Educating pain

Abstract

In times in which we ask ourselves how political cruelty and torments can be forgotten, Nietzsche’s pleadoyer for pain to serve the purpose of education, surprises. What might sound like a mere provocation, rather lies at the heart of the Nietzschean philosophy. As is pointed out, Nietzsche’s contention that pain is the most powerful aid to mnemonics, originates from his philosophy of pain as the main condition of all forms of creation. The title “educating (bilden) pain” expresses Nietzsche’s advocacy of an education towards pain as the dynamo of creation. In this paper I explore how Nietzsche’s notion of pain is linked to two concepts of Bildung. In the first part I investigate the relation between pain and “Bildung” in the sense of “creation”, and in the second part I link this to the relation between pain and “Bildung” in the sense of “education”. By these means, I try to answer the question: how far can pain, which is seen as the condition of creation, be linked to conditions of education.     

Pain intensity and pain unpleasantness in triathletes: A study examining their associations with pain catastrophizing and pain expectations

ObjectiveTriathletes represent a growing and unique population of individuals willing to endure significant mental and physical stress to practice the sport they love. However, little is known about the pain experienced while training for and competing in a triathlon and how psychological factors influence this experience. This study will assess pain experienced by triathletes in training and competition, and investigate the association between pain catastrophizing and pain expectations with triathlon pain intensity and pain unpleasantness.DesignIn this observational study, a sample of 261 triathletes completed two online surveys before and after participating in a triathlon.ResultsModerate levels of pain intensity and pain unpleasantness were reported during training and competition. Pain catastrophizing was positively associated with expected and actual triathlon pain unpleasantness, but not with pain intensity. Expected pain intensity was also significantly associated with pain intensity experienced while competing, whereas expected pain unpleasantness was significantly related to both triathlon pain intensity and unpleasantness. Finally, regression analysis revealed pain catastrophizing and pain expectations to be unique predictors of triathlon pain intensity and pain unpleasantness.ConclusionThis study highlights the important role of psychological factors in triathletes' experience of pain and could eventually help tailor interventions aimed at improving the practice of triathlon.     

Enhanced corticospinal response to observed pain in pain synesthetes

Observing noxious injury to another’s hand is known to induce corticospinal inhibition that can be measured in the observer’s corresponding muscle. Here, we investigated whether acquired pain synesthetes, individuals who experience actual pain when observing injury to another, demonstrate less corticospinal inhibition than do controls during pain observation, as a potential mechanism for the experience of vicarious pain. We recorded motor-evoked potentials (MEPs) induced at two time points through transcranial magnetic stimulation while participants observed videos of a hand at rest, a hypodermic needle penetrating the skin, a Q-tip touching the skin, and a hypodermic needle penetrating an apple. We compared MEPs in three groups: 7 amputees who experience pain synesthesia, 11 nonsynesthete amputees who experience phantom limb pain, and 10 healthy controls. Results indicated that the pain synesthete group demonstrated significantly enhanced MEP response to the needle penetrating the hand, relative to the needle not having yet penetrated the hand, as compared with controls. This effect was not observed exclusively in the same muscle where noxious stimulation was applied. We speculate that our findings reflect a generalized response to pain observation arising from hyperactivity of motor mirror neurons not involved in direct one-to-one simulation but, rather, in the representation of another’s experience.     

Prior exposure to extreme pain alters neural response to pain in others

In the extant literature examining the brain mechanisms implicated in pain perception, researchers have theorized that the overlapping responses to pain in the self and in others mark the human capacity for empathy. Here we investigated how prior exposure to extreme pain affects pain perception, by assessing the dynamics of pain processing in veterans who were previously exposed to severe injury. Forty-three participants (28 pain-exposed and 15 controls) underwent whole-head magnetoencephalography (MEG) while viewing photographs of limbs in painful and nonpainful (neutral) conditions. Among controls, an early (0–220 ms) “pain effect” in the posterior cingulate and sensorimotor cortices, and a later (760–900 ms) “pain effect” in the posterior cingulate cortex, superior temporal gyrus/insula, and fusiform gyrus were found, indicated by enhanced alpha suppression to the pain versus nonpain conditions. Importantly, pain-exposed participants exhibited an atypical pain response in the posterior cingulate cortex, indicated by a normative response to pain, but no pain-to-no-pain differentiation. This may suggest that individuals exposed to extreme pain may perceive neutral stimuli as potentially threatening. Our findings demonstrate alterations in pain perception following extreme pain exposure, chart the sequence from automatic to evaluative pain processing, and emphasize the importance of considering past experiences in studying the neural response to others’ states.     

疼痛恐惧的形成及其对疼痛知觉的影响

脑岛、杏仁核是疼痛恐惧形成的重要神经网络中心。疼痛恐惧增强了慢性疼痛患者的疼痛知觉体验, 进而加剧抑郁、焦虑情绪和功能损伤程度。脑岛、杏仁核、前额皮层和前扣带回是疼痛恐惧影响疼痛知觉的重要神经基础。通过认知方法干预疼痛恐惧可以改善患者的抑郁、焦虑情绪, 减少功能损伤。未来研究应拓展疼痛恐惧的测量工具, 采用功能磁共振成像技术进一步揭示疼痛恐惧影响慢性疼痛患者疼痛知觉的神经机制。     

Effects of pain acceptance and pain control strategies on physical impairment in individuals with chronic low back pain

Psychosocial treatments for chronic pain are effective. There is a need, however, to understand the processes involved in determining how these treatments contribute to behavior change. Control and acceptance strategies represent two potentially important processes involved in treatment, although they differ significantly in approach. Results from laboratory-based studies suggest that acceptance-oriented strategies significantly enhance pain tolerance and behavioral persistence, compared with control-oriented strategies. There is a need, however, to investigate processes of acceptance and control directly in clinical settings. The present study investigated the effects of three brief instructional sets (pain control, pain acceptance, continued practice) on demonstrated physical impairment in 74 individuals with chronic low back pain using an analogue experimental design. After controlling for baseline performance, the pain acceptance group demonstrated greater overall functioning on a set of 7 standardized physical tasks relative to the other two groups, which did not differ from one another. Further, the acceptance group exhibited a 16.3% improvement in impairment, whereas the pain control group worsened by 8.3% and the continued practice group improved by 2.5%. These results suggest that acceptance may be a key process involved in behavior change in individuals with chronic pain.     

Automatic processing of pain: the change of implicit pain associations after psychotherapy

This study explores the utility of a pain IAT for the assessment of dysfunctional cognitive beliefs in chronic pain patients before and after a cognitive behaviour therapy. A patient group suffering from chronic pain (N=25) treated with a 4-week cognitive behavioural psychotherapy is compared with an untreated healthy control group (N=27) at two points in time. In addition, both groups completed a self-esteem questionnaire (Rosenberg-scale) and a self-esteem IAT. In the clinical group a questionnaire assessing self-reported pain cognitions was administered. The pain IAT was able to differentiate between chronic pain patients and healthy controls before the treatment. Most important, pain-related implicit associations could be shown to change over the course of treatment in the clinical group of chronic pain patients. Results provide first evidence for an application of the IAT in chronic pain research.     

Thoughts provoked by pain

Despite the growing interest in the cognitive component of chronic pain, little information has been collected on the variety of thoughts provoked by pain experience. A new assessment instrument (the Cognitive Evaluative Questionnaire--CEQ) has been utilized with 127 chronic pain patients and their cognitions classified into seven discrete clusters. The results confirm the heterogeneity of pain cognitions, the majority of which are likely to play a role in enhancing or perpetuating chronic pain. The relationship of these cognitions to chronic avoidance behavior is discussed.     

Chronic benign pain

Chronic benign pain (CBP) can be defined as a type of unpleasant sensory experience that arises from inflammation, visceral stress or damage, or other such pathophysiologic process(es), and that is not associated with a metastatic process. A patient's complaint of pain should be taken seriously by the practitioner, both in terms of the discomfort evoked and the likelihood that the potential cause of the pain requires diagnostic evaluation. This article reviews the diagnosis and treatment of the following common conditions associated with CBP syndromes: fibromyalgia, lower back pain syndrome, sickle-cell disease, reflex sympathetic dystrophy syndrome, and peripheral neuropathies.     

Threat of pain influences social context effects on verbal pain report and facial expression

Current theoretical models of pain catastrophizing have diverging predictions regarding the role of social context and perceived threat on pain expression. The communal coping model of catastrophizing predicts that high pain catastrophizers display more pain expression in the presence of another, regardless of the threat value of the pain, while a cognitive appraisal model predicts high pain catastrophizers to express more pain when pain has increased threat value, regardless of social context. A 2 × 2 factorial design was used to test the validity of both predictions. Healthy participants with varying levels of pain catastrophizing were exposed to a cold pressor task, consisting of a 60 s immersion and 60 s recovery period. Interestingly, the immersion results revealed that beyond and independent from the effects of pain catastrophizing, the effect of threat on verbal pain report and facial expression was dependent on social context and vice versa. In a threatening context, perceived threat of pain mediated the inhibitory effect of social presence on pain expression, suggesting that the observer acted as a safety signal. In the recovery period, social presence enhanced facial expression, but only when no threat was induced. The results are discussed in terms of the dynamic interaction between social context and threat appraisals.     

Empathy gaps for social pain: why people underestimate the pain of social suffering

In 5 studies, the authors examined the hypothesis that people have systematically distorted beliefs about the pain of social suffering. By integrating research on empathy gaps for physical pain (Loewenstein, 1996) with social pain theory (MacDonald & Leary, 2005), the authors generated the hypothesis that people generally underestimate the severity of social pain (ostracism, shame, etc.)--a biased judgment that is only corrected when people actively experience social pain for themselves. Using a social exclusion manipulation, Studies 1-4 found that nonexcluded participants consistently underestimated the severity of social pain compared with excluded participants, who had a heightened appreciation for social pain. This empathy gap for social pain occurred when participants evaluated both the pain of others (interpersonal empathy gap) as well as the pain participants themselves experienced in the past (intrapersonal empathy gap). The authors argue that beliefs about social pain are important because they govern how people react to socially distressing events. In Study 5, middle school teachers were asked to evaluate policies regarding emotional bullying at school. This revealed that actively experiencing social pain heightened the estimated pain of emotional bullying, which in turn led teachers to recommend both more comprehensive treatment for bullied students and greater punishment for students who bully.     

No pain,no change: Reductions in prior negative affect following physical pain

In general, organisms are motivated to avoid stimuli that induce pain. However, some individuals intentionally inflict pain on themselves (e.g., nonsuicidal self-injury) and report doing so for the perceived emotional benefits following the experience of pain. Two controlled laboratory studies sought to expand upon the relatively limited literature on the effects of pain on emotion. In Study 1, participants provided momentary affect ratings immediately before and after experiencing physical pain. Results demonstrated that both positive affect and negative affect (NA) decreased following the experience of pain. In the Study 2, we examined the effect that individual differences in emotional reactivity had on affective reactions to pain. Individuals high in emotional reactivity experienced larger decreases in NA following the experience of pain than individuals who were low in emotional reactivity. Our findings may potentially explain why some individuals intentionally seek out the experience of pain.     

The clinical pain acceptance Q-sort: a tool for assessment and facilitation of pain acceptance

The topic of pain acceptance can be clinically difficult to raise in a respectful way. This article introduces a method of managing the topic of pain acceptance in daily clinical practice: The clinical pain acceptance Q-sort. The Q-sort procedure comprises 13 small cards with printed statements concerning pain acceptance on the one side, score numbers on the other side. The procedure involves the patient handling and prioritizing the statements in a personally meaningful order. Both quantitative and qualitative use of the tool is possible. The method has a three-fold outcome: (1) topics of pain acceptance are presented in a multi-faceted way for the chronic pain patient, (2) an approximate assessment of the level of pain acceptance issues is offered to the clinician, and (3) good opportunities for a therapeutic discussion on pain acceptance are made available. The clinical pain acceptance Q-sort procedure may positively contribute to daily clinical work with pain acceptance in a straightforward way. The method provides options for assessment of pain acceptance, for better understanding of the patient, and for clinical training in psychological pain management.     

Effects of anger suppression on pain severity and pain behaviors among chronic pain patients: evaluation of an ironic process model

OBJECTIVE: Evidence for links between anger inhibition or suppression and chronic pain severity is based mostly on studies with correlation designs. Following from ironic process theory, we proposed that attempts to suppress angry thoughts during provocation would increase subsequent pain intensity among chronic low back pain (CLBP) patients, and do so through paradoxically enhanced accessibility of anger. DESIGN: CLBP patients (N = 58) were assigned to suppression and nonsuppression conditions while performing a computer maze task with a harassing confederate. A structured pain behavior task (SPBT) followed. MAIN OUTCOME MEASURES: Self-reported anger, anxiety, and sadness following maze task. Self-reported pain severity and number of observed pain behaviors during SPBT. RESULTS: Patients told to suppress during provocation: (a) reported greater anger following the maze task, reported greater pain intensity during the SPBT, and exhibited more pain behaviors than patients not suppressing; (b) postmaze anger levels significantly mediated group differences on pain behaviors. CONCLUSION: Attempts by CLBP patients to suppress anger may aggravate pain related to their clinical condition through ironically increased feelings of anger.     

The consequences of pain: The social and physical pain overlap on psychological responses

Current theories suggest that social and physical pain overlap in their neurological and physiological outcomes. We investigated how social and physical pain overlap in their psychological responses by testing the hypothesis that both social and physical pain would thwart satisfaction on four human needs, worsen mood, and increase desire to aggress. In Experiment 1, recalling an experience of social or physical pain produced overlapping effects in the form of thwarted self‐esteem and control needs and increased negative affect and desire to aggress. In Experiment 2, we induced social (Cyberball ostracism) or physical pain (cold pressor) within the laboratory session, and found that both pain types produced feelings of being ignored and excluded, and thwarted belonging, self‐esteem, control, and meaningful existence. Our results provide further support to pain overlap theories and indicate that social and physical pain cause common psychological consequences, resulting in new ways to understand and manage pain. Copyright © 2011 John Wiley & Sons, Ltd.     

Hypnosis and clinical pain

Hypnosis has been demonstrated to reduce analogue pain, and studies on the mechanisms of laboratory pain reduction have provided useful applications to clinical populations. Studies showing central nervous system activity during hypnotic procedures offer preliminary information concerning possible physiological mechanisms of hypnotic analgesia. Randomized controlled studies with clinical populations indicate that hypnosis has a reliable and significant impact on acute procedural pain and chronic pain conditions. Methodological issues of this body of research are discussed, as are methods to better integrate hypnosis into comprehensive pain treatment.     

When good pain turns bad

Classically, pain is viewed as being mediated solely by neurons. However, recent research has shown that activated glial cells (astrocytes and microglia) within the spinal cord amplify pain. These nonneuronal cells play a major role in the creation and maintenance of pathological pain. Glia become activated by immune challenges (viral or bacterial infection) and by substances released by neurons within the pain pathway. Activated glia amplify pain by releasing proinflammatory cytokines. Taken together, research findings suggest a novel approach to human pain control that targets glia. In addition, it is likely that such glial-neuronal interactions are not unique to pain, but rather reflect a general rule of sensory processing.     

Cognitive differentiation, back pain, and psychogenic pain drawings

Two groups of subjects with back pain were studied (n = 67). All subjects underwent a battery of psychological tests which included a test of psychological differentiation (the Rod-and-Frame Test), a test of psychological defenses (Meta-contrast Technique), and the Eysenck Personality Inventory. In addition, the subjects drew a pain picture and answered a questionnaire on pain-related issues. Each group of subjects was then subdivided into 4 groups depending on the judged abnormality of their pain drawings. The two main groups were compared overall and the subgroups of the two back-pain groups compared with each other. The Meta-contrast Technique results show that depression was quite common among back-pain subjects as a whole compared to a painless group of subjects. Differences were found on field-dependence; subjects with abnormal pain drawings were more field-dependent than those with "normal" pain drawings. Few other between-group statistical differences were noted between the two back-pain groups. Expected scores on hysteria were not noted among the abnormal drawing makers, neither were there differences between the groups on the items of pain duration, physical functionings, or of depression.     

Social discounting of pain

Impatience can be formalized as a delay discount rate, describing how the subjective value of reward decreases as it is delayed. By analogy, selfishness can be formalized as a social discount rate, representing how the subjective value of rewarding another person decreases with increasing social distance. Delay and social discount rates for reward are correlated across individuals. However no previous work has examined whether this relationship also holds for aversive outcomes. Neither has previous work described a functional form for social discounting of pain in humans. This is a pertinent question, since preferences over aversive outcomes formally diverge from those for reward. We addressed this issue in an experiment in which healthy adult participants (N = 67) chose the timing and intensity of hypothetical pain for themselves and others. In keeping with previous studies, participants showed a strong preference for immediate over delayed pain. Participants showed greater concern for pain in close others than for their own pain, though this hyperaltruism was steeply discounted with increasing social distance. Impatience for pain and social discounting of pain were weakly correlated across individuals. Our results extend a link between impatience and selfishness to the aversive domain.