Pain

Physical Pain: Physical pain is fairly obvious. Although it itself can take several forms of cutting, burning, freezing, throbbing, aching, or even just itching and discomfort. Many people believe physical pain to be something which can be "cured" and gotten rid of. The amount of pain-killing (reality-dulling?) medicines we have nowadays is testament to that.

Emotional Pain: This can be caused by a bad event (a breakup, loss of a job, a family member), or empathy (from your friend's pain). Emotional pain seems (for me at least) not to go away as quickly as physical pain. I think a lot of people either ignore it, or hope it goes away, instead of actively dealing with the source of their problems and making peace with whatever ails them. However, our modern society also tries to "cure" emotional pain with drugs like Prozac or Zoloft.

Spiritual Pain: Although many people might not call this a kind of "pain", I'll put it here anyway. It would probably better be described as "spiritual anxiety". It could be that a person is having a spiritual crisis and wants to believe something but doesn't know what. It could also be spiritual guilt at having done something wrong, and depending on your religion, fear of eternal pain. No medicines for this yet, but when the "Jesus Pill" (*shudder*), comes out, you saw it here first.

Pain is life's reminder that we exist.

Painless expanses of time melt together into a non-descript state of reverie, supreme happiness a drug that dulls the senses, never restoring them until the happiness be smitten. The sensation of happiness is not unlike the feeling of dreaming a sweet dream, the covers separating one's body from the cold, harsh elements that lurk; but wherever they lurk it's far from here, we don't know them and we couldn't name them. Because they don't concern us.

What is commonly believed to be the test of whether a person is dreaming? Pain. The pinch that brings the subject back to reality, back in touch with the things they had forgotten about, the things they neglected in their intoxicating bliss. We are weak, vincible, mortal. We are bound to a frail system of tissue and fluids. We are subject to involuntary states of consciousness that we call feelings, at times unconquerable by the strongest will.

Yes, we definitely do exist, of this much I can be sure...

pain also happens to be the French word for "bread".

"So what," you say, and rightly so. Well, I'd like to relate a little experience that changed my attitude toward the French word to bread:

A friend and I were touring around in Germany, enjoying the (theoretically) limitless speed of the Autobahn. Suddenly, while passing a line of trucks, we found ourselves next to this humongous (by European standards) truck. All of the truck's main body was painted bright fire engine red. On each side, a single word was painted in huge white block letters more than half the height of the available space:

PAIN

My friend just kind of gave a little gasp, while I was mentally floored for some seconds. A goodly portion of my field of view was red. Red like fire, red like the devil, red like blood. In the midst of this, four letters representing what may be the most unpleasant of sensations. The brief but vivid associations this conjured up felt like being in a short story by Edgar Allan Poe.

OK OK, we both speak some French, and we eventually realized what the truck was about, and it checked out with the French license plates and all, but it sure felt kind of strange for a while. Some otherwise unknown bakery in France has made a lasting impression on me.

At the beginning of my first ever neurology tutorial, the lecturer stood up and threw a question out to the class:

"What is pain?"

Several hands went tentatively into the air. Then were quickly withdrawn before the lecturer could point to them for an answer. The question is one of those that people think should be easy to answer, but on further reflection realise that it's not that easy. For most, the basic definition is that pain is the feeling or perception of irritating, sore, stinging, aching, throbbing, miserable or unbearable sensations arising from within the body. A neuroscientist would further classify pain as being the affective perception of nociceptive stimulation, and that it was not so much a sensation as a complex experience that is the product of interaction of various physical, mental and emotional components. Or, to put it a mite more simply, pain is both a physical reality and an abstract concept. Which isn't really an answer at all. So maybe there is no answer.

Function of Pain

What I do know is that pain is essential. Those who are born with an inability to feel pain, physical pain, tend to die young. This is because pain is instrumental in our navigation of the world. One woman born with this condition received intensive early training in order to recognise and avoid damaging situations. She died from sepsis aged 28, deformed and misshaped from degeneration of her joints. Why did this happen? Well, if you were to attempt to pull your finger back as far as it would go right now, you'd experience pain; this is your body's way of telling you not to do that because you're damaging yourself. Someone unable to feel pain could sit there doing this all day - till their finger snapped if they wanted. And they still wouldn't be able to feel pain. They'd burn themselves getting into a too hot bath. They'd get pressure sores while sleeping in bed because they're body is unable to sense that it needs to turn over. Pain is essential.

However, too much pain can be equally as damaging, as anyone with phantom limb pain or bone metastases can tell you. For these people, even high dose opoids bring little, if any, relief to their pain. Sometimes, people are so desperate to escape their physical pain they will consent to radical surgery to cut out nerves, nerve roots, and even parts of their brain. Tragically, this often makes little difference to their pain state. There is a large amount of money being ploughed into researching pain mechanisms; the reason for this is more than obvious.

Pain Perception

The term that describes the process by which the body is able to sense a painful stimulus is called nociception, (from the Latin 'nocere', to harm). The sensory cells that are activated by painful stimuli are called nociceptors, and there are several different classes of nociceptors, so, a chemical nociceptor will respond to substances such as histamine, a mechanical nociceptor will respond to pressure, and a thermal nociceptor will respond to an increase or decrease in temperature. There are two types of fibres that carry pain stimuli to spinal cord and brain. The fast ones are the Aδ fibres which are lightly myelinated. The C fibres are slower and unmyelinated. If you were to step on a sharp piece of glass, you'd have a sudden burst of localised pain that would cause you to quickly bring your foot off the floor to stop the pain caused by the glass cutting into your skin. This response is mediated by the Aδ fibres. After a few seconds, a dull pain will make itself apparent in the area where you have cut yourself. This is the response carried by the C fibres to remind you that you've cut your foot, and you should be a bit careful when using it while the wound is healing.

The body has yet to develop a piece of neural circuitry to force you to wear shoes at all times.

What happens to the stimuli transmitted by the nociceptive afferents upon reaching the spinal cord is a little more complicated. The information gets broken up and fed into both nerve tracts that lead to the brain and also sent into various spinal reflex arcs to facilitate non-conscious reactions - such as the sudden withdrawing of a finger away from a needle that you caught the sharp side of whilst sewing. The main tract that runs to the brain with nociceptive information is the spinothalamic tract, which runs to the thalamus of the brain, a small mass of grey matter at the base of the brain (from thalamos, the Latin for 'inner room', in turn derived from the Greek tholos, 'vault'). The thalamus is an amazing feat of biological engineering; the best analogy is to think of it as a telephone switchboard. A switchboard that is operated by the CEO of your brain. All sensory input (excluding only a part of the olfactory (smell) tract) and motor output passes through this amazing piece of tissue, and is subject to regulation by it. The thalamus breaks up the nociceptive stimuli and passes it on to the appropriate pieces of cortex for processing, such as the primary somatosensory cortex (S1), a small strip of brain that deals entirely with the sensory aspects of the body e.g., touch, proprioception, pain, etc.

Endogenous Mechanisms of Pain Control

Have you ever wondered how, as a child when you bruised your knee and ran to your mother for hugs and sympathy, her giving your knee a kiss and rubbing it better did actually make the pain go away? There is actually a neural basis for both of these magic remedies that mum would dole out.

Whenever we hurt ourselves, we always rub the area that we knocked as an instinctive reaction. And most of the time, it does actually stop the pain, or at least dull the ache. It's thought that by rubbing the area that we've just carelessly caught on a table as we walked past, we are activating the Aβ nerve fibres in our skin, which are mechanosensory fibres that carry information to our brains about touch. Theses fibres interact with interneurones in the spinal cord, which in turn synapse with the nociceptive fibres carrying the pain signals that have just been set off by that stupid bloody table, who put that there, etc., etc. These interneurones have a suppressive effect on the C fibre via presynaptic inhibition, acting as a gate to control the transmission of pain stimuli. This is technically just a hypothesis, called the gate-control hypothesis no less, but it does nicely explain the universal behaviour reaction to pain - the rubbing of the injured area. This is the mechanism taken advantage of by TENS (transcutaneous electrical neural stimulation) machines, where electrodes are placed on the skin over a peripheral nerve. TENS devices are often used quite successfully to treat some types of intractable pain.

Then there's mum's amazing skill at kissing away the pain. I suppose I don't need to tell you that it's got nothing to do with the kissing, so much as the belief the child has that his mum kissing his knee better will make his knee better. The kissing of the knee results in the release of endorphins, the body's own pain relief substances. Endorphins are small proteins that are chemically a part of the opoid family, and so have similar effects to morphine and heroin. They can also be as addictive as morphine or heroin, as proved by anyone who needs to get a gym fix in everyday. The endorphins are also implicated with regard to the placebo effect in pain relief. A placebo (from the Latin 'I shall please') is an inert substance that, none the less, produces a clinical effect. A good example in this case is in post-operative patients who, on being told that they are being given pain relief, are actually only injected with normal saline but still report a decrease in their pain symptoms. The belief that they are being given a treatment that will work is enough for the pain relief systems of the brain to be activated. This placebo effect is probably also a likely explanation for other methods of pain relief, such as acupuncture, hypnosis, and a loving mother's kiss.

Then there's the story of people who sustain horrific injuries and apparently feel no pain, or people that suddenly become super strong in order to lift a car off the person trapped underneath. This phenomenon is actually the result of descending inhibition coming from an area of the brain called the periaqueductal grey matter (PAG). It can be activated by strong emotion and stress, and also by those possessive of a stoic nature. It is this particular pain modulation mechanism that explains the difference in different people's pain thresholds.

Pain Dysfunction

There are two clinical pain states: physiological pain (i.e., pain caused by stimulation of nociceptors) and neuropathic pain (i.e., intractable pain that is maladaptive and has no logical stimulus).

Physiological pain is the everyday pain that we are all very familiar with, be it a paper cut or a broken leg. However, this pain state can often morph into slightly more sinister pain states due to the release of various substances (such as substance P and CGRP (calcitonin gene related protein)), resulting in a hyperalgesia, where even the slightest touch will set off an exaggerated pain response. These changes are not permanent however, and as the wound heals normal pain perception will be re-established.

Neuropathic pain is pain that results from damage to the nervous system that results in permanent changes to central nervous system (CNS) connections. There are various hypothesised mechanisms by which this can happen, but the result's always the same; an inescapable, constant pain that is resistant to many prescribed forms of analgesia. This type of pain is often associated with those who have either ripped out the nerve roots that supply a limb, or people who have an amputation injury. The pain appears to come from the deadened / missing extremity, and is very hard to treat. Often, patients will experience an allodynia - the interpretation of previously innocuous stimuli as being painful. For instance, if I were to stroke the cheek of a person who lost their arm in a motorcycle accident, they might experience an excruciating pain in their missing limb. The reasons for this are beyond the scope of this write up to explain unfortunately, but those with an interest in neurology and pain can read up further in various papers and in the more advanced neurological textbooks.

I did a whole three months of degree work focusing on pain. When you've studied a subject in depth, it's hard to know what should and shouldn't go into a brief summary. If you feel there's anything missing, let me know and I'll add it in if I think it's appropriate.

Pain

Pain – – has an Element of Blank – –
It cannot recollect
When it begun – – or if there were
A time when it was not – –

Goal: Achieve catharsis of the soul. Possible outcome: None

Being in a state of pain, of deep and utter pain from rejection, does something to you. So many people have described this feeling in the past, and many more will try to describe it in the future. What I feel right now might not be comprehensible to anyone but me. But I still do write it.

Brain scans carried out on volunteers showed that when they suffered a social snub, the brain's "pain centre" went into overdrive. The finding suggests that any emotional stress, such as the demise of a relationship or the loss of a loved one, might be far more closely linked to real pain than previously thought.

Matthew D. Lieberman, assistant professor of psychology at UCLA, The Guardian, October 10, 2003²

Pain makes a mess of all feelings and emotions. It affects both body and mind, leaving you with that sting in your chest, nausea, sleeplessness, confused and with a non-existing self-esteem. Ok; reality described.

When everything was gold

Your mail:

If I had been lying close to your back I would put my nose in your hair
and as much of your body as near mine as possible.
Then I would have felt someone's pulse and I wouldn't be sure
which one of us this pulse belonged to. I would have sensed
the heat coming from you, while you tenderly had shown me with your hands that you were
ready, or perhaps satisfied. Caresses, touches.
All the things there are so few and so useless words to describe.

If I had been lying close to your back and put my hand gently on your stomach,
what would you feel?

My reply:

If you had been lying close to my back and gently put your hand on my stomach,
I would probably be quiet. Quiet to perceive the revolt of my senses,
a revolt that would start in my gut and spread out in my body.
My nerves would probably control my senses, conquer them without weapons
just by outnumbering them. There would be sparkles and fire,
and no one would hand over buckets of water to put the flames away.

If you had been lying close to my back and gently put your hand on my stomach,
I wouldn't hesitate jumping into that fire,
walking on coals would be like floating on air, the heat would sooth me
even though the possibility for burns and blisters would be present.

If you had been lying close to my back and gently put your hand on my stomach,
I would want to get even closer to you,
to wipe away the skin that separates us,
I would want to move to the beat of your heart
as you move to the beat of mine.

If you had been lying close to my back and gently put your hand on my stomach,
I would have felt the possibility
that we were going somewhere together,
and then I would have taken you by the hand and led us there...

Your reply:

...I would have let you. Would have let you take me by the hand
and felt that I got tensed and relaxed,
I would have had knives and butterflies in my stomach and millions of stars in my head.
I think of your hands, your lips and your hair
which you have to put behind your ear when you bend to fetch something.
I think of what your hands may do to me
and everything I want to do in return when our bodies live a life of their own
and all reason and sense are gone like morning dew at dawn.
Take my hand and feel.
Turn around, let me caress your back. Give me a grin.
Give me your lips and set fire to yet another part of my body.
You glow, pulsating like blood.
I feel you against my chest, you prickle me and I tickle you.
Now we're not even two anymore, going to that somewhere,
greedy, blood filled and ready.
My pulse beats heavily.
I hold your face in my hands... taste... it burns...
eyes closed and hands strolling red hot fields and valleys.
I want to feel you even more... will you let me?

I let you.

Intermezzo

What would you feel if someone you held dear suddenly and totally unexpected told you, by e-mail, that they didn't want to see you again. Ever. On the same day you took a leap of faith and shared your dark nightmares and fragile hopes with them. That you were accused and judged for something you've written down as a short-story. That they told you that your thoughts and fantasies told the truth about who you were and what you had done. (I wonder what they would say about Bret Easton Ellis by the way.) That their fear of what you might do in the future was so strong that all their faith in you had gone. That all your insurances of innocence had no value and were refused delivered. That you were denied the opportunity to explain yourself, that none of your phone calls, messages or mails were replied upon.

You would get hurt, wouldn't you? Even though you were able to think rationally for a bit, even if you could understand their reaction. Or at least be able to see that it was this person's own hang-ups that messed up the situation.

Rationally we can say being excluded doesn't matter, but rejection of any form still appears to register automatically in the brain, and the mechanism appears to be similar to the experience of physical pain...

Matthew D. Lieberman, assistant professor of psychology at UCLA, Science, October 9, 2003³

I thought I could be a writer, putting my inner thoughts, hopes, dreams, fears through a metamorphosis that would turn them into situations and feelings that someone else could recognize and be familiar with. I was always afraid of what my loved ones would say if they were able to read what I put down on paper. But I gave it a shot. You disappointed me; reacting just the way I feared. I can't believe how you forgot that summer so fast.

You can't do anything about what people think about your work. They're mostly going to be wrong. They're going to criticize you and they're going to think it's about them. Anyone who thinks your work reflects badly on them is going to be mostly wrong, as your work is your own struggle to understand your own self. You won't be able to prove they're wrong; most people are not going to understand the project of the writer, the manifold whatevers of writing. They're just not going to get it and you have to live with that. It helps to believe that there is nothing shameful about trying to understand one's own self in public; it may be unsightly but it is useful work, and instructive to others.

Cary Tennis, salon.com, June 24, 2005 (my emphasis)⁴

Being a writer yourself, you still didn't understand. You could only feel your own shame, fear of rejection and low self-esteem. No golden empathy could slip away from those dark feelings in your brain. I totally misjudged you. And I didn't know you well enough.

I do see the contours of your inner torments. I only wish you could see them yourself. But when you just cut me off with no explanation at all, I'm having a hard time understanding. That makes coming over you really difficult.

As a wise man just said to me:

If words get you into trouble, it was trouble that was already on its way to begin with⁵.

Maybe that's the bitter part of it all.

A mad girl fighting for things she believes in

I needed to know. Needed to know what was going on inside your skull covered with that black hair that looks so spiky, but feels so soft. I usually don't do these things. Don't want to be a nuisance to anyone; don't want to make a fool out of myself. But this time I didn't care. Some times you just have to fight for the things you believe in. It is my strong belief that talking to each other is the only way to try to solve problems that has occurred. When you denied me that opportunity I couldn't just give in. And that's why I spent hours in your garden, outside your bedroom window, waiting for you to get up when your alarm clock rang. Then you couldn't run away. Then I could make contact. Then I would be able to look into your eyes. I awed for that moment. What would I see?

I saw rejection, contempt, anger. I tried to tell you all the things I wanted you to know, tried to beg you to forgive my thoughtlessness. Tried to explain that my words were nothing but words and had nothing to do with the way I am or what I'm capable of doing to you. But your angry look paralyzed my ability to speak rationally. Some words came out of my mouth, but I can't remember what I said anymore. It has all faded away in the big, black fog that covers that part of my memory. I remember some of your words though.

You're nuts, sitting here all night. Now I really know that I've made the right decision. Go home, you wacko! I don't want to see you again!

So that's it. To you I was ready for hospitalizing in a mental institution. For me I was just a girl fighting for things she believes in.

This shows clearly that two people may interpret the same situation in totally opposite ways, depending on their earlier experiences. And that if there's not a will to understand each other, there sure as hell is not a way either.

Lonely adolescents unwittingly adopt harmful ways of escaping the sadness... (...) Another unproductive coping mechanism is to deny any interest in socializing more or in relating more intimately: "I'm not interested in having a girl/boyfriend." (...) Gaining awareness of these escape mechanisms might help the person get motivated to learn social skills and build his/her self-esteem.

Clayton E. Tucker-Ladd, Psychological Self Help, Chapter 6⁶

This is why you rejected me. You're so scared that it's better to cut clean. So you think. I can understand that fear. I pity you for not being strong enough to even try to change your ways.

But my pain is still there.

What pain does to love

In order to live through this period of pain I have to withdraw my love for you, to put it in a drawer, to distance myself from it. Maybe that's the hardest part of it all.

At first the drawer is kept wide open. I can see my love for you almost totally exposed, but it is so valuable to me, I can't stand doing anything else than keeping it there for all to see. But your ongoing rejection is so painful that I just have to close this drawer a bit. I struggle, pushing with all my strength. It's very hard to even reduce the gap by an inch.

`Cause I miss you.

Everyone is looking for someone to blame
But you share my bed, you share my name
Well, go ahead and call the cops
You don't meet nice girls in coffee shops
She said baby, I still love you
Sometimes there's nothin left to do

Oh you got to
Hold on, hold on
You got to hold on
Take my hand, I'm standing right here, you got to
Just hold on.

Well, God bless your crooked little heart St. Louis got the best of me
I miss your broken-china voice
How I wish you were still here with me

Excerpts from "Hold On" by Tom Waits⁷

I mourn. I sit alone, getting utterly drunk. I watch old technicolor movies. Ingrid Bergman makes me cry. I'm sure that all is lost. My tongue curls itself while I call a friend on the phone.

`Sall over with m'fella. 'Saful. `Sunbearable. He woan come back.

Then, despising myself for my self pity I cry:

`I'm `sgusting, I know. Tell me t'stop. Tell me I don lov'im. Tell me I'm better of without'im. That fukin freak.

In time this drawer will be closed. But it may never be locked. I have no key. You took that away with you.

The afterworld

Surrounded by pain, I hesitate to go forward. I read a lot of stuff, in order to help myself understand, to get ideas and messages that could get my screwed-up head back in its right state.

Feeling terribly upset when losing a lover may be hard but desirable. After listening to the pain for hours, I have often asked a person who has just been rejected, "How would you rather react to such an important loss?" The point is: your sadness comes from your good traits--you were loving, devoted, caring, committed, trusting, and involved. You had given your whole self to the relationship. Isn't that the way you want to be? Isn't that the way you want your future partners to be? Would you really want to be so self-centered, so uninvolved that you could easily dismiss a love relationship?

Clayton E. Tucker-Ladd, Psychological Self Help, Chapter 6⁸

Yes, this makes sense. I'm trying to force my neurons to perceive the truth of this statement, but they're a hell of a bunch. Fighting back in every way they can. My shoulders still attached to my ears, my smile still gone, my gut still acting like I'm sitting in the most terrible rollercoaster ever built. But I breathe. I live.

Who needs love?... who needs the pain of it?... Well, it seems we all do, no matter how much it may hurt. We all need it, because without it we would not be human, without it we would be lost, without it we simply could not exist... Without love - even with all the agony it causes - this world, this life would be truly unbearable...

P. J. Oszmann, January 1999. Revised October 2004⁹

I cling to this. Yes, I need love. I want love. And because this last bit of reason in my mind has survived, I live. In pain, alright. But I still live. Being able to write and to share my inner emotions helps me. Although I still live from minute to minute, I live. The sun is shining today. I'm not out there yet. But the sun still shines. I'm human. Are you?

(No disclaimer attached.)

References:

¹ Emily Dickinson, The Complete Poems, New York: bartleby.com, 2000
² http://www.biopsychiatry.com/misc/rejection-sensitivity.html
³ http://www.scienceblog.com/community/older/archives/O/c/ucl3182.shtml
⁴ http://www.salon.com/mwt/col/tenn/2005/06/24/afraid_to_write/
⁵ Augustine
⁶ http://mentalhelp.net/psyhelp/chap6/chap6m.htm
⁷ http://www.lyricsfreak.com/t/tom-waits/138874.html
⁸ http://mentalhelp.net/psyhelp/chap6/chap6l.htm
⁹ http://authorsden.com/visit/viewarticle.asp?id=19703&AuthorID=6177

Pain (?), n. [OE. peine, F. peine, fr. L. poena, penalty, punishment, torment, pain; akin to Gr. penalty. Cf. Penal, Pine to languish, Punish.]

1.

Punishment suffered or denounced; suffering or evil inflicted as a punishment for crime, or connected with the commission of a crime; penalty.

Chaucer.

We will, by way of mulct or pain, lay it upon him.
Bacon.

Interpose, on pain of my displeasure.
Dryden.

None shall presume to fly, under pain of death.
Addison.

2.

Any uneasy sensation in animal bodies, from slight uneasiness to extreme distress or torture, proceeding from a derangement of functions, disease, or injury by violence; bodily distress; bodily suffering; an ache; a smart.

Chaucer.

⇒ Pain may occur in any part of the body where sensory nerves are distributed, and it is always due to some kind of stimulation of them. The sensation is generally referred to the peripheral end of the nerve.

3. pl.

Specifically, the throes or travail of childbirth.

She bowed herself and travailed, for her pains came upon her.
1 Sam. iv. 19.

4.

Uneasiness of mind; mental distress; disquietude; anxiety; grief; solicitude; anguish.

Chaucer.

In rapture as in pain.
Keble.

5.

See Pains, labor, effort.

Bill of pains and penalties. See under Bill. -- To die in the pain, to be tortured to death. [Obs.] Chaucer.

© Webster 1913.

Pain, v. t. [imp. & p. p. Pained (?); p. pr. & vb. n. Paining.] [OE. peinen, OF. pener, F. peiner to fatigue. See Pain, n.]

1.

To inflict suffering upon as a penalty; to punish.

Wyclif (Acts xxii. 5).

2.

To put to bodily uneasiness or anguish; to afflict with uneasy sensations of any degree of intensity; to torment; to torture; as, his dinner or his wound pained him; his stomach pained him.

Excess of cold, as well as heat, pains us.
Lock

3.

To render uneasy in mind; to disquiet; to distress; to grieve; as a child's faults pain his parents.

I am pained at my very heart.
Jer. iv. 19.

To pain one's self, to exert or trouble one's self; to take pains; to be solicitous. [Obs.] "She pained her to do all that she might."

Chaucer.

Syn. -- To disquiet; trouble; afflict; grieve; aggrieve; distress; agonize; torment; torture.

© Webster 1913.