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.     

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.     

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.     

Avoiding unbearable pain

This presentation describes the way in which defence mechanisms and resistance manifested themselves in the analysis of a man with a narcissistic personality disorder. In the course of the analysis, there were changes in the forms taken by the defence and the resistance, signalling important genetic and dynamic conditions in his life. Both represented desperate attempts to avoid the unbearably painful feelings and affects which he had experienced in his childhood, and bore witness to early and primitive defence mechanisms such as denial, splitting and projective identification. The defence can also be seen as an expression of an unconscious fear of being re-traumatised. The idealisation of the analyst in the first years of the analysis can therefore be understood as a precondition for entering into this kind of process. It also represented a defence against aggressive and homosexual feelings in the transference which first became clear during the final phase of the analysis and could then be worked through. At this point, the analyst's reactions to his own unconscious countertransference were of help in understanding what was actually going on. This analysis may also suggest that defects and trauma in the earliest years may be conducive to alexithymia, deficient contact between feelings and words, linked to the risk of developing serious psychosomatic illnesses. This may be a consequence of the fact that the child's feelings and affects were neither accepted, understood nor affirmed in words, or they may even have been met with rejection or ridicule. A connection between narcissistic personality disorders and alexithymia can possibly be seen here.     

Why pain hurts

We have made great strides in understanding how the human brain constructs the multidimensional experience of pain – both acute and chronic – over the past few decades. Pain wears many guises, but at its core, it hurts. How is this core component of pain represented in the brain, and how can we target it for relief?     

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.     

Understanding neuropathic pain

Neuropathic pain is defined as a chronic pain condition that occurs or persists after a primary lesion or dysfunction of the peripheral or central nervous system. Traumatic injury of peripheral nerves also increases the excitability of nociceptors in and around nerve trunks and involves components released from nerve terminals (neurogenic inflammation) and immunological and vascular components from cells resident within or recruited into the affected area. Action potentials generated in nociceptors and injured nerve fibers release excitatory neurotransmitters at their synaptic terminals such as L-glutamate and substance P and trigger cellular events in the central nervous system that extend over different time frames. Short-term alterations of neuronal excitability, reflected for example in rapid changes of neuronal discharge activity, are sensitive to conventional analgesics, and do not commonly involve alterations in activity-dependent gene expression. Novel compounds and new regimens for drug treatment to influence activity-dependent long-term changes in pain transducing and suppressive systems (pain matrix) are emerging.     

Measuring clinical pain

There are two goals in attempts to measure, the intention to describe and the intention to compare. These two functions work hand in hand and are brought to fruition in psychological and educational testing only by psychometrics that can produce person-free item calibrations and item-free person measures. The only such psychometrics that currently exist is that based on George Rasch's work. One of the consequences of using the tools Rasch left us is the Pain Scale, a rating scale that asks the person in pain to compare the intensityof his/her own pain with that he/she imagines is described by some 25 adjectives. Analyses of the responses of 53 people with chronic lower back pain to the Pain Scale using the Rasch partial-credit latent-trait model show that they were very much in agreement about the amount of hurt implied by each of the adjectives. An examination of person fit to the partial-credit model gave no hint of a response set in the data but two people did differ very much from their peers in their operational definitions of back pain and were studied separately. The evidence from these two people suggested that they either could not understand the task before them or could not get enough perspective on their pain to describe its intensity.I would like to thank Benjamin Wright and Geoff Masters for their help with this research. Drs. David J. Smith and James B. Boscardin were the first to bring my attention to the problem of measuring pain and were generous in their financial support of this work.     

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.     

Opioids: from physical pain to the pain of social isolation

The opioid systems play an important role in mediating both physical pain and negative affects (eg, the pain of social isolation). From an evolutionary perspective, it is not surprising that the neurocircuitry and neurochemistry of physical pain would overlap with that involved in complex social emotions. Exposure to trauma as well as a range of gene variants in the opioid system may be associated with alterations in opioid systems function, with changes in reward processing, and with vulnerability to substance abuse. A role for interventions with opioid agents in depression and anxiety disorders has been suggested.     

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.