PAIN WITHOUT A CAUSE: ORPHAN PAINS

Posted on June 7th, 2011, by admin
There are many pains whose cause is not known. If a diligent search has been made in the periphery and no cause is found, we have seen that clinicians act as though there was only one alternative. They blame faulty thinking, which, for many classical-thinking doctors, is the same as saying that there is no cause and even no disease. They ignore a century’s work on disorders of the spinal cord and brainstem and target the mind. The mind for them is foreign territory owned by the patient. Because they believe that the mind is governed by free will, they are saying that the patient has invented the pain for some devious purpose. A mountain of hogwash has been written about patients inventing pain for some symbolic purpose or as a method of manipulating other people. These are the doctors who repeat again and again to a Second World War amputee in pain that there is nothing wrong with him and that it is all in his head.
Of all the hundreds of patients I have seen, there was only one I believed had a ‘symbolic’ pain, by which I mean that the patient uses the word ‘pain’ to represent some other urgent need. Bill Noordenbos, a neurosurgeon in Amsterdam and the kindest, gentlest doctor I have known, introduced me to a Dutch woman with one arm amputated. She complained of a burning pain in her phantom hand but she went on to say that only one finger was burning. Neither of us had ever heard a patient describe so localized a pain so we went on to explore the details.
She had been driving her car on a hot summer day with her arm out of the window. A car driving from the opposite direction scraped along the side of her car and sliced off her arm. That evening, her husband came to see her in hospital and told her that he had no use for a one-armed wife and was leaving her. On further questioning of this poor woman, she said that her pain came from her wedding ring, which was burning her finger. She was given intensive counselling so that she came to see the loss of her arm as a tragedy but the loss of her husband as long overdue. The pain in her hand went away.
A dramatic example of an incorrect search for the location of the cause of pain is seen in patients with a damaged spinal cord who report pain in the numb part of their bodies.
Some patients who have their spinal cord cut across develop a deep, severe pain located in the completely anaesthetized part of their body. There are some twenty cases in the literature in which surgeons have believed that some pain-producing nerve impulses must be travelling through their useless spinal cord and that the pain-producing nerves originate in the damaged spinal cord. They have therefore opened up the spinal cord above the area of damage and have removed completely some segments of the remaining cord. The operation has no effect on the pain and should never be done. This is a truly central pain. Some cells that have lost their normal input have reacted in an attempt to recreate their former role by raising their excitability and beginning to fire steadily. No one knows where these cells are because we do not yet have the diagnostic tools to locate them. Vigorous research is in progress to find these cells and, perhaps even more importantly, to understand the chemistry of their excitability, explaining what makes them run wild.
I have mocked the search for the cause of pain which jumps from a peripheral cause straight to cognitive processes, as though the only function for the massive, complex, intervening nervous system was simply a mechanical relay. Of course, that is not to say that cognitive processes play no role in pain. All of us have sources of aches and pains that fail to capture our attention when we are busy and happy and yet can dominate us when we are down, lonely and miserable. The last chapters of this book will integrate sources of pain into the vast repertoire of possible reactions that are the nature of us and our brains. This chapter has attacked simplistic solutions that propose that, if an appropriate cause for pain cannot be detected in peripheral tissue, then the pain must be an invention of the mind. There are alternative solutions to the problem of pain without a detectable peripheral cause. Diagnostic methods are not yet good enough to detect all disorders, particularly in nerves and soft tissue. Increased sensitivity of nerve cells in spinal cord and brainstem can produce ‘false’ signals but present diagnostic methods do not yet permit the detection of such abnormal activity.
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