One of these pains is not like the others.

“Lumpers” vs. “Splitters”. How far do we go in pain with putting everyone into the same category?

Wicksell, et al Eur J Pain. 2007 Sep 18, publishing on the idea that pain should be accepted rather than treated, seem to be focusing on minor pain syndromes that simply do not inform on the topic of central pain. We certainly hope we are not reading it correctly. In the era of functional MRI, it is too late in the day to pretend all pain can be lumped together under one psychological categorization, if that is what they are doing. If so, perhaps the idea could be extended to surgical pain and anesthesia be eliminated. If the authors have discovered some psychological way to “embrace” pain, perhaps they should put their skin where their mouth is. “Scalpel, please.”

When you are faced with pain which you are helpless to treat, and the white coat seems a little gray, why not save face and call the whole process psychological? Of course, for those willing to try to help shield patients from the ravages of severe pain, the white coat dazzles, even if the pain cannot be eliminated. We have never asked omnipotence of caregivers and we hope they do not ask it of us. Indifference to agonizing pain is certainly beyond the power of the human beings who experience it. Condescension by observers is not helpful, It is not possible to shame the CP sufferer out of his/her pain, although it would appear some are willing to try.

We are back into the thick of it, and the source is even more shocking. Karolinska in Sweden has long been spoken of almost in reverential tones by central pain patients, Zuszannah Weisenfeld-Halin and Jorgen Boivie are giants in the world of nerve injury pain, and we owe much to them, especially for developing early animal models of central pain. Particularly illuminating to the medical words was Boivie’s observation that paradoxically one must LOSE some sensation in order to become a candidate for MORE SEVERE pain.(Boivie’s Paradox). Dr. Pat Wall, one of the originators of painonline, paid tribute to Boivie on numerous occasions, including in the Textbook of Pain, which he coauthored with Ron Melzack. It has for years been the standard work on pain.

We feel like crying “Oh no!” It appears that once again, the reality of central pain is just too much for some normal individuals to swallow. As the work with functional MRI (fMRI) has matured, we had concluded, wrongly, that the reality of pain after brain/cord injury would no longer be questioned. We were wrong.

These authors from Children’s Hospital present a psychological test which they claim calls for a new way to look at pain. The idea appears to be that “traditional” ideas of pain “treatment” may have to give way to “acceptance and exposure” to pain.

What this seems to mean, at base, is that pain is often psychological, so treatment might better be aimed at teaching people to accept rather than treat pain.

This is, in our opinion, so preposterous with respect to central pain that we would not pay any attention, except that it is coming from Karolinska. The barbarian hordes seem to be winning and it is not because pain patients are decadent.

We see this as the reappearance of the blindness that led to serious books on pain making no mention of central pain at all, even after such greats as S. Weir Mitchell had done remarkable jobs of describing both the physical (Mitchell’s delay) and psychological (the temperament of the most nervous girl) aspects of central pain

An example of the omission of even a discussion of central pain can be seen in the tome, “Pain Syndromes” by Judovich and Bates {Univ. of Pa.) in 1949, which failed to even mention central pain, but did devote space to such things as pain in an old scar or pain after gall blacder removal, two entities which are not remotely in the same severity category with central pain.

Judovich was published TEN years after Riddoch was already describing central pain ih the Lancet as “a pain beyond pain”. The focus of Judovich on peripheral pain can be seen in the subtitle on the introductory page, “Treatment by Paravertebral Nerve Block”. If you can’t block it, why give it credibility? Hello! What if the pain is coming from the brain? Admittedly, including pain of central origin does mess up a textbook on pain treatment.

It is odd to go to a pain clinic and realize that most of the patients there regard their state as highly noteworthy, even if it is comparatively minor next to central pain. Rather than fitting central pain onto some Procrustes bed of minor pains, patient concern with minor pain informs us just how terrible central pain is. This tells us that even small amounts of pain are VERY distressing. What then about the most severe pain states?

No doubt when encountering the patient with low back pain (which will afflict something like 85% of Americans) it is easy to conclude that the patient must simply “deal with it” and “become one with the pain”, whatever that means. This idea has about as much to do with central pain as a rainstorm has to do with Hurricane Katrina. It is a mistake to lump low back patients with central pain patients. Yes, they both have pain, but NO, they are nothing alike.

Like other publications on the psychological origin of “all” pain, recent functional MRI research cannot be squared with the old idea that pain is psychological. Physicians should avoid generalizations which sweep all pain under one rug. To survive, central pain patients are desperately trying to avoid “cognitive fusion” with the pain, not seen in a true light if the doctor advocates exposure to the pain and “acceptance”. And pardon us for asking, but is “cognitive fusion” anything like Dr. Spock’s “mind meld”?

Once again, we see the value of the capsaicin test as reality check. Just a little under the skin here, and the authors of any article claiming all pain must be accepted will find that they cannot mentally eliminate it, even if the capsaicin is just in one little area, and only for a few minutes.

Genghis Khan was a person. You are a person. Therefore, what may be said with respect to Genghis Khan may be said of you. See the illogic!

Authors on pain should stop regarding anything which entails pain as identical to anything else in which pain is an issue. All patients with central pain lived normal lives before CP. They were not in a pain vacuum. They all experienced other pains such as childbirth, accidents, etc. We must take them at their word when they say that central pain is something else entirely. Don’t believe us? Hold still while we put just a little capsaicin* under the skin. There now, how does that feel? Have your psychological skills rendered that comfy?


*Capsaicin excites some of the same pain receptors, the TRPV-1 receptors, which are known to be hypersensitized in central pain.