Saturday, June 1, 2013

On Measuring Pain


Maybe with the new technology we want have to ask patients, “on a scale of 1-10 how much pain do you feel?”  Maybe our machines will ask the brain and body directly and the body will express our pain ineffably.  We will get precise answers and we can judge our therapy and our medication based on what the brain/body relates.   We are just about there.

  New work at the University of Michigan has been measuring the brains of subjects undergoing pain of heat, for example.(see for example http://articles.latimes.com/2013/apr/10/science/la-sci-pain-measure-fmri-20130409).  They show a characteristic brain pattern.   Later pain shows similar patterns and provides the scientist with a measure and brain pattern of pain.  What they found is a typical neural pattern for each person’s pain.   The way they did this is by putting patients in a fMRI scanner and then added warm to very hot stimuli to see the brain response.  They also teased out emotional pain as differentiated from physical pain.  And they could then know what subject was in pain.   Something I did thirty years ago. But we will leave that for the moment.   Just to say that we could tell about patients coming in for sessions as to what level they were on.  Those heavily depressed and deeply into birth trauma had those long slow brain waves and very low body temperature.   The key index for hopelessness is those brain waves and body temp.
It is the rare depressive who doesn’t show those signs.

   The investigators then looked at painkilling drugs  (remifentanil).  It not only suppressed the neural signature but also the subjective report of pain.  Here we see that drugs can inhibit the reactions to pain but perhaps not pain itself; this may be particularly true when pain is imprinted and endures.  What they are hoping for is a reliable measure of pain so they can titrate, for example, what kind of tranquilizers to inject.  And they could measure effectiveness of drugs.  They want to take subjectivity out of the equation so that high-tech scanners could do all of the work.   Yet, they admit, they still will need patients’ reports.

Here is the dilemma: will the suppression of pain eliminate that pain?  Or will there be a rebound with more pain emerging after suppression by medication?  If we only look at current behavior and cognitive effects we may go off the rails and think that the pain has been done away with.  Or, if they rely only on the machines they may falsely see that the patient does not need painkillers when she clearly does.  Our patients descend slowly into imprinted painful memory and we know right away how much pain there is.  But we are not practicing general medicine where doctors need machines like that.  (see: The New England Journal of Medicine. April 2013).

   Our advantage here is that the patient teases out for us the difference between emotional and physical pain.   We don’t have to extrapolate from a number on the machine to the patient’s condition.   When see a patient entering a session with 95.6 body temperature we know what to expect.  And we know where the patient will be going; it is just a matter of helping her get there.  And at the end of the session when body temp goes up three degrees we see a normalization process taking place.   The patient is indeed becoming normal, not only in her “mind” but everywhere in her system.

  Here is the problem with the research: if they see big signatures of pain with no obvious pain they might refer the person for addiction help.  But suppose that pain is heavily hidden and maybe the person herself is unaware of it.  It doesn’t mean she has not pain; it means that it is buried under loads of repression and may be inaccessible for the moment.  It is not addiction; it is simply that we cannot see the pain they are in.

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6 comments:

  1. Andrew D AtkinJune 2, 2013 at 12:28 AM

    I think I might have have commented before that we could look at measuring the brain activity of people being legally tortured in countries where it is still legal to do such things, as formal punishment. A very black way of learning, but it gives us the option of studying the brain processing traumatic-level pain nonetheless. The findings could be invaluable to our progress. And although it's bad taste - the fact is you would be doing no more harm than is being done anyway.

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    Replies
    1. EmmaJune 3, 2013 at 2:31 AM

      Well you would - because instead of the resources invested in measuring the brain, you could use them to help free the people.
      "Evil prospers when good men do nothing."

      Delete
    2. Andrew D AtkinJune 3, 2013 at 10:54 AM

      Well Emma, I know I sound like a Nazi doctor but, if we can demonstrate the neurological impact of trauma more clearly it might help the Singaporean government (and other) to reconsider their methods of punishment.

      Also, waving the flag of peace and thinking only politically correct thoughts, ahead or realism, is indeed "doing nothing". The road to hell is paved with good intentions, is another saying. Also, we need to think carefully if it's best to free violent offenders, of course.

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  2. apolloJune 2, 2013 at 4:30 PM

    I find it interesting that pain can be analyzed and identified. But as Art points out, we are wired to find pain and have it come up, almost without help in ideal circumstance, which are also rare circumstances. So many ways we suffer damage makes it hard for pain to just rise.

    I still marvel that medical science can pretend not to see, know, or understand PT. I think they are faking it. They know too much about too many things. It is lamentable that people are in pain and society prevents that from being fixed when it is quite curable. What really are we as a species, when we block, hinder, and suppress our own well-being. What monsters we are, really.

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  3. S. W. AlexanderJune 5, 2013 at 4:55 AM

    This comment has been removed by the author.

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  4. S. W. AlexanderJune 11, 2013 at 5:02 AM

    Dr. Janov and all
    Maybe measuring pain via fMRI, even though it shows a characteristic brain pattern, will not really tell us where the pain originated.
    To determine if we are in pain, we can use DNA markers which tell us if we are sensitive to higher pain levels.
    But, what does it really mean?
    I remember being diagnosed with emphysema and received Albuterol while in reality it was anxiety that caused my shortness of breath. When Albuterol, a sulfa-based med, worsened my breathing (because I’m allergic to sulfa) the doctor at Kaiser Permanente indicated that I’m a hypochondriac.
    Patients are often in pain without being able to pinpoint the exact cause. For this reason doctors are reluctant to prescribe pain meds – they simply label the one in pain as 'addict'.
    Technology may indicate and support that fact that we are in pain, but what can a patient do if the doctor has not the knowledge, or is pressed by insurance companies to reduce the pain-meds.
    What we need is a clinically-trained and sensitive person who is able to interpret the pain to its origin.
    Sieglinde

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Quotes for "Life Before Birth"

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Bailey Endowed Chair of Animal Well Being Science
Washington State University

Dr. Janov’s essential insight—that our earliest experiences strongly influence later well being—is no longer in doubt. Thanks to advances in neuroscience, immunology, and epigenetics, we can now see some of the mechanisms of action at the heart of these developmental processes. His long-held belief that the brain, human development, and psychological well being need to studied in the context of evolution—from the brainstem up—now lies at the heart of the integration of neuroscience and psychotherapy.
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In Life Before Birth Dr. Arthur Janov illuminates the sources of much that happens during life after birth. Lucidly, the pioneer of primal therapy provides the scientific rationale for treatments that take us through our original, non-verbal memories—to essential depths of experience that the superficial cognitive-behavioral modalities currently in fashion cannot possibly touch, let alone transform.
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K.J.S. Anand, MBBS, D. Phil, FAACP, FCCM, FRCPCH, Professor of Pediatrics, Anesthesiology, Anatomy & Neurobiology, Senior Scholar, Center for Excellence in Faith and Health, Methodist Le Bonheur Healthcare System


A baby's brain grows more while in the womb than at any time in a child's life. Life Before Birth: The Hidden Script That Rules Our Lives is a valuable guide to creating healthier babies and offers insight into healing our early primal wounds. Dr. Janov integrates the most recent scientific research about prenatal development with the psychobiological reality that these early experiences do cast a long shadow over our entire lifespan. With a wealth of experience and a history of successful psychotherapeutic treatment, Dr. Janov is well positioned to speak with clarity and precision on a topic that remains critically important.
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Editor