Dimensions and Definition of Central Pain Article

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Dimensions and Definition of

Central Pain

In evaluating Central Pain, clinicians must remind themselves that their eyes do

not measure pain.

Pain Axiom #1

The ability to understand the severity of invisible pain distinguishes the

professional from the layman.

Corollary to Axiom #1

It is the nature and disposition of nearly all professionals to underestimate

the magnitude of Central Pain.

What Central Pain Is and Is Not

The term, " Central Pain " should be reserved for those who have the fully

developed syndrome and who are in a pain crisis. The term, " Central Pain " has

embedded in it a sense of emergency. Any other approach is likely to send out

into the streets, unaided, the sickest patient the physician has ever treated.

The inclusion of patients who are experiencing minor neuropathic symptoms under

the rubric, " Central Pain " works against the patient with classical Central Pain

How Do You Expect a Torture Victim to Appear?

Reporters who have interviewed torture victims often encounter a quiet,

withdrawn, demoralized, broken person who is not obviously in physical pain. The

visitor may or may not believe what the individual says has been done to her.

Inhumanity is inherently unbelievable. This is true whether inflicted by humans

or by disease in the nervous system.

Torture victims are humiliated, embarrassed and often refuse to discuss what

they have endured. On the other hand, if the reporter encounters a carpenter who

has hit his thumb with a hammer, there may be obvious physical evidence of a

pain reaction. Have the eyes acted as a proper scale for pain. Not unless the

mind and imagination are informed first.

In some ways, the situation is even more difficult for the Central Pain patient.

They are not avoiding the mention of something in the past. They are

experiencing it in the present. Furthermore, the pain is not going to stop, no

matter how cooperative the patient is, until death ends it. Over and over come

reports from pain clinics that those in really severe pain behave in an

unexpected fashion. They frequently giggle. Why? Because of the extreme

embarrassment.

Severe Pain is Humiliating, Especially in the Present

The physician really matters to the Central Pain patient. The examiner must

imagine him at a social event which really matters to him, and at which his

escort expects him to behave in a socially acceptable fashion. In his pants are

scorpions and spiders stinging him continually as he attempts to make meaningful

conversation. The crook has stolen goods hidden at his feet and his pants are on

fire as he talks to the policeman, trying to pretend nothing is wrong. Are these

not scripts for humor? The behavior of the severe pain patient may therefore be

withdrawn, talkative, silly, or even patronizing, because severe pain is

humiliating.

Nature Hands Central Pain Patients a Tragedy Every Day

Central Pain patients are like the torture victim. They become defeated,

dehumanized, and broken by the unremitting agony. They may well not wish to

rehearse their fear, their loss of humanity, their concessions to the pain, the

self-loathing. This aspect of chronic torture must be remembered, and proper,

sensitive cues must be given by the examiner before an open response can

reasonably be expected.

The patient will often have been disbelieved and have no desire to add the

humiliation of rejection to the humiliation of her severe pain. Thus, clinicians

must have educated minds. Particularly the eyes, the " great monopolists of the

senses " , must be schooled, and sometimes, overruled. As Mark Twain stated it,

" You can't trust your eyes, if your imagination is out of focus " .

Miss Manners Is Not a Good Physician

Not uncommonly, a physician encounters a patient with injury to the spinal

medulla (cord) or other nerve structure, which confers a light burning,

something like a sunburn. It causes moderate to moderately severe distress.

Patients commonly flex their willpower and derive pride in their ability to

" tough out " the pain or to ignore it. Those relating to the patient may praise

them for " never complaining " , or " for not burdening others " . These compliments

are well deserved and such behavior adorns what we find noble in mankind.

However, this posture will prevent any understanding of Central Pain. The

physician should avoid adopting the attitude of a " Miss Manners " and should not

chide the patient for telling the truth. The presence of fully developed Central

Pain should always signal that the patient needs immediate help. They should be

encouraged to communicate fully and openly in order that saving assistance may

be rendered.

The Natural History of Telling Others About Central Pain

Clinics capable of diagnosing Central Pain tend to be confined to large, urban

centers. It is rare enough that the condition is seldom recognized outside pain

centers. A patient fortunate enough to have been diagnosed correctly by a pain

specialist still has the problem of returning home and trying to explain to her

family why she is unable to function. If her husband speaks to a local

physician, who manages to find a brief reference to the disease in a text, the

wording will often describe a potpourri of everything from mild tingling to real

pain. More often than not, back will come the exhortation that the wife will

just have to learn to live with the pain and the best way is to deal is to learn

to " ignore it " . (After all, don't we all have to live with our aches and pains?)

The husband becomes even more cynical toward his wife's desperate pleadings for

help. The wife knows she cannot function--her husband tells her she must live

normally, and has the doctor to back him. How many really sick people can

withstand this pressure?

The Harm A Little Knowledge Can Do

The brutalization that this process causes is a not uncommon precipitator of

divorce, destruction of family, and suicide. First she loses her feeling of

pain-free existence, then her self identity, then the support of her doctor,

then the love of her husband, then her family, then her life. If the husband

believes her, he must make tremendous adjustments, as must the entire family to

accommodate any brain injured person.

Central Pain patients have sensations of torture which are neurologically

identical to the real thing. They simply lack the destruction of flesh. They may

not desire deliverance from death, they may desire the deliverance of death.

Ignorance can make physicians callused in such a way as to add, rather than

detract from the plight of the unfortunate.

The Brain Systems By Which Humans " Deal " With Pain Are Disabled In Central Pain

The patient needs compassion. She needs her physician to understand that a

diseased nervous system is capable of duplicating the sensation of tissue

destruction, even if the problem is in the nerve and not in the body part. The

patient needs no self-congratulatory examples of how the lecturer, or someone

they have read about, has endured pain. Central Pain is well beyond normal pain.

The brain mechanisms by which humans " deal " with normal pain have been disabled.

Therefore, Central Pain cannot be " dealt with " , it can only be " endured " .

The Blood/Brain Barrier to Understanding

There is a tendency to say that Central Pain is indescribable, to put that in

the hip pocket, and walk away. This overlooks the fact that patients can tell us

a great deal about the behavior of ineffable pains. They can convey sufficient

information to permit rational categorization of the cases.

Treatment regimens should be tested against specifics, not against a term,

" Central Pain " . Before rational therapies can be developed and compared for any

disorder, criteria for the condition must be delineated to make sure apples are

not being compared to oranges. Normally, the starting point for categorizing

pain disease is the patient's symptoms. Ironically, in Central Pain, this is the

last place anyone would attempt to categorize Central Pain. The reason is that

the pain is " indescribable " .

How Will You Know If You've Helped Me

If You Don't Know What's Wrong?

The result of a lack of vocabulary has been the introduction into the literature

of therapies, including very serious brain surgery, which are not tied to any

qualitative symptoms whatever. Central Pain has many manifestations. Therapeutic

treatments should distinguish symptoms and indicate which specific

manifestations have been helped and which have not. Reports which treat the pain

as a binary switch (on/off) rather than the elaborate combination of events

which it is, paint with too broad a brush. Clinicians in every specialty learn

to diagnose by subtle differences in patient responses to careful questioning.

This article urges a similar approach in Central Pain.

These patients constitute living laboratories of pain and have much to say. One

must simply listen much more closely, or as Einstein said, we must become " more

curious " .