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Well-integrated pain observers modulate aversive arousal through late top-down neural processes

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By Robin Caryn Rabin

Can looking at the photograph of a loved one make pain go away? Numerous studies show that strong social connections have benefits for health. People who have active social lives seem to live longer than those who are isolated, and married cancer patients have a better outlook than divorced cancer patients. Now, a study suggests that merely looking at a photograph of a loved one can relieve the sensation of physical pain.

Psychologists at the University of California, Los Angeles, recruited 25 women who had steady boyfriends. Using a tool that applied heat to the women’s forearms, they turned up the temperature until it was slightly uncomfortable and asked the women to rate the pain they experienced on a scale of one to 20.

The researchers manipulated the heat and recorded the women’s reactions under different conditions: while she was looking at a photo of her boyfriend, or a photo of a complete stranger and a chair. They also had the women rate the pain while they held the hand of a stranger hidden behind a curtain, and as they held their boyfriend’s hand or a squeeze ball.

More here.

Walter Van der Broek

There is a significant decline in empathy occurs during the third year of medical school. This decline occurs during a time when the curriculum is shifting toward patient-care activities.

  • There is a significant decline in empathy during third year of medical school, regardless of gender or specialty interest.
  • Every year women scored significantly higher than men.This seems to be regardless of population studied. It also appeared in Italian Physicians and Japanese medical students.
  • Except for scores at baseline, students interested in people-oriented specialties scored significantly higher than students interested in tech-oriented specialties.
  • The magnitude of the decline (effects) was much smaller for women and students interested in people oriented specialties. 

Why is empathy important?
Responsiveness to the emotional state of another plays a fundamental role in the patient doctor relationship (PDR) as well as in other human interaction. Sympathy and empathy are not the only responses in the PDR. Other responses can be consolation, kindness, politeness,compassion, and pity.

What is empathy (the long version)?
The most clarifying definition of empathy is based on viewing it as a process. This process of empathy consists of the following stages.

  • The patient expresses feelings by way of verbal and non-verbal communication. Patients are not always aware of these expressions.
  • The doctor also notices these emotions in himself more or less voluntary, more or less conscious. He or she coming aware of these feelings usually comes after the fact (affective empathy).
  • Realizing these feelings as being from the patient is the cognitive empathy. Together with everything the doctor knows about the patient as a patient and as a person, he or she is coming to know the inner feelings of the patient(cognitive empathy).
  • The doctor can now express these feelings for the patient or act on them for the patient(expressed empathy).
  • The patient receives this empathy (received empathy).

More here.

The definition is as follows: 

“An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. 

Note: The inability to communicate verbally does not negate the possibility that an individual is experiencing pain and is in need of appropriate pain-relieving treatment. Pain is always subjective. Each individual learns the application of the word through experiences related to injury in early life. Biologists recognize that those stimuli which cause pain are liable to damage tissue. Accordingly, pain is that experience we associate with actual or potential tissue damage. It is unquestionably a sensation in a part or parts of the body, but it is also always unpleasant and therefore also an emotional experience. Experiences which resemble pain but are not unpleasant, e.g., pricking, should not be called pain. Unpleasant abnormal experiences (dysesthesias) may also be pain but are not necessarily so because, subjectively, they may not have the usual sensory qualities of pain. 

Many people report pain in the absence of tissue damage or any likely pathophysiological cause; usually this happens for psychological reasons. There is usually no way to distinguish their experience from that due to tissue damage if we take the subjective report. If they regard their experience as pain and if they report it in the same ways as pain caused by tissue damage, it should be accepted as pain. This definition avoids tying pain to the stimulus. Activity induced in the nociceptor and nociceptive pathways by a noxious stimulus is not pain, which is always a psychological state, even though we may well appreciate that pain most often has a proximate physical cause”.  

Questions: 

1. The first sentence in the defintion associates pain with tissue pathology. What follows in the Note refers to the ‘subjectivity’ of pain. There seems to be an epistemic priority in play between the ‘objective’ measure of pain in terms of tissue insult and the ‘subjective’ criterion of when to categorize an experience as pain. The definition appears to accord authority on the nature and amount of pain to the patient (first-person authority). If this is correct, then pain researchers are studying the objectively observable causes of a subjective experience, but not pain characterised as an objective physical state. According to the definition, all objective measures of pain (eg, neuroscientific explanations) are logically prior to the subjective ones. Is this analysis accurate? Not quite. The IASP definition is compatible with neuroscientific discovery of pain experiences as states of the brain; for then objective measures will likely have not less than equal epsitemic authority. Still, it is curious the definition grants this, but leaves open the question of the nature of pain. 

2. What might explain the epistemic priority in the IASP definition? I suggest that it is the first-person authority (near-infallability) of pain self-report. Consider the statements (1) and (1*): 

(1) I am in pain. 

(1*) Susan is in pain. 

What does ‘being true’ amount to in these statements? I think it amounts to something quite different. The truth of (1) is guaranteeed by truthfulness, since it is not liable to mistake or error, only to insincerity. I give three reasons for this claim: 

– (1*) can be verified, but not (1). Is there such a thing as my ‘finding out’ that I am in pain or ‘recognizing’ pain from my sensations?

– (1) cannot allow of error or doubt, but (1*) can. The subject of pain cannot misidentify himself/herself or misapply pain language (‘I thought I had a pain, but it was an itch, and it was Susan’s, not mine’ seems nonsensical);

– (1) does not express a knowledge claim, but (1*) does.

Jeanna Bryner, Livescience.com

A social snub can deliver a seemingly painful blow. Now, it turns out that sting may be real. A gene linked with physical pain is also associated with a person’s sensitivity to rejection, a new study finds.

The discovery doesn’t suggest that being chosen last for a pick-up ball game, say, will send you limping off the field. Rather, a rare form of the so-called mu-opioid receptor gene (OPRM1) is likely involved in the emotional aspect of physical pain — essentially, how much a person is bothered by a throbbing leg, for instance.

In the study, 122 participants indicated how much they agreed or disagreed with statements, such as “I am very sensitive to any signs that a person might not want to talk to me.” Their saliva was also analyzed for OPRM1. (People with a rare form of OPRM1 experience more physical pain than others.)

Then, the researchers used functional magnetic resonance imaging (fMRI) to scan the brains of 31 of the participants during a virtual ball-tossing game. Initially, each participant was included with two virtual players before being excluded when the virtual players stopped throwing the ball to them.

Individuals with the rare OPRM1 variant were more sensitive to social rejection. The mutant-gene carriers also showed more activity in brain regions linked with physical and social pain, including the dorsal anterior cingulate cortex and anterior insula.

Such social pain may have benefited our ancestors. “Because social connection is so important, feeling literally hurt by not having social connections may be an adaptive way to make sure we keep them,” said study researcher Naomi Eisenberger of UCLA.

She added, “Over the course of evolution, the social attachment system — which ensures social connection — may have actually borrowed some of the mechanisms of the pain system to maintain social connections.”

More here.

JM Livengood, pain.com

The author, a psychologist in a pain control center, was asked by the editor of The Clinical Journal of Pain to relate her personal experience with neuropathic pain. Her chronic pain began six years previously when her car was rear-ended by a large tractor-trailer truck. After several weeks of traction, rest, and a cervical collar, healing began. One year later she was re-injured in a fall and in addition to the cervical injury also injured her lumbar spine. She experienced right upper and lower extremity numbness, loss of fine motor skills in the right hand, and difficulty walking. Despite her neurosurgeon’s urging to maintain strict bed rest for two months, she put herself on a walking program to prevent muscle atrophy. She continued to have chronic pain with occasional flare-ups.

Several months later, in the process of building a patio lounge chair, her already weakened spine was again injured. She required surgery, including a fusion at C4-5, along with removal of a ruptured disc and removal of several fragments from the spinal canal. Presurgical nerve damage caused prolonged motor weakness and numbness. Also, when the bone graft was removed from the iliac crest, injured nerves left her with neuropathic pain in the left thigh and leg. During the subsequent healing months, the author learned personally about definitions of complex regional pain syndrome (CRPS), allodynia, dysesthesia, hyperesthesia, and about listening to patients in pain and believing their story. She discusses several “do’s and don’ts” for surgeons and for patients, related to her personal experience. Probably the most valuable advice for pain management professionals is to listen to your patients. Ask them what is wrong and they will tell you. It is common to ask patients questions which relate to the experience of chronic pain, but do not seem to relate to CRPS symptoms. For example, “When is your pain worse?” “What positions worsen pain?” While these activities do relate to chronic pain, there is no mention of experiences that affect neuropathic pain such as encountering a sudden blast of water while in the shower, walking into an air conditioned room, or walking outside on a windy day. Also, questionnaires contain descriptions of chronic pain symptoms but not CRPS symptoms such as crawling ants, stinging bees, and soft cotton being rubbed across one’s skin. The author describes the feeling of cold air from air conditioning or wind contacting her skin feeling like lightning-sharp goose bumps like cactus spikes. She experienced an intense burning, stinging sensation as though a swarm of angry yellow jackets was stinging profusely and unrelentingly. Areas of her skin felt hot and cold simultaneously. She had a feeling of soft puffs of cotton containing shards of razor-sharp steel being rubbed agonizingly slowly over her skin where the bone graft was taken. Also, she described a feeling of a soft feather being rubbed tortuously slowly and softly over her skin. These are symptoms which the author feared no one would believe if she actually described how they felt.

As a psychologist, she never actually disbelieved, but did doubt patients who told her they hurt too badly to comply with their relaxation and visual imagery exercises. She never disbelieved, but did doubt patients who reported that their pain “moved” or increased after receiving a nerve block. As a patient, she learned what they meant.

She emphasizes the importance of treating patients with empathy, respect, and explanations of treatments. One of the most beneficial things she gained by being a patient is to listen to her patients and try to actually hear what they are telling her, instead of listening for what she thinks the patients should say in order for her to impose a known treatment on a familiar sounding problem. She believes persons stereotyped as “professional” patients may simply be patients seeking professional help.

Journal: Clin J Pain, 12(2):90-93, 1996. 0 References Vanderbilt Pain Control Center, 401 Medical Arts Bldg., 1211 21st Ave., South, Nashville, TN 37232 (Dr JM Livengood) JAC.03 OC9608/278 ©1996.

 

Claudia Campbell, pain.com

Pam and John are currently in physical therapy following similar car accidents. They both are receiving therapy for strained necks. However, Pam appears more “down” and catastrophizes that her physical therapy sessions are more painful than helpful. John, on the other hand, routinely trades jokes with his physical therapist during each session and remarks positively on the improvements to his health and functioning. Why do these two patients have such different responses to pain, and are their responses linked to their personalities or their gender?

A variety of characteristics, from genetics to psychosocial processes, contribute to how people perceive pain. A person’s sex (a more biologically-driven term)/gender (a sociocultural term) emerged as a critical factor in shaping the experience of pain. Over the last 15 years an explosion of research has documented differences between how men and women respond to pain and analgesic medications meant to reduce pain (see Greenspan et al., 2007 for a comprehensive review).

Women are more likely than men to report acute and chronic pain, and they use pain-relieving medication more often, even when equating for pain severity. Women also have greater prevalence (in many cases, 50-100% higher relative to men) of many chronic pain conditions including headache, temporomandibular joint disorder (TMD), fibromyalgia, irritable bowel syndrome, and arthritis8, and they report greater pain than men in experimental models, where healthy individuals undergo standard noxious stimuli2.

A number of psychosocial and interpersonal variables also contribute to pain; a few of the well-studied factors include age, race/ethnicity, mood, and coping. A great deal of study has focused on catastrophizing, a maladaptive coping strategy characterized by a negative cognitive and affective response to pain (like feelings of helplessness, magnification, and ruminative thoughts about pain), which is more common in women. Sex differences in catastrophizing may mediate the difference between men and women with chronic pain and in experimental settings1. Similarly, depressive symptoms are more frequently reported by women and have been found to predict future musculoskeletal disorders like low back pain.

More here.

Emanuel Derman, The Edge

But what is happiness? In The Ethics, written in 1677, Spinoza ambitiously tried to do for the emotions what Euclid did for geometry. Euclid began with ‘primitives’, his raw material, the elements that everyone understands. In geometry, these were points and lines. He then added axioms, self-evident logical principles that no one would argue with, stating for example that ‘If equals are added to equals, then the wholes are equal’. Finally, he proceeded to theorems, interesting deductions he could prove from the primitives and the axioms. One of them is Pythagoras’ theorem that relates triangles to squares: the sum of the squares of the sides of right-angled triangle are equal to the square of the hypotenuse.

Spinoza approached human emotions the way Euclid approached triangles and squares, aiming to understand their inter-relations by means of principles, logic and deduction.

Spinoza’s primitives were pain, pleasure and desire. Everyone who inhabits a human body recognizes these feelings. Just as financial stock options are derivatives that depend on the underlying stock price, so more complex emotions depend on these three primitives pain, pleasure and desire.

More here.  

By Madison Park, CNN

Despite two injections of anesthetic, Amy Anderson felt like her dentist was jamming rods into her tooth during a root canal. She writhed in pain as her infected tooth was hollowed with a drill, its nerve amputated, and then sealed.

“I knew this time something was wrong. I could feel my lips,” said the Syracuse, New York, resident, who told her dentist the drugs weren’t working.

Her doctor kept assuring her she had given her a proper dose and said: “I’m almost done.”

“I was hurting so bad, I was hitting myself in the stomach,” said Anderson, a redhead. “I almost wanted to hit her.”

Studies have indicated that redheads may be more sensitive to pain and may need more anesthetics to numb them.

New research published in this month’s Journal of American Dental Association found that painful experiences at the dentist might cause more anxiety for men and women with red hair, who were twice as likely to avoid dental care than people with dark hair. 

“Redheads are sensitive to pain,” said Dr. Daniel Sessler, an Outcomes Research Department chair at The Cleveland Clinic, in Cleveland, Ohio, who is one of the authors.

“They require more generalized anesthesia, localized anesthesia. The conventional doses fail. They have bad experiences at the dentist and because of the bad experiences, they could avoid dental care.”

Sessler, an anesthesiologist, began studying redheads’ sensitivity to pain after hearing chatter from colleagues.

“The persistent rumor in the anesthesia community was that redheads were difficult to anesthetize,” Sessler said. “They didn’t go under, had a lot of pain, didn’t respond well to anesthesia. Urban legends usually don’t start studies, but it was such an intriguing observation.”

This led to two studies. In 2004, research showed that people with red hair need 20 percent more general anesthesia than blonds and brunettes.

A 2005 study indicated that redheads are more sensitive to thermal pain and are more resistant to the effects of local anesthesia.

Researchers believe variants of the melanocortin-1 receptor gene play a role. This MC1R gene produces melanin, which gives skin, hair and eyes their color.

While blond, brown and black-haired people produce melanin, those with red hair have a mutation of this receptor. It produces a different coloring called pheomelanin, which results in freckles, fair skin and ginger hair. About 5 percent of whites are estimated to have these characteristics.

While the relationship between MC1R and pain sensitivity is not entirely understood, researchers have found MC1R receptors in the brain and some of them are known to influence pain sensitivity.

Non-redheads can also carry a variant of the MC1R gene. In this dental study that had 144 participants, about a quarter of the non-redheads had variants of the MC1R gene. These people also experienced heightened anxiety and avoided dental care compared with others who did not have the variant.

More here.

The study published in Pain by Makikio Yamada and Jean Decety [19] investigates the unexplored relation of perceived pain to the emergence of empathic concern. According to the authors, the question itself appears problematic. For, how can detected pain at once urge observers to avoid the source of threat and also instigate approach-behaviors in the form of empathy and provision of care? In this letter, we claim that the pathway to empathy for pain is not paradoxical, but is paved by the human capacity to separate perceptions from aversive self-oriented responses and, thereby, to free up those perceptions to acquire symbolic and interactive meaning. 

Pain warns of physical threat and danger on the one hand and also signals an opportunity to care for and heal the person in pain on the other [17]. The protective function of pain instigating behavioral escape perhaps is more primitive, because self-focus likely precedes the care of others [2]. Intense self-focus in observers perceiving another person’s state is linked to aversive self-oriented emotions (e.g., discomfort, anxiety) that may be negatively associated with regulatory capacities [7]. By contrast, sympathy for others is positively related to the capacity of observers to voluntarily limit their emotional response to a zone that is arousing but not aversive [8]. With respect to pain, higher levels of aversive self-focus have been found in individuals who experience the threat-value of pain in their child [9] or their spouse [15] in a personally distressing way. These individuals would be expected to have a reduced capacity to voluntarily regulate their emotional state and an initial tendency to focus on their own emotional needs [6]. Other-oriented emotional responses such as empathy would likely be inhibited or delayed [1; 9]. Since sympathy is positively associated with regulatory capacities, sympathy for pain should promote recognition of the other’s state because the observer’s regulation of her own emotions is the basis for identification with the emotions of others [5]. The ability to manage or ‘tame’ an emotion-based response to the other in pain therefore permits an observer to attend to the emotional needs of the other and may facilitate sympathy for pain and helping behaviors [7]. Put another way, a response that remains ‘catastrophic’ tends to undermine interpersonal exchanges and empathy; but a regulated emotion can be used for interacting with others [13].  

Observers able to control their response to detected pain in others can voluntarily reflect on their own emotions, and the possible emotions of the other in pain. Adults and older children can say, ‘Are you hurt?’, and see how the other person responds to this statement. Or perhaps an observer thinks to herself, ‘Help him now’. In both situations, the observer is exploring options based on a process of reflective thinking involving the use of symbols rather than an aversive emotional response based on the perception of pain in the other and a potential threat to oneself [13]. Consulting a symbol enables an observer to know consciously the state he is in; he can now reflect on the emotion rather than let it overwhelm him [13]. We propose that emotion-based reactions and voluntary regulatory capacities are positively linked [6] to the degree in which an emotion is transformed into a symbolic and interactive form [13]. By contrast, if an emotional reaction remains catastrophic, it pushes for an aversive response; there is awareness of the physiologic states but not an understanding of other emotions or reactions. For example, an observer to pain in another person might think, ‘My heart is beating fast. I need to get out of here because I am scared’ (and then the person runs) [6]. But individuals who can fully symbolize the emotion and reflect on the feeling can describe how it feels to be distressed and can connect it with similar experiences in oneself or even others [13]. This pattern may link accessing long-term memories to process emotional responses at a deeper level [13], and planning effective helping and caring behaviors [7]. 

In healthy development, emotions such as fear and anger tend to be transformed from fixed catastrophic reactions into interactive patterns and symbols in the second half of year one and the second year of life and thereafter [11;12;13]. The catastrophic responses of infants to tissue pathology become shaped by parents and caregivers into differentiated and socially responsive patterns of behavior [14]. The infant who looks to a parent or caregiver when in pain is learning to show distress, to negotiate [16], and to get her needs met [4; 10]. As this happens, emotional responses are no longer locked into patterns of intense self-focus; preschoolers able to bring a parent to provide help when others are in pain can modulate their aversive response through interactions with others [4; 10]. The development of normal language allows children to use words and sentences to symbolize pain. This may facilitate other-oriented interactions and reflective thinking through sharing emotions and ideas. For example, a toddler may represent painful distress in role-playing scenarios to direct or manipulate the attention of parents and siblings [4]. Just as a baby or infant exists in the social circumstance of a baby/caregiver relationship [18], an emotional response that has become an interactive symbol exists in the circumstance of its interactive pattern [11]. Without the modulating influence of an interaction, the child’s response to a person in pain may grow more intense and she may be left using the aversive self-oriented feelings. Her expression of emotion is, therefore, not part of a fine-tuned regulated symbolic system: it may be simply a self-oriented emotional response. We argue that the separation of a perception from its aversive response may explain how perceived pain shapes its threat values and instigates empathic behavior.  

 

References

  1. Cano, A, Leonard, MT, and Franz, A. The significant other version of the Pain Catastrophizing Scale (PCS-S). Pain 2005; 119: 26-37.
  2. Craig, KD. The Social Communication Model of Pain. Canadian Psychology 2009; 50: 22-32.
  3. Craig, KD, McMahon, RS, Morison, JD, and Zaskow, C. Developmental changes in infant pain expression during immunization. Social Science and Medicine 1984; 19: 1331-1337.
  4. Craig, KD, and Korol, CT. Developmental issues in understanding, assessing, and managing pediatric pain. In: Walco G,  Goldschneider K, editors. Pain in Children: a practical guide for primary care. Totowa, NJ, The Humana Press, Inc, 2008. pp. 9-20.
  5. Decety J, and Jackson, PL. The functional architecture of human empathy. Behavioral and Cognitive Neuroscience Reviews 2004; 3: 71-100.
  6. Eisenberg, N. Distinctions among various modes of empathy-related reactions: A matter of importance in humans. Behavioral and Brain Sciences 2002; 25: 33-34.
  7. Goubert, L, Craig KD, and Buysse, A. Perceiving pain in others: Experimental and Clinical Evidence on the Role of Empathy. In: Ickes W, Decety J, editors. The social neuroscience of empathy. Cambridge, MA: MIT Press, 2009.  pp. 153-165.
  8. Goubert L, Vervoort T, and Crombez G. Pain demands attention from others: The approach/avoidance paradox. Pain 2009; 143: 5-6.
  9. Goubert L, Vervoort T, Sullivan, MJL, Verhoeven, K, and Crombez G. Parental emotional responses to their child’s pain: the role of dispositional empathy and parental catastrophizing about their child’s pain. Pain 2008; 9: 272-279.
  10. Goubert, L, Craig, KD, Vervoot, T, Morley, S, Sullivan, MJL, Williams, ACdeC, Cano, A and Crombez, G. Facing others in pain: the effects of empathy. Pain 2005; 118: 285-288.
  11. Greenspan, I. Intelligence and adaptation: An integration of psychoanalytic and Piagetian developmental psychology. Psychological Issues Monograph Series, nos. 47-48. New York: International Universities Press, 1979.
  12. Greenspan, I. The development of the ego: Implications for personality theory, psychopathology, and the psychotherapeutic process. New York: International Universities Press, 1989.
  13. Greenspan, I, and Shanker, SG. The first idea: How symbols, language, and intelligence evolved from our primate ancestors to modern humans. Cambridge, MA: Da Capo Press, 2004.
  14. Hermann, C. Modeling, social learning of pain. In: Schmidt, RF, Willis, WD, editors. The Encyclopedia of Pain. Heidelberg: Springer-Verlag, 2007. p. 13.
  15. Leonard, MT, and Cano, A. Pain affects spouses too: Personal experience with pain and catastrophizing as correlates of spouse distress. Pain 2006; 126: 139-146.
  16. Sullivan, MD. Finding pain between minds and bodies. The Clinical Journal of Pain 2001; 17: 146-156.
  17. Williams, C. de C, A. Facial expression of pain: an evolutionary account. Behavioral and Brain Sciences 2002; 25: 439-488.
  18. Winnicott, DW. The child, the family and the outside world. Reading, Mass.: Addison-Wesley, 1987.
  19. Yamada, M, and Decety, J. Unconscious affective processing and empathy: An investigation of subliminal priming on the detection of painful facial expressions. Pain 2009; 143: 71–75. 

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