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The Nature of Pain

A dialogue with neurologist David Agnew, MD and bodywork therapist Ann Todhunter Brode, CST

Ann: According to a recently published study from the VA Hospital in Ann Arbor, Michigan, there is more to pain than the sensory markers of quality and intensity. There is also the personal perception of pain, the affective feeling of unpleasantness, which can translate to suffering. From your many years as a neurologist specializing in pain, would you tell us more about this aspect of pain?

David: Pain, both acute and chronic, is largely a personal experience, determined by many factors, among them past experience, perceived threat, and the context in which the painful event occurs. For example, it was reported that during the Normandy invasion during World War II, many soldiers whose wounds were so serious that, for them, the war was over, reported no pain and, though not in shock, declined morphine; the observation was made that for them, the injuries meant that they no longer had to face death and that their war was over. Another study reported years ago from the National Institute of Dental Health described how volunteers continued to report acute, shock- like tooth pain long after a test electrical stimulation to a dental nerve was stopped; an anatomically separate part of the face had been touched when the tooth shock was given, and the pain had become a Pavlovian learned response that took many hours to days to "unlearn". While the mechanisms for these observations are still not certain, the limbic system, a "switchboard" - like region deep in the brain's center, as well as the frontal and temporal regions, typically associated with affect and memory, are believed to come into play. Phantom limb pain is usually associated with the context of the amputation: traumatic amputations typically cause the lost limb to feel painful, while those with lifesaving amputations, as for cancer or gangrene, report non-painful phantom limbs. In a report I made to the second World Congress of the International Association for the Study of Pain (IASP) in Edinburgh years ago, my colleagues and I at the City of Hope showed that 50 patients reporting pain following stroke (central or thalamic pain) were statistically more likely to have had an unhappy marriage before the stroke than those with the same stroke damage, confirmed by brain scan, and that marital counseling was the most effective pain relieving therapy, more so than any medication, including narcotics. We also found that healthy volunteers reported widely different acute pain intensities from day to day given the same intensity of laser stimulation to the same body part, depending on their mood and their experiences that day.

David Agnew is a Santa Barbara physician specializing in neurology and pain management. He is also a member of the public relations committee of the American Academy of Neurological and Orthopedic Surgeons and Assistant Clinical Professor at USC.

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