Sunday, June 29, 2014

Fabbro & Crescentini: "Facing the experience of pain: A neuropsychological perspective."

Most of the time my mental life feels like I'm in an undertow being dragged through time toward open sea - it's OK,  I've learned that I can breathe just fine deep under the pressure of all this mental water: Once in awhile, though, I feel like a surprise current lifts me up into sunshine and oxygen. 

This paper is like that surprise current. In fact, it's like the outline of the book I would always have written but never did, because what would have been the point, who would give a (you know)...  the grand finale of the book would have been how to touch people who have pain, or something totally and equally mundane and presumptuous, in that most of my outer life has to do with that and only that, and most people already think they already know how to do that, and they're right and wrong at the same time, and have all kinds of reasons why they think they're right and I'm wrong, and a lot of the time I think I must be wrong, while at least some of the time I think they are, and so on and so forth..  so it's gets exhausting trying to figure out how to surface by myself. Which is why I like to be part of SomaSimple where the regulars all joke about how dead we all already are...

Then someone posts a paper to SomaSimple, and it turns out to be absolutely the medicine I never even knew I needed.

The paper is about pain. Here is the abstract. Facing the experience of pain: A neuropsychological perspective. 

"Pain is an experience that none of us would like to have but that each one of us is destined to experience in our lives. Despite its pervasiveness, the experience of pain remains problematic and complex in its depth. Pain is a multidimensional experience that involves nociception as well as emotional and cognitive aspects that can modulate its perception. Following a brief discussion of the neurobiological mechanisms underlying pain, the purpose of this review is to discuss the main psychological, neuropsychological, cultural, and existential aspects which are the basis of diverse forms of pain, like the pain of separation from caregivers or from ourselves (e.g., connected to the thought of our death), the suffering that we experience observing other people's pain, the pain of change and the existential pain connected to the temporal dimension of the mind. Finally, after a discussion of how the mind is able to not only create but also alleviate the pain, through mechanisms such as the expectation of the treatment and the hope of healing, we conclude by discussing neuropsychological research data and the attitude promoted by mindfulness meditation in relation to the pain. An attitude in which, instead to avoid and reject the pain, one learns to face mindfully the experience of pain."

One has to look past the typical error these authors and almost everybody else makes, referring to "pain receptors" instead of nociceptors or conflating the meanings into each other interchangeably.

It's set up with 8 sections, possibly reflective of a Buddhist eight-fold path arrangement, possibly reflective of an eight-week mindfulness training program for pain, or maybe both. Ultimately it's about mindful acceptance of pain, any kind of pain, including existential angst. The authors point out in section 7, "The pain of change" (my favourite!) that the culture we're in does nothing to alleviate certain incorrect perceptions about physical and psychological existence. They more less say, the culture promotes illusion by reinforcing the false idea that objects are permanent (they can't be - everything is subject to entropy, everything burns in the fire eventually); furthermore the culture does us no favour by feeding us fairytales about what happens after - that only messes up our heads more, leaving us less capable of helping ourselves to combat our own suffering in the here and now. 

Here is the synopsis:

1. Pain is inevitable. There is pain of all kinds in all creatures, e.g., anxiety of separation from caregiver seen in baby chicks. 

2. Neuroanatomy, discussion of medial & lateral ascending nociceptive systems, and descending control systems. 

3. Section 7 specifically: After a comment related to how hard it has been for science to study consciousness, the authors describe brain evolution, describe the "blocks" (building blocks, not impediments) inside the brain and their generally accepted function. Basic neuroanatomy. Triune brain type stuff. 

4. A definition: 
"Many authors believe that consciousness is the world that appears every morning when we wake up after a, more or less unconscious, sleep. When the world appears, two “entities” are manifested to consciousness: on the one hand the objects that populate the world and on the other the subject (the self) who observes and interacts with them. Both the objects in the world and the self are arranged in space and, as we have seen for humans, also in time [90–92]. Now we begin to think that the objects, the self, the space and the time may not be real, but only “mental constructs”." 

5. A long section supporting that view with references.

6. Description of a "basal block"  "consisting of a spinal cord, the brain stem (with a well-developed and layered optic tectum), the hypothalamus, the oldest portions of the cerebellum, and some telencephalic structures (e.g., diencephalon, olfactory lobe)" - all vertebrates have this. It's the oldest part. It provides a rudimentary "sense of self". Vision developed.

7. Mammals developed a "second block" - "considerable development of both the medial cerebral cortex (hippocampus, limbic lobe) and the lateral cortex (temporal lobe and parietal lobe)." These came with the ability to autonomously thermoregulate/be active in the nighttime. Hearing and smell evolved. A second level of representation of "self" formed - sounds and smells became paired with visual "imagination." 

8. A third level of representation developed with acquisition of language. Language however depends a lot, still, on visual imagery. 

9. Then, a little tutorial on how everything is a verb, not a noun. 

"At this point it is questionable whether in the outside world there are space, time, and objects. Albert Einstein believed that the concept of “object” was probably a creation of the human mind and of some other animal [111]. The idea that there are stable objects is operationally useful for moving through the world. If I refer to a particular book or a particular car it is not difficult to understand each other at the practical level. However, it is necessary to distinguish the practical level from the ontological level. For the Greek philosopher Heraclitus (535–475 BC) and for the Indian philosophical and psychological genius known as the Buddha (485–405 BC) objects do not really exist but there exist only processes. In this sense, a book, a car, a house originate (are built), show (last for a certain period of time), and then disappear. For Heraclitus and the Buddha all things behave like fire: originate, burn up, and then are extinguished [112,113]. Now we know that all entities known in the universe are, in effect, processes."

My bolds. Everything is subject to entropy, baby. Everything.

10. The authors go on: it isn't easy, being free to think of oneself as a "process" and not a "thing", particularly since the culture continually reinforces the idea that one is a "thing." 
"Moving from a worldview formed by “stable objects” to a worldview formed by processes is not easy. The confusion between a representation of the existing world composed of space, time, objects, and self and the ontological dimension has generated in humans what has been called the “pain of change”, or the pain of existence [114]. To consider the world as ontologically consisting of objects has encouraged humans to desire to possess and accumulate. Not only humans have been affected by the fear of change, which probably has its neurobiological origin in the pain of separation. Moreover, in current scientific and philosophical thinking, the idea has prevailed that the equilibrium is the ideal condition, while it is obvious that the biological and cultural life are based only on changes, or the progressive succession of one crisis after another. In thermodynamic, in fact, equilibrium corresponds to the “Heat Death” [115]. Humans have learned through culture and education to consider the processes as objects and, at a deeper level, to consider the self as an object of indefinite or eternal duration. Thus, the idea of separation from the self and the thought of one’s own death have become the primary sources of anguish [13]. Instead of changing the perspective, many cultures, especially the West, have developed a series of myths and stories to avoid the pain of change [116]."

That's it, in a nutshell. Our brain/mind becomes habituated to thinking processes served up by our culture that do not serve us well in the long run. I've often criticized the English language for not having enough verbs, and too many nouns, and for turning concepts into nouns as though they were something real instead of a symbol of a thought "process".. 
But I digress: back to the paper.

11. The authors continue:
"Starting with some typical human neuropsychological experiences (e.g., out of body experiences, OBEs), supernatural realities have probably been conceived in which the change is no longer present and the self (often referred to as soul) is eternal [117]. Instead of dealing with the pain with awareness, trying to stay with dignity in front of it, it was decided to adopt the strategy of avoidance and escape [118]. Unfortunately, the escape from a psychological problem does not extinguish the problem, but probably nourishes it [73,119]."

Exactly - religion was invented to serve the culture, not the humans processing, not the human processors, within it. Religion and culture have been allowed to dominate, keep terrified people terrified of life, and terrified of death, giving them stories instead of helping them integrate the simple facts of existence. We're here one minute, and the next we're gone. Religions colonize minds to the point of such complete dissociation that people are willing to "die" to support the very religion that dissociates them from having an intact psychology. Artificially installed, self-perpetuating, positive-feedback-loopy craziness. 
But again, I have digressed.

12. The last section is mostly a plug for mindfulness meditation, for pain - be it the pain of existence or physically perceived pain. 
"The attitude of mindfulness meditation in the treatment of pain is completely different from the so-called natural reactions. First of all, the universality of the conditions of illness, suffering and pain are recognized... Through mindfulness one learns to become aware of physical and/or psychological pain when it is present; moreover one also learns, slowly and with a lot of difficulties, to become aware of the impulses that arise in response to pain. Thus, instead of reacting, we learn to stand still and look carefully at all the sensations of pain and at what is happening in our minds. Not only we try not to run away from pain, but we also try to cultivate an attitude of kind reception of it, maintaining at the same time a slight smile on the lips and an attitude of non-attachment (letting go) [127–129]... [a bunch more neuroanatomy] ...   The courses of eight weeks of mindfulness meditation that are organized in a number of hospitals to cope with the pain are definitely a good starting point; however, the understanding of what mindfulness really is, is achieved only through a series of insights that come from a long and steady meditation practice [137–139]. In fact, according to Grant and Rainville, they are required at least 2000 h of practice (about eight years with a meditative practice of 1 h per day) to be able to develop some analgesic effects through meditation [140]. To mindfully face the experience of pain is therefore not at all easy, but it is possible."

OK, here I feel a bit of a departure.. I'd rather speed that up a bit.
I get that existence is, all by itself, painful and angst-ridden. I get that that's just life. There really isn't anything better to do with one's life than to get through as best you can, with whatever brain you've managed to grow in spite of whatever culture you may have ended up in, with all sorts of influences and circumstances well beyond your own control, and with a healthy attitude born from having separated existential wheat from cultural chaff, not buying the lies anymore, doing a thorough mental, emotional, psychological house-cleaning, tossing out all irrelevancies. I don't think you can get to my age and still be healthy if that hasn't been done at some point along the way.

But if it's physically perceived pain, well, there are some things I think we can do about that, if it's the kind that changes with movement or position or use. 

Having said that, I do recall a pain I once felt deep in my right hip, sort of pelvic floor, sort of buttock... I think it started up from trying to do abduction stretches or something. It lasted a long time. Months and months. I got some treatment for it, and it felt better, but still it was bad enough I couldn't sit on the floor cross-legged for very long.
I went to a meditation event. Lots of other people were in the room, sitting on the floor. I couldn't - I had to sit in a chair. We were asked to focus on any pain we felt, and send it "light". Whatever kind of pain didn't matter. I chose my crabby butt pain to focus on.
I remember what I was wearing, and I remember there was some tinkly sitar music CD playing. Wonderfully, surprisingly, all the residual pain suddenly vanished along with the movement impairment. So... 

It went away in a single afternoon, not after 2000 hours.

It went away in one distinct moment. I do distinctly remember how relieving that felt.
It never ever came back. Not in that part of my representational map, anyway.. 

Yay for my capable brain. I have no idea how it did that. I only care that it could, and did. 


Fabbro F, Crescentini C; Facing the experience of pain: A neuropsychological perspective. Phys Life Rev. 2013 Dec 19. pii: S1571-0645(13)00202-9


Matthew J. Taylor, PT, PhD said...

A beautiful reflection of your experience Diane. My teacher Richard Miller, PhD who developed i-Rest for the wounded military has discovered that going beyond a kind reception to an enthusiastic (great etymological verb based word there) welcoming of what is present is key for healing.
Thanks for the bold, courageous verb you are in sharing this article. ~ matt

Diane Jacobs said...

Thank YOU for distinguishing verb from noun, Matt. :)

Hard to be enthusiastic about having pain, for most people.
Hard, as a therapist, to get people to be present, but that is what it takes.

Anna G Hoffmann said...

Hi Diane!
These words landed so perfect here in Stockholm at this moment.
Including the comments.

What about leaving getting ANYTHING as a therapist behind and just be mindful, celebrating any process that is already happening?

Like this comment that creates itself like water moving over and under rocks. Water moved downwards by gravitation, towards sea and lake until sunshine creates new clouds and so on so forth...

Angaho aka Anna Ganga Hoffmann

Diane Jacobs said...

Interesting Anna - I agree with your water analogy. On the wall at work I have an enlarged photo, black and white; water flows down a beach toward the sea, making its way around a rock obstacle.