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 Dimensions and Definition of
Central Pain
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In evaluating Central Pain, clinicians must remind themselves that their
eyes do not measure pain.
Pain Axiom #1
The ability to understand the severity of invisible pain distinguishes the
professional from the layman.
Corollary to Axiom #1
It is the nature and disposition of nearly all professionals to underestimate
the magnitude of Central Pain.
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What Central Pain Is and Is Not
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The term, "Central Pain" should be reserved for those who have
the fully developed syndrome and who are in a pain crisis. The term, "Central
Pain" has embedded in it a sense of emergency. Any other approach is likely to send
out into the streets, unaided, the sickest patient the physician has ever treated. The
inclusion of patients who are experiencing minor neuropathic symptoms under the rubric,
"Central Pain" works against the patient with classical Central Pain
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How Do You Expect a Torture Victim to Appear?
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Reporters who have interviewed torture victims often encounter a quiet,
withdrawn, demoralized, broken person who is not obviously in physical pain. The visitor
may or may not believe what the individual says has been done to her. Inhumanity is
inherently unbelievable. This is true whether inflicted by humans or by disease in the
nervous system. Torture victims are humiliated, embarrassed and often refuse to discuss
what they have endured. On the other hand, if the reporter encounters a carpenter who has
hit his thumb with a hammer, there may be obvious physical evidence of a pain reaction.
Have the eyes acted as a proper scale for pain. Not unless the mind and imagination are
informed first.
In some ways, the situation is even more difficult for the Central Pain patient. They
are not avoiding the mention of something in the past. They are experiencing it in the
present. Furthermore, the pain is not going to stop, no matter how cooperative the patient
is, until death ends it. Over and over come reports from pain clinics that those in really
severe pain behave in an unexpected fashion. They frequently giggle. Why? Because of the
extreme embarrassment.
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Severe Pain is Humiliating, Especially in the Present
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The physician really matters to the Central Pain patient. The examiner
must imagine him at a social event which really matters to him, and at which his escort
expects him to behave in a socially acceptable fashion. In his pants are scorpions and
spiders stinging him continually as he attempts to make meaningful conversation. The crook
has stolen goods hidden at his feet and his pants are on fire as he talks to the
policeman, trying to pretend nothing is wrong. Are these not scripts for humor? The
behavior of the severe pain patient may therefore be withdrawn, talkative, silly, or even
patronizing, because severe pain is humiliating.
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Nature Hands Central Pain Patients a Tragedy Every Day
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Central Pain patients are like the torture victim. They become defeated,
dehumanized, and broken by the unremitting agony. They may well not wish to rehearse their
fear, their loss of humanity, their concessions to the pain, the self-loathing. This
aspect of chronic torture must be remembered, and proper, sensitive cues must be given by
the examiner before an open response can reasonably be expected. The patient will often
have been disbelieved and have no desire to add the humiliation of rejection to the
humiliation of her severe pain. Thus, clinicians must have educated minds. Particularly
the eyes, the "great monopolists of the senses", must be schooled, and
sometimes, overruled. As Mark Twain stated it, "You can't trust your eyes, if
your imagination is out of focus".
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Miss Manners Is Not a Good Physician
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Not uncommonly, a physician encounters a patient with injury to the spinal
medulla (cord) or other nerve structure, which confers a light burning, something like a
sunburn. It causes moderate to moderately severe distress. Patients commonly flex their
willpower and derive pride in their ability to "tough out" the pain or to ignore
it. Those relating to the patient may praise them for "never complaining", or
"for not burdening others". These compliments are well deserved and such
behavior adorns what we find noble in mankind. However, this posture will prevent any
understanding of Central Pain. The physician should avoid adopting the attitude of a
"Miss Manners" and should not chide the patient for telling the truth. The
presence of fully developed Central Pain should always signal that the patient needs
immediate help. They should be encouraged to communicate fully and openly in order that
saving assistance may be rendered.
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The Natural History of Telling Others About Central Pain
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Clinics capable of diagnosing Central Pain tend to be confined to large,
urban centers. It is rare enough that the condition is seldom recognized outside pain
centers. A patient fortunate enough to have been diagnosed correctly by a pain specialist
still has the problem of returning home and trying to explain to her family why she is
unable to function. If her husband speaks to a local physician, who manages to find a
brief reference to the disease in a text, the wording will often describe a potpourri of
everything from mild tingling to real pain. More often than not, back will come the
exhortation that the wife will just have to learn to live with the pain and the best way
is to deal is to learn to "ignore it". (After all, don't we all have to live
with our aches and pains?) The husband becomes even more cynical toward his wife's
desperate pleadings for help. The wife knows she cannot function--her husband tells her
she must live normally, and has the doctor to back him. How many really sick people can
withstand this pressure?
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The Harm A Little Knowledge Can Do
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The brutalization that this process causes is a not uncommon precipitator
of divorce, destruction of family, and suicide. First she loses her feeling of pain-free
existence, then her self identity, then the support of her doctor, then the love of her
husband, then her family, then her life. If the husband believes her, he must make
tremendous adjustments, as must the entire family to accommodate any brain injured person.
Central Pain patients have sensations of torture which are neurologically identical to
the real thing. They simply lack the destruction of flesh. They may not desire deliverance
from death, they may desire the deliverance of death. Ignorance
can make physicians callused in such a way as to add, rather than detract from the plight
of the unfortunate.
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The Brain Systems By Which Humans "Deal" With Pain Are
Disabled In Central Pain
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The patient needs compassion. She needs her physician to understand that a
diseased nervous system is capable of duplicating the sensation of tissue destruction,
even if the problem is in the nerve and not in the body part. The patient needs no
self-congratulatory examples of how the lecturer, or someone they have read about, has
endured pain. Central Pain is well beyond normal pain. The brain mechanisms by which
humans "deal" with normal pain have been disabled. Therefore, Central Pain
cannot be "dealt with", it can only be "endured".
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The Blood/Brain Barrier to Understanding
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There is a tendency to say that Central Pain is indescribable, to
put that in the hip pocket, and walk away. This overlooks the fact that patients can tell
us a great deal about the behavior of ineffable pains. They can convey sufficient
information to permit rational categorization of the cases. Treatment
regimens should be tested against specifics, not against a term, "Central Pain".
Before rational therapies can be developed and compared for any disorder, criteria for the
condition must be delineated to make sure apples are not being compared to oranges.
Normally, the starting point for categorizing pain disease is the patient's symptoms.
Ironically, in Central Pain, this is the last place anyone would attempt to categorize
Central Pain. The reason is that the pain is "indescribable".
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How Will You Know If You've Helped Me
If You Don't Know What's Wrong?
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The result of a lack of vocabulary has been the introduction into the
literature of therapies, including very serious brain surgery, which are not tied to any
qualitative symptoms whatever. Central Pain has many manifestations. Therapeutic
treatments should distinguish symptoms and indicate which specific manifestations
have been helped and which have not. Reports which treat the pain as a binary switch
(on/off) rather than the elaborate combination of events which it is, paint with too broad
a brush. Clinicians in every specialty learn to diagnose by subtle differences in patient
responses to careful questioning. This article urges a similar approach in Central Pain. These
patients constitute living laboratories of pain and have much to say. One must simply
listen much more closely, or as Einstein said, we must become "more curious".
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Disclaimer:
All material on PainOnline is strictly the opinion of the
authors of the material on this Web site. PainOnline does not attempt to
offer medical advice. If you have concerns about your health, please see a
qualified health care provider.Copyright © 2001 by David Berg
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