room, people with aches and pains, some severe, some unremitting, medical tools not adequate to obliterate it from peoples' lives entirely, or for some, not at all.. but it isn't part of MY human condition - in fact, I'd hasten to suggest that there are a lot of completely ordinary people of all ages out there walking around, doing life, who declare themselves painfree, and that therefore chronic pain is NOT inevitably "part of the human condition".

Now, I would argue that pain itself is, of course, part of the human condition, as the natural protective response it evolved to be. Then it goes away. I get that about a fifth of people live with various pains of a chronic sort. But a fifth isn't the entire human condition. It's still a fifth. Not five fifths.

So that bugged me a bit.

Then, this:
"Our backs didn't have enough evolutionary time to make the full engineering adjustment to upright posture -- so low back pain is endemic."
Um.. any cursory reading of evolutionary biology will tell us that bipedal posture arose about 4 million years ago. As humans, scanning the horizon looking for food with brains five times bigger than they really need to be to run critters our size - human bipeds have been around for only about couple hundred thousand years. I think our backs have had WAY more time to adapt to upright locomotion than we've had time to adapt to our own existence as a species, with all its social constraints and demands funnelled through various cultural mechanisms. 

So, that bugged me a little bit, also.

Next, this:
"Because our ancestors didn't often live beyond age 40, natural selection didn't protect us from the pains that so often come from aging -- especially arthritis."
Hmmnn.. I really think that's debatable. Why is aging being conflated into chronic pain? I know lots of old folk living out in their communities at advanced ages who don't complain of having pain. They are active and social and engaged. They seem comfortable in their bodies. I'm talking about people in their 80's, 90's.. The only thing they get a bit worried about is falling on the ice that we have to put up with, here, for almost half of every year. So they go out and buy canes that have picks on the end, and go out anyway, buy groceries and so on. They're old. If they had pain, they'd mention it, complain about it. They're independent and they're honest.

Furthermore, since when did arthritis and chronic pain become so conflated into each other? People can have a lot of pain variability depending on how their perception is handled. Other people can have incidental findings of joint degeneration without pain.

I appreciate his overall stance, though, not wanting pain to be considered a mental illness or disorder. Me too.

Furthermore, I do also appreciate all the hard work that has been done to drag chronic pain up out of the ditch of being completely and mistakenly a physical disorder ostensibly tied to some condition or other for which no confirmatory medical test on the planet exists.

I appreciate that it has been separated into two bins, one labeled "nociceptive input" and the other labelled "pain output" or "pain perception" thanks to Ron Melzack and his neuromatrix model. I appreciate all the brain science out there that suggests there is an old 500-million year old "brain" in charge of regulating nociception, and another newer 200 thousand year old part which is human and concerned with extracting or establishing meaning from social interaction and has to exist fused to the older more reactive more bossy part which has seniority and takes over if it thinks it has to.
To me, human existence of the most optimally comfortable kind has to do with allowing time for those two main brain parts to establish, grow, and maintain a good relationship, mostly via feedback from enjoyment of physicality.

It seems to me, pain challenges that relationship something awful. Getting that relationship, right inside a human, in their brain, back up on the rails and moving again, is what my job as a therapist is all about.

It's good these two agree, Frances the psychiatrist and Negraeff the anesthesiologist and pain management specialist. Still the topic continues to be about which of two categories, mental or physical, pain belongs in. Like a pingpong match. 

In my opinion, and in the opinion of John Quintner and his coauthors, pain is in a third category. Pain isn't a mental illness, although it can make people come off their rails: it isn't strictly physical, in terms of being associable in any direct consistently measurable fashion with tissue injury: no - it is in a third place
No dualism please. 
There is no either and no or. 
There is just ... pain. 
When it's there. 
And that varies, depending.. 

And one more thing: pain is not a noun - it's a verb that makes one feel as though one can't..  move about, or be a verb, ...can't be a human, moving.


May 4 / 2013 - UPDATE: via Vaughn Bell, on MindHacks blog:  National Institute of Mental Health abandoning the DSM. 

4. John Quintner, Milton L. Cohen, David Buchanan, Owen D. Williamson; Pain Medicine and Its Models: Helping or Hindering? Pain Medicine Volume 9, Issue 7, pages 824–834, October 2008
Objective.To identify whether the biopsychosocial framework of illness has overcome the limitations of the biomedical model of disease when applied in the practice of pain medicine.
Design.  Critical review of the literature concerning the application of biopsychosocial models to the praxis of pain medicine and the concepts of living systems. 
Results.  The biopsychosocial model of illness, formulated by Engel in 1977, has generated the International Association for the Study of Pain (IASP) definition of pain, two major conceptual frameworks in pain medicine, and three putative explanatory models for pain. However, in the absence of a theory that seeks to understand the lived experience of pain as an emergent and unpredictable phenomenon, these progeny of the biopsychosocial model have been caught in circular argument and have been unable to overcome biomedical reductionism or the perpetuation of body–mind dualism. In particular, the implication that pain can be a “thing” separate and distinct from the body bears little relationship to the lived experience of pain. Such marginalizing results when an observer attempts to reduce the experience of the pain of another person. 
Conclusions.  The self-referentiality of living systems (through their qualities of autopoiesis, noncentrality and negentropy) sees pain “emerge” in unpredictable ways that defy any lineal reduction of the lived experience to any particular “thing.” Pain therefore constitutes an aporia, a space and presence that defies us access to its secrets. We suggest a project in which pain may be apprehended in the clinical encounter, through the engagement of two autonomous self-referential beings in the intersubjective or so-called third space, from which new therapeutic possibilities can arise.

5. R Melzack; Pain and the neuromatrix in the brain. Journal of Dental Education. December 1, 2001 vol. 65no. 12 1378-1382 Full pdf.

Abstract: The neuromatrix theory of pain proposes that pain is a multidimensional experience produced by characteristic “neurosignature” patterns of nerve impulses generated by a widely distributed neural network—the “body-self neuromatrix”—in the brain. These neurosignature patterns may be triggered by sensory inputs, but they may also be generated independently of them. Acute pains evoked by brief noxious inputs have been meticulously investigated by neuroscientists, and their sensory transmission mechanisms are generally well understood. In contrast, chronic pain syndromes, which are often characterized by severe pain associated with little or no discernible injury or pathology, remain a mystery. Furthermore, chronic psychological or physical stress is often associated with chronic pain, but the relationship is poorly understood. The neuromatrix theory of pain provides a new conceptual framework to examine these problems. It proposes that the output patterns of the body-self neuromatrix activate perceptual, homeostatic, and behavioral programs after injury, pathology, or chronic stress. Pain, then, is produced by the output of a widely distributed neural network in the brain rather than directly by sensory input evoked by injury, inflammation, or other pathology. The neuromatrix, which is genetically determined and modified by sensory experience, is the primary mechanism that generates the neural pattern that produces pain. Its output pattern is determined by multiple influences, of which the somatic sensory input is only a part, that converge on the neuromatrix.

6. Candida S McCabe; When Illusion Becomes Reality. Rheumatology Advance Access published March 29, 2011
7. Catherine Preston,  Roger Newport;  Analgesic effects of multisensory illusions in osteoarthritis. Rheumatology (2011) doi:10.1093/rheumatology/ker104 First published online: March 29, 2011 (full text)
8. Deborah Brauser; DSM-5 Somatic Symptom Disorder Debate Rages On. Medscape Mar. 21, 2013 (login required)

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