A long time ago, when I was more adventurous, I joined a medical expedition to Ethiopia. One evening, I was taken to a cemetery on a hill in Addis Ababa. There, between the toppling gravestones and under rusty sheets of corrugated iron was where the lepers lived. As we walked through the desolation, somewhere between life and death, people approached us holding out the stumps of what had once been hands and fingers. I greeted them, holding the stumps that were proffered to me. That simple contact seemed important.
Leprosy affects the nerves to the fingers and toes. People with this dreadful disease lose all sensation and cannot feel when they are injured. So, when their fingers and toes get burnt and cut, they become infected, lose their blood supply and drop off.
Pain is a protective sensation. It signals injury or disease and forces us to protect the part that hurts and allow it to heal. Cellular injury releases chemicals that cause inflammation, which not only causes redness and swelling but also involves stimulation of nociceptive (pain sensing) nerves that locate the site of the damage. When we hurt ourselves, messages are sent to the brain. The sensory cortex processes the location of the pain; whereas affective or emotional regions of the brainstem, the thalamus, reticular formation, raphe nucleus with projections to the cingulate gyrus and frontal cortex deal with the unpleasantness of the pain. But these brain regions don’t just activate when we hurt ourselves. They are also active when we remember the context of the pain or even ‘experience’ another’s pain.
Pain is not always proportional to the damage and can even be ‘felt’ in areas where there is little damage or even no damage at all. Moreover, tissue damage can heal in three to six months but the pain of the injury can linger on, often for years. People can even experience pain in a part of the body that is no longer there.
A friend of mine was once travelling on the roof of a train in East Africa when he noticed too late they were coming to a bridge. He was unable to get back inside in time and his arm was ripped off at the shoulder. He survived, but years later, he still felt intense cramping pain in the fingers of his absent right hand whenever he recalled the accident. He had what has been described as a phantom limb.
Pain does not exist in the body, it ‘exists’ in the brain. Nerves transfer impulses from the injured part to the thalamus and sensory cortex, which translate it into the physical sensation of pain and reference it to the site of injury. Thus even when a limb has been amputated, the representation of that limb exists in the brain and can respond to the memory of the injury with the sensation of pain.
Pain is not just a physical sensation, when it continues and becomes chronic, it becomes more diffuse and has a dominant emotional component. Therapist and trauma survivor, Carolyn Spring, wrote in her book, Trauma and the Body: ‘My pain is affected by my memories, my expectation and anticipation, my fear, my sense of threat, the meaning I’ve attributed to it and my mood and whether I’ve slept or not. It began to act like an air raid siren, warning me when painful emotions were flying in.’
Visceral pain, the type of pain that arises deep in the body, in the chest or the abdomen, for example, differs from the pain we feel from the skin. It is conveyed to consciousness by the sympathetic nervous system and is more diffuse, more difficult to localise, more of an emotional experience and may carry more meaning.
Abdominal pain may be induced by inflammation in the gut, or lack of blood supply produced by stretching or spasm, but in IBS, there is often nothing obvious to account for the pain. Instead, it seems that the gut is more sensitive than usual. When a balloon is inflated in the rectum, patients with IBS experience pain at lower levels of distension than in healthy subjects. Nevertheless, stress can induce hypersensitivity in healthy subjects.
For most of the time, we are completely unaware of the contractions and movements in the gut. The sensations are suppressed by activity in descending nerve tracts from the brain stem. But feelings of anxiety, distress, injustice, guilt or shame can remove the inhibition, unmasking sensation and allowing us to experience even normal movements as pain, bloating or nausea. In Fibromyalgia and IBS, there is evidence that lack of the neurotransmitter, serotonin, in these fibres may be responsible for hyperalgesia.
Marjorie was suffering from severe abdominal pain. She had had it for eight years and had done the rounds of all the specialists in the area. She had had Xrays and scans, samples of her blood, urine and stool had been taken for analysis. She had been treated with anti-spasmodics, painkillers, ani-inflammatory drugs: everything, but everything was normal. She was at her wits end, depressed and constipated but even laxatives and antidepressants failed to relieve the pain.
She arrived in a wheelchair. Her face was a mask of pain and she frequently winced as she told me her story, which was a litany of grievance, lists of appointments and failed tests and treatments, incompetent doctors. There were no obvious triggers. Everything seemed to make it worse and nothing had helped. I felt in danger of sinking into the quicksand of hopelessness that Marjorie was in, so I decided to take time out. I asked the nurse to get her ready for me to examine her abdomen. Marjorie struggled out of the chair and walked slowly across to the couch, but as she did so, she bent herself forward and held the lower part of her stomach. It reminded me of women I had seen on the gynaecological wards a day or so after their operation.
‘Have you had an operation?’ I asked her.
She looked shocked and a little frightened. ‘Yes, but it was eight years ago.’ ‘I had to have a hysterectomy for fibroids. I was in dreadful pain afterwards’.
‘And you’ve never really got over it? ‘So what was going on around that time?’
Her face crumpled and she needed to be helped on to the couch. ‘My twin sister was killed.’
That was something I wasn’t prepared for. I sat down and let her tell her story.
‘She was in Germany and was five months pregnant. Her husband was in the army. Anyway after a row, she told him that the baby wasn’t his. He completely lost it and beat her up, kicking her in the stomach so hard that she lost the baby and died of her injuries. They said she had ruptured her uterus and suffered a severe haemorrhage’.
‘They told me the day after my operation. I wasn’t well enough to go to the funeral.’
‘And you’ve had pain ever since.’
‘Yes. I’ve not dared to tell anybody about this. It’s too upsetting. They let him out of prison after three years and he’s back in England now. If I said anything, I am so afraid he would come and get me too.’
Marjorie does not have any obvious ongoing damage to the gut, but she has been badly hurt and never wants to experience anything like it again. Her fear combined with a daily sense of loss and injustice keeps the pain going. Grievance can prolong pain and increase its intensity. Think of a car crash victim, the worker who blames his employer for his industrial injury, the operation that went wrong. Studies in healthy volunteers showed that they experienced much more pain after plunging their hands in ice cold water if they were being interviewed about something unfair that had happened in their lives.
The victim’s sense of injustice doesn’t always stem from the accident; it might come from how they are treated afterwards by health professionals, insurance representatives or unsupportive family members.
Pain can be relieved by rest, relaxation, sleep, confidence, social support, hypnosis, distraction and activity, all of which increase activity in descending inhibitory pathways. Even swearing can help. Explaining the nature and origin of the pain can help relieve pain by giving people a sense of control over it. Confidence and belief can work miracles when drugs are ineffective. In some trials, as many as 60% of patients with unexplained or functional abdominal pain responded to a placebo. Just the belief that it will get better was enough to dull the sensation.
If the way we feel can affect our experience of pain, it may also affect other gut sensations and reactions.
Hi, I really enjoyed you’re post. Were you able to help Marjorie and was her pain relieved?
Thank you, Matt. Yes, over the next few weeks, she was able to talk a lot more about what happened, and while she never forgot that had happened, it lost the power to cause long term disability and only occasionally returned to remind her.
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