Ask the Doctor: All Pain is in Your Head

Over the course of the 30 years I practice exclusively in the area of chronic pain, I have spoken to many patients and families trying to explain in simple terms what pain means to a person, how our emotional reactions colour our pain experience and what ways (beyond medicines I prescribe) can change this experience. It is not unusual for me to end my conversation with the statement: “Your pain is truly in your head, …. That means in your brain”. One of the stories I use to back up such a statement is the following, from my own experience as a mother and a scientist.

Many years ago, as I was giving a good night kiss to my two boys, my three year old son Alex, whispered: “Mom, I can’t  get this ring out” and he showed me his swollen right index finger The “ring” was an old washer the little devil had fetched from somewhere and pushed it around his finger. I tried in vain to pull it out using liquid soap but Alex would not stay still, screaming and running around the house and I could not control him. I was alone with my other son Nicholas, a year older, falling asleep. I called a neighbour asking her to watch Nicholas, and took Alex with me to the nearest hospital emergency.

Even at 10:30 p.m., the emergency room was packed with old and young, nervous and resigned, some looking very sick and others calm and patient. Despite his affliction, Alex cruised the room curiously, showing from time to time his swollen finger to other patients. Then he would sit down to play with some spare lego blocks lying on the floor. Strangely, he seemed fairly busy and comfortable while I was freaking out.

His finger looked more and more swollen like a freshly cooked wiener. It was already an hour and I was getting very uncomfortable as I was worried about cutting off the circulation, which meant he could damage the finger permanently. Alex, however, seemed quite absorbed with the blocks and only when I ask he would say “burn, squeeze.” I asked the nurse a couple of times when Alex was going to be seen but the response was sharp– there were other people before him... I called my house to speak to my neighbour and found out that her husband had just returned home. She encouraged me to return home because “maybe all of us can try to take this thing out.”

By midnight, when I parked the car in the driveway, Alex ran to the house to show the neighbours the “big finger”.  Things had progressed and we did not have much time. Steven, good 6 ft 2” tall, headlocked Alex, while I wrapped my whole body around my son’s little legs, and his wife Susan rubbed some vegetable oil around Alex’s finger.  As Alex became totally consumed in his efforts to escape delivering generous kicks to my ribs, Susan within a few seconds pulled the washer off. At the end, I could not tell who was more exhausted, Alex who fought frantically or the three adults who were worried for his finger and what to do about it.

Once the washer was off, it left a deep mark in Alex’s finger, but the colour was getting back to normal. Nevertheless, we now had a new problem. Alex kept howling and squirming, waving his finger in the air and was inconsolable (big difference with his controlled demeanor in the emergency room)! He refused to go to bed and demanded to see Ninja in the middle of the night (those folks whose kids are now late 20s or so, would remember the magical Japanese cartoon warriors who had mesmerized a generation of kids).  I succumbed to the demand and Alex collapsed to sleep within minutes. Next day he never mentioned his finger when we prepared him for the day care. However, I was told later he was displaying his slightly swollen finger to the kids and daycare attendants whenever he would remember (but this finger never stopped him from playing and using his hand freely)!

This is a real life example of what constitutes pain, a complex and multifaceted experience, even when it is acute. Clearly Alex’s tight constriction deprived his finger from blood, and produced chemicals that irritated the nerves of his hand and sent a signal to his little brain: “Finger in trouble”. But if this were the case, why did Alex seem oblivious most of the time in the emergency room, and why did he keep screaming once the constriction was removed?

So, let’s try to understand what pain means for the body and what it means for the mind. Some years ago when I wrote a series of papers for e-CARP Advocacy all related to “blocking pain”, I made the comment that there is a difference between “pain”, the sensory experience that stems from injured tissues (exactly what the finger was telling Alex’s brain), and “suffering”, our emotional reaction to this sensory experience (Alex’s reaction to removing the washer off his finger). These two are intertwined, but they can also be separate. In other words, if you can divide the experience of feeling that something is harmful to the body from the emotional reaction to it, …. you do not feel the pain or you feel a lot less pain.

How then can you harness the emotional reaction? There are several ways and one of them is to “alter” the meaning of pain. For example, if you attach a different meaning to this painful sensory experience, the pain may be subdued. For example, turning the thought “pain is damaging my body”, to the thought “pain is honourable” the pain may be blocked. Another way is to draw attention away from the painful stimulus (eg. to distract one’s self from the physical source of pain by devoting brain resources to “something else”). In most cases, tissue damaging stimulation will make us worried and anxious. It is only then that tissue damage will be perceived as pain by our conscious brain. In the example of my son, Alex could not link the constrictive effects of the washer with the very real risk of harming his finger irreversibly; furthermore, he was immensely distracted with the lego blocks in the emergency room and by the environment itself with all these strange people and new experiences.  Alex was only truly hurting when he associated the swollen finger with his feelings for what these three “big people” had done to him, even though the constriction of the finger was gone and his circulation was getting restored.

So, next time you are in pain, attend to it as you should, maybe take a pain killer off the counter or apply a cold dressing, but also turn on your TV to your favorite show or movie and let your brain wander! It will have less opportunity to “feel” pain.

 

Angela Mailis Gagnon, MD, MSc, FRCPC(PhysMed)
Director, Comprehensive Pain Program,
Senior Investigator, Krembil Neuroscience Centre
Toronto Western Hospital,
Chair ACTION Ontario www.actionontario.ca
www.drangelamailis.com