User:Anthonyhcole/Sandbox

Three essays. A work in progress.

Tonic pain

This essay compares my experience of pain with what I have found in the scientific literature.

Stephen and I were happy twin toddlers: playful, affectionate, curious, beginning to string words into sentences when, quite suddenly, I regressed. I went quiet. I became miserable, irritable, anxious, inattentive and solitary, and stayed that way.

Constant pain from a botched and unnecessary medical intervention caused me life-long emotional, cognitive and social damage. It comes from a spot halfway up my back, to the left of my spine where there is a scar. The muscle beneath that scar is atrophied and the muscle around it is a little bulky.

It starts soon after I engage that large, flat anti-gravity muscle, when I sit or stand. It's "tonic" pain: constant, rising and falling only slowly in intensity. The longer I'm up, the more it hurts and it takes hours for the pain to resolve after I lie down.

Most people in chronic pain experience periods of intense pain (like an endometriosis flare or moving an arthritic joint) between periods of less or no pain. With me, the pain is nearly always present and when the intensity changes it changes very, very slowly and predictably. My pain is more like a trait than the harrowing succession of painful events typical of chronic pain.

This constant negative tone, this lens through which I experience the world, distorts everything that matters.

It slows my thinking speed, reduces my working memory capacity, impairs my concentration and undermines my self-control. It increases the intensity, frequency and duration of negative moods and negative emotional events, and it makes me neurotic; it numbs my social feelings; it isolates me from others and it leaves me distracted and inattentive.

I've searched the pain science journals, textbooks and other literature to see if pain affects others in this way:

Cognition: The negative impact of pain on mental processing speed, working memory capacity, attention control, impulse inhibition, emotion regulation and other cognitive processes is well-attested in the pain literature.

Mood and emotion: Pain science has focussed on misery (depression) and anxiety, it pays some attention to irritability and little attention to neuroticism (exaggerated affective response to negative stimuli) but it has found all of these are amplified by pain.

Social feelings: I'm not aware of any scientific research into the impact of pain on social feelings (empathy, compassion, shame, guilt, rejection, affection etc.). Here, Michael Schatman, editor-in-chief of the Journal of Pain Research, recently told me, "I agree with you regarding the lack of study in this area."

But pain numbs my social feelings.

In 2004 I read an fMRI brain study that found the distress of physical pain shares grey matter with the distress of rejection — a social feeling. I don't know whether that's been confirmed but it might help to explain, neurologically, how physical suffering can interfere with social feelings.

After I lie down the pain slowly recedes and, in time, social feelings begin to emerge, but I'm usually alone and asleep by then. In my dreams, I feel others' feelings and respond with my own. I love my dreams.

When I rise the next day and the pain begins, social feelings fade again into impotent, vague notions, distant memories, not the visceral affective guardrails I need to successfully navigate society.

Social engagement: This section explains a disturbance of affective contact in me.

• I can't convey appropriate feelings by facial expression. I can't return a timely, sincere smile when suffering is swamping my sensorium. Failure to display a timely sincere (Duchenne) smile elicits distrust in the observer.
• The human male (but not female) face in pain activates the human observer's amygdala. The amygdala is involved in, among other things, the processing of fear and aggression.

• People in pain are excessively reactive to negative stimuli, so negative facial expressions from others hurt us a lot. A negative look is, for me, more like traumatic abuse than the social slap on the wrist it is for most people.

If we make eye contact when I'm in pain, you will see my pain and my failure to display a timely sincere smile, and I will see your automatic, primative emotional response: distrust, fear and aggression. It's an ugly emotional moment for both of us but especially so for me.

I can't look at you when you're looking at me, out of fear and certainty of being hurt by your expression. So, the interplay of emotional facial expression, the universal semaphore of displayed, exchanged feelings, is disabled in me and its absence marks me out as remote, shifty and strange and I miss important social cues.

No one is studying the impact of pain on emotional facial semaphore or intersubjectivity

Inattention: The present is usually so toxic, I retreat into distraction and absent-mindedness. My surroundings are still available to that part of me that drives my car and opens the fridge door but mindful, deliberate me is mostly absent and lives by glimpses.

"Death is preferred over prolonged severe pain but even mild to moderate pain, if continued long enough, will bleed life of its pleasure, transforming the individual into a sufferer whose overriding goal is to drive this experience from consciousness." — Kenneth L. Casey. 2019.

The impact of distraction on pain intensity and unpleasantness is well-attested in the pain literature.

Anti-charm: And then there's emotional contagion. You feel my pain. It hurts you to be around me. I have the opposite of charisma. Nobody talks or writes about this.

______

So, I have found some fragments of myself in the literature (my various pain-related neuropsychological defecits, my pain-related tendency toward absent-mindedness and inattention, my pain-related propensity to negative mood states and neuroticism) but the other fragments I discuss above (tonic pain as a unique class of chronic pain, pain's impact on social feeling, pain's impact on intersubjectivity, anti-charm: the instinctive aversion you feel toward me) are all missing from the literature.

______

This is a seriously disabling set of symptoms. I watch them come and go, rise and fall with the pain, day after day.

It's not been easy. The pain is awful, and all that stuff above is too, but I'm also heartbroken and have been since I lost my family's affection and the world turned away when I was a toddler.

My family were very patient and kind and took good care of me and I am so grateful for that. But they couldn't give me sincere, spontaneous affectionate smiles and shared feelings. No one could. I've spent most of my life not being smiled upon and not sharing feelings.

The heartbreak from this affective isolation never remitted in my childhood and only for a few moments in my adult life.

My family could have talked to me and listened to me, though. They could have engaged me in uncomfortable, clumsy, embarrassing conversations, which would have been enormously rewarding and helpful for me, but nobody did that back then with kids like me.

______

This happened to one individual, a barely-verbal toddler. If it had happened to a robust, intelligent, worldly twenty-five year old, or another toddler with a different biological inheritance, different life experiences and different social environment from mine, the outcome may have been very different. This is only me I'm describing here. But it is me. It is an honest report and I'd like you to believe me.

Distress

What is it? What does it do to us?

In 1968 Ronald Melzack and Kenneth Casey re-imagined pain as more than just a sensation, and this conceptual model now underpins all thinking in modern pain psychology and pain neuroscience. They described three dimensions of pain:

1. sensory-discriminative: sense of the quality, location, duration and intensity of the pain
2. affective-motivational: unpleasantness and urge to escape the unpleasantness
3. cognitive-evaluative: cognitions such as appraisal, cultural values, distraction and hypnotic suggestion.

It is the affective-motivational dimension, the unpleasantness, that harms us.

Unpleasantness is also called "suffering", "discomfort", "torment", "anguish", "hurt", "negative affect", "negative valence", "negative hedonic tone", "aversiveness" and "distress". I'll use "distress" here.

Distress is found in three classes of feelings:

1. It is a dimension of unpleasant homeostatic feelings like hunger, fatigue and hyperthermia. Unpleasant homeostatic feelings torment us with distress until we satisfy them with specific behaviour aimed at maintaining the body in its ideal state. (In hunger: eating, in fatigue: resting, and in hyperthermia: stepping into the shade.)

Sheep respond to hunger, fatigue and hyperthermia by grazing and resting in the shade of a tree.

2. Distress also plays a role in negative emotions like grief, anger and fear, and negative moods like misery, irritability and anxiety.

3. And it is an essential part of some social feelings (e.g., empathy, rejection, shame, loneliness).

Distress likely evolved first and was enlisted by homeostatic feelings, emotions and social feelings as they emerged later in animal evolution.

It is likely that just one neural network generates distress, and every unpleasant feeling employs this one distress network.

What does distress do to us?

I am studying the effect of distress on human emotion, cognition and social engagement and I have focussed on three causes of distress — hunger, sleep deprivation and pain — because each of these has a body of scholarship addressing, to some extent, its affective, cognitive and social impacts.

I have more reading to do but it is looking like each of these distressing homeostatic feelings generates in humans the same set of clinically significant symptoms:

• Increased frequency, intensity and duration of negative mood states (e.g., misery, anxiety and irritability) and negative emotional events (e.g., grief, fear and anger), and heightened affective response to negative stimuli (neuroticism): things that hurt, hurt more.
• Slowed mental processing speed, reduced working memory capacity and impaired attention control, impulse inhibition and emotion regulation.
• Impaired social feeling/social engagement.

Until someone finds an instance of distress that does not cause this cluster of symptoms, I shall assume all distress, regardless of its cause, produces this syndrome.

(The above is the first third of a larger essay where I speculate about the role of distress in mental illness. I include this excerpt here only so you can better understand the next, most important essay: Inuring.)

Inuring

I always knew there was something wrong with me. I have an identical twin: a perfect control. He played and made friends and I did not. He was happy, attentive, affectionate, sensitive, witty and loquacious. I was not. I kept hoping and waiting for nature to sweep me up and usher me through all the developmental stages I'd seen him effortlessly glide through but it never happened.

Throughout my childhood I'd felt discomfort in my back but didn't pay it much attention until, when I was nineteen, I smoked marijuana for the first time and I saw clearly in that instant that this discomfort was intense muscle pain coming from a spot halfway up my back to the left of my spine, and I saw it was this that had been ruining me.

I "saw" this because marijuana connected my feelings with my consciousness and cognitions, and marijuana reduced the pain's distress and intensity, and that sudden drop in distress and intensity, which I'd never experienced before, drew the pain to my attention.

I tried all the drugs and therapies but the most effective intervention was simply lying down for hours. Marijuana eased the pain but it took a serious toll in weariness and stupidity.

And if I rubbed a spot on my back at the centre of the pain it sometimes helped a bit. Three years later, at the beach, somebody touched me there and said, "What's that scar?"

I asked Mum and she told me I'd had a birthmark X-rayed when I was a toddler to accelerate the birthmark's involution.

Raised, bright red birthmarks usually involute — melt back into the skin and disappear — over childhood without any intervention but mine was close to the spine and doctors thought it might cause a spinal blood vessel malformation followed by paralysis and a slow, agonising death. It's called Cobb syndrome.

It's voodoo. When I looked in the 2000s there were very few cases in the literature. The likelihood of a birthmark being followed by a spinal artereovenus malformation in the same dermatome seems no greater than chance.

Looking at the recent literature, it appears radiation of birthmarks as a prophylactic intervention for Cobb syndrome is no longer standard practice.

And the radiation intensity necessary to trigger involution is closer to imaging intensity than the intensity required to cause muscle damage, so I'm guessing the radiotherapist got the dose wrong.

______

If the pain intensity rises more rapidly than usual (from extreme exertion, say) or falls more rapidly than usual (from, say, smoking dope) then it comes sharply into consciousness. But when the pain's intensity follows its usual slow, familiar, predictable temporal course, when it creeps up on me and fades away slowly, I don't notice it. The distress, however, is undiminished and, when it is intense, it crushes me.

This sensory inuring or habituation might be a function of Melzack and Casey's third dimension of pain, the cognitive-evaluative dimension.

Pain science is familiar with analgesia caused by the excitement of sport or war where a player or combatant can temporarily experience no suffering and no awareness of pain in very traumatic injury, like a severed tendon or limb amputation. This is thought to be cognitive suppression of both the sensory and affective dimensions of pain.

Distraction, hypnosis and placebo, three more cognitive processes, can all modify both the affective and sensory dimensions of pain, or just the affective dimension depending on context.

I've never read an account of pain's sensory but not its affective dimension being suppressed by a cognitive process ... or by any other process for that matter. This may be addressed in the homeostatic feeling literature, I suppose. I've got a lot more reading to do. But, for now, this is another fragment of me I haven't found in the literature: sensory inuring to familiar, unsurprising, unalarming tonic pain.

Random scratchpad (ignore)

• Pain seems to make boys autistic and girls borderline. Borderline personality disorder (BPD) is a personality disorder (PD) characterised by significant distress.

"There is no doubt that the indicators of harmful emotional dysregulation, volatility, unpredictability and self-injury render BPD a legitimate mental disorder. It is unclear, however, why [DSM III] classified it as a personality disorder.

"Its trademark indicator, emotional dysregulation, is virtually the opposite of the rigidity that characterises a PD. Moreover, unlike other PDs, but like mood conditions, the symptoms of BPD are not egosyntonic [compatible with one's view of oneself and one's place in the world], cause great distress and lead to efforts to get rid of them.

"Kraepelin's classification of borderline states as a kind of mood disorder marked by impulsivity, frequent mood changes and irritability seemed to better fit this condition than the inflexibility that marks other personality disorders.

"Indeed, recent research indicates that nearly half of people with a bipolar diagnosis also meet criteria for BPD. Subsequent DSMs maintain the seemingly mistaken placement of BPD as a personality rather than mood disorder."

Alan V Horwitz, 2023. "Personality Disorders". Chapter 5.

• Hooten, W. Michael (July 2016). "Chronic Pain and Mental Health Disorders: Shared Neural Mechanisms, Epidemiology, and Treatment". Mayo Clinic Proceedings. 91 (7): 955–970. doi:10.1016/j.mayocp.2016.04.029. ISSN 1942-5546. PMID 27344405.

• Li, Tianbi; Decety, Jean; Hua, Zihui; Li, Guoxiang; Yi, Li (August 2024). "Empathy in autistic children: Emotional overarousal in response to others' physical pain". Autism Research. 17 (8): 1640–1650. doi:10.1002/aur.3200. ISSN 1939-3792.
• Autism seemed to demonstrate what happened when people developed without giving or receiving affection — Understanding Autism: Parents, Doctors, and the History of a Disorder. Princeton University Press. 2011-11-07. ISBN 978-1-4008-4039-7.

• Thomas Beddoes (1806) A Manual of Health, or the Invalid Conducted Safely Through the Seasons, p 75:

  "Upon examining a particular child it has occurred to me many scores of times to ask the parent, 'Pray, have you any more children?'

  " 'Yes but they none of them complain.'

  " 'Be so good as to bring them. I would wish to examine them myself.'

  "A child roars when suffering from a sharp pain but when pain creeps on them by degrees, when they find themselves in dull pain, they will rarely complain, and yet that is when I need to see them."

  Quoted on page 166 in The Worst of Evils: The Fight Against Pain (2006) by Thomas Dormandy.

• "When depression is well marked its exact form varies greatly — grief finding causes for unhappiness in the past, fear which seeks them in the future, and a simple sense of wretchedness about the present seem the primary types." ... "In part, the mood expresses the individual temperament as determined by the interaction of inborn constitution with the sum of experience, remote as well as recent." — Mapother, Edward (November 13, 1926). "Discussion on Manic-Depressive Psychosis". British Medical Journal: 872-879.

• Ballantyne, Jane C.; Sullivan, Mark D. (2015-11-26). "Intensity of Chronic Pain — The Wrong Metric?". New England Journal of Medicine. 373 (22): 2098–2099. doi:10.1056/NEJMp1507136. ISSN 0028-4793.

• "... even when opium does not abolish pain, the pain no longer preys on the person's mind." Diocles of Carystus, a fourth century BC Greek physician, quoted in Thomas Dormandy, The Worst of Evils: The Fight Against Pain (2006), Ch. 2.

• "[A mid-career psychiatrist and brain imager] described how a person might have a very pure, identifiable and innate genetic lesion that disturbed their language functioning. Because of the person's language problems, the psychiatrist pointed out, people in their environment would react differently to them. So, this very small and innate molecular difference would radically alter that person's social surroundings. This environmental input might then lead to a measurable biological difference elsewhere in their brain which someone like this psychiatrist might measure ..." — Fitzgerald, Des (2017) "Introduction", Tracing autism: uncertainty, ambiguity, and the affective labor of neuroscience. In vivo. Seattle: University of Washington press. ISBN 978-0-295-74191-8.
• "In these decerebrated animals [animals whose cortex and thalamus has been surgically removed] a noxious mechanical or thermal stimulus regularly evoked a [...] response that resembled the angry, defensive reaction of a distressed intact animal. The decerebrated animal would open its eyes with pupils dilated, turn its head toward the stimulated site, bare its teeth, and sometimes snarl and snap. Only noxious stimuli were effective in evoking this response.

  [...]

  Because these reflex responses were evoked only by noxious stimuli and fully resembled the reaction of an intact, angry, distressed, and defensive animal to an unpleasant and threatening event, they were called 'pseudoaffective reflexes.'

  [...]

  Additional experiments revealed that only an intact ventrolateral quadrant of the spinal cord was necessary for the pseudoaffective reflex to occur."

Casey, Kenneth L. (2019). Chasing pain: the search for a neurobiological mechanism. New York, NY: Oxford University Press. ISBN 978-0-19-088023-1. OCLC 1066088921. Chapter: 4

Back when these experiments were performed, scientists studied only male subjects.

I wonder if decerebrated female cats and dogs, like their male conspecifics, display fear and rage in response to pain. That is, is the female primative emotional response to pain as scary as the male primative emotional response to pain. If the male but not female primal emotional response to pain is fear and rage, this may explain our negative (amygdala) response to the male but not female face in pain.

Just guessing here but the female reflexive primordial emotional response to pain may be more like fear and grief. (I think that is so in humans, anyway.)

Fear and rage in others evoke fear in us. Fear and grief evoke a different emotion. Compassion, maybe? But not fear.

We need to study sex differences in the way we respond emotionally to pain and the way others respond emotionally to us in pain.

• Robert Spitzer, main author of DSM III, defines mental illness: "In DSM III, each of the mental disorders is conceptualised as a clinically significant behavioural or psychological syndrome or pattern that occurs in an individual and that is typically associated with either a painful symptom (distress) or impairment in one or more important areas of functioning (disability).

"In addition, there is an inference that there is a behavioural, psychological or biological dysfunction, and that the disturbance is not only in the relationship between the individual and society. When the disturbance is limited to a conflict between an individual and society, this may represent social deviance, which may or may not be commendable, but is not, by itself a mental disorder." — Quoted in DSM: A history of psychiatry's bible (2021) by Allan V. Horowitz, chapter 3.

• "Every single day [the patient's] pain is experienced by the world around them."

— Keith Meldrum

Inuring

"... individual nociceptor activity is not always a faithful reflection of stimulus intensity. With prolonged stimulation, the spiking of some nociceptors may decline, or even cease, although the applied stimulus intensity is unchanged." — Craig, ibid, ch. 6

Charm and its opposite

• Allan V. Horwitz on the drift of emphasis from "character" to "personality" with the birth of individualism:

"By the end of the ninteenth century, personality was a major source of interest both in Europe and the US.

"Personality referred to the typical ways that people behaved, thought, felt and related to others. Qualities related to charm - the ability to form friendships, likeability and the ability to project energy - replaced the earlier emphasis on duty, moral courage and integrity.

"As traditional and local bonds unravelled, social solidarity itself came to rest on the ability of these newly free individuals to integrate personally their diverse social roles."

Horwitz, Allan V. (2023). Personality disorders: a short history of narcissistic, borderline, antisocial, and other types. Baltimore: Johns Hopkins University Press. ISBN 978-1-4214-4610-3.

Suicide

Compare rates in chronic pain, itch, dyspnea, etc., with suicide rates in mental illness.