PainOnline.com

Some articles have appeared in print interpreting helpfulness by spouses as contributing to “exaggeration” by CP patients. Of course, to those of us with CP, this just shows that CP patients are willing to try to penetrate the vocabulary barrier if the spouse seems willing to listen. We may appear to be joking here as we assault the colossal humbug of the “helpful spouse” but we are actually very saddened by the false notions appearing in the literature.

Impotence at treating pain weighs in the millions of pounds per square inch on the minds of doctors in a pain clinic. They are sometimes driven to a type of defensiveness which leads to an accusation of weakness in the patient, which is most unfortunate.

I. IT SHOULD BE BORN IN MIND, THAT ALL MATERIALS ON PSYCHOLOGICAL EFFECTS OF SEVERE PAIN ARE FOOTED ON THE DISMAL FACT THAT WE DO NOT HAVE A SATISFACTORY TREATMENT FOR CENTRAL PAIN. ALL COMMENTS FLOW FROM THE ABSENCE OF A CURE. (If there is no stress, there is no psychology).

II. OBSERVATIONS ON PAIN BEHAVIOR WOULD NOT EXIST, AT ALL, IF DOCTORS COULD ACTUALLY TREAT PAIN OF CENTRAL ORIGIN. ONLY IN THE ABSENCE OF A CURE DO COMMENTS ON PATIENT BEHAVIOR WITH RESPECT TO CP ARISE. THEREFORE THE CENTRAL PROBLEM IS THAT THERE IS “NO CURE”, NOT HOW PATIENTS OR THEIR SPOUSES, REACT TO THE REALITY OF THE ABSENCE OF A CURE.

III. IT IS NOT PAIN TREATMENT TO MAKE GUESSES ABOUT WHETHER SOMEONE IS EXAGGERATING CP, AND IF TREATMENT IS INVOLVED, THE DOCTOR IS BY DEFINITION “TREATING” PERSONALITY, NOT PAIN. IT WOULD THEREFORE BE MORE HONEST TO LABEL THE CLINIC AS A PERSONALITY CLINIC, JUST SO EVERYONE IS CLEAR ABOUT WHAT IS GOING ON. (Likewise, we think any articles should appear in a journal addressing personality.
______________

Now we go to another place and time:

Conversation from the Salem, Massachusetts Pain Clinic, 1636 A.D.

“What is your job?”

“My job is to spot exaggeration in the most severe pain state known to man, Central Pain.”

“Hmm. Sounds difficult. If everyone is in extreme pain, how do you spot the exaggerator? I mean, isn’t that like looking at the deep end of the pool for those kids going under for the third time, to spot those who will actually drown?”

“You see, that is the beauty of it. You just look for a supportive spouse or parent. Then you can spot the exaggerator every time.”

“Perhaps you should see a psychiatrist.”

“Sir. I AM a psychiatrist!”

“Does that mean you think CP is psychiatric? How come the rats given CP chew off their legs. Is that psychiatric?”

“Psychiatrists don’t need lab animals. We know what we see.”

“What about Pavlov’s dogs?”

“We don’t treat dogs, We treat humans”

“You treat by accusing helpful family of being a cause of CP?”

“Those heinous wives and mothers DO make CP worse.”

“How could they? I thought CP was caused by upregulation of the Nav1.3 ion channels and the loss of the chloride carrier, reversing the effect of GABA inhibition.”

“Sir, we aren’t TALKING about neurochemistry”

“Then why talk at all?”
_____________

The Mongol hordes of outdated pain ideas seem to be overrunning the land again. The Great Khan has a white coat on and is circulating around in the pain clinics, chanting platitudes like some mystic out of the East, and getting paid pretty well for it, with none of those irritating, after hours calls. He has a following, and we can expect some more articles in the future.

We realize it is with the greatest daring that we challenge anything in print, but then, some things are so easily punctured, it is too hard to resist the temptation. Which brings us to the myth of the “helpful spouse”, who supposedly engenders such astonishing wickedness as the exaggeration of pain in a loved one (by comparison, the ignoring of pain, and the failure to relieve it are not being mentioned in these articles, but then the docs would be protesting themselves instead of helpful family members).

We are not qualified to respond to any characterizations of pain patients as pertains to low back pain, arthritis, etc. We are only expert on Central Pain, and very much regret the fact that we actually know what we know, AND that some doctors who obviously do NOT know, do not know that they do NOT know. Whew!

What is really troubling from a scientific point of view about these opinion pieces on pain exaggeration is the utter lack of quantification. It is as if a group of novelists are trying to write scientific papers. Take for example, the term “exaggeration”.

“Ideas must be distinct before reason can act upon them.” (Thos. Jefferson) And no one could possibly derive a distinct idea, even in the remotest sense, of what the authors mean by “exaggeration”. Is it exaggeration in one of the symptoms, the extent of body surface covered, the evoking stimuli, or in the impact on the mind, which is under discussion? Or is it that the psychiatrists object to the vocalization of pain, which is something else entirely. Do they even know themselves?

Each of these areas have many aspects, but the blanket attack on exaggeration seems as vague as some of Torguemada’s accusations during the Spanish Inquisition. It is sort of like being given a ticket for “bad citizenship”. CP is the big time–not a regression to elementary school. In the pain world, you don’t get to use the word “pain” without a context because the essence of pain clinics is that they are supposed to be a little more sophisticated than vague generalizations. They don’t get to give a lousy medical history just because “they don’t get it”. It sounds more like a taunt on the playground that groups might hurl at each other without getting very specific. “You guys are exaggerators” “No, YOU are big fat exaggerators”. Exaggerators of WHAT???

Exaggeration COULD refer to the sensations or components. In this case, any attempt to clarify should include information on what it is which is being exaggerated. If it refers to the perception of pain, then the authors must explain whether the person was exaggerating the pain of light touch, the muscle dysesthesia, the hyperpathia, the allodynia, the lancinating pains, the pins and needles, the visceral overfulness, the working memory loss, or what? Since most patients do not have all of these Wall/McHenry components then the author MUST specify which were present and in what proportion among the exaggerators. Perhaps a patient was exaggerating in having a symptom when they did not, in which case the doctor must explain how the fabrication was detected; or for example, how the symptom claimed varied from the actual way it presents in CP.

The very nature of exaggeration requires that the author explain what experimental technique was used to determine whether any of the components was being exaggerated. For example, ambient room temperature affects about half of CP patients, evoking greater pain, so the ambient temperature must have been controlled, as well as the amount of clothing etc. to quantify exaggeration. Correct scientific method should have explained how each of the variables in each of the Wall/McHenry components were controlled for.

The distribution of the exaggeration must be described, such as whether the patient was exaggerating the symptoms on the distal extremity or on the proximal trunk. Tests such as those used by Gonzales at Mayo Clinic to detect tactile phantoms could also have been run to see if some sort of calibration of the disease could be made against which one might measure the claimed severity of symptoms.

Perhaps the authors were not interested in the severity of symptoms but only the severity of change in affect in patients, without regard for severity of symptoms. This makes no sense whatsoever since if the impact on affect matches the severity of symptoms then there could be no claim of exaggeration. Since affect can be manifest as anger, depression, acting out, verbalization, withdrawal, or by many other means, the authors should at the very least have indicated WHICH of these reactions had changed and which had been used as a measure for testing exaggeration.

The fact that NONE of the above structures and controls were included in the ariticle reveals that it was not a research paper at all. It was an opinion piece, and scientists give little heed to opinion pieces. They are much like facts as letters to the editor are like the front page of the newspaper.

IN FACT, WRITING SUCH AN OPINION PIECE AS IF IT WERE A RESEARCH PAPER IS THE GREATEST EXAGGERATION OF ALL!!! If they were looking for exaggeration, it was certainly something with which the authors had a great deal of personal experience and personal involvement.

The latest, neo-Medieval ideas on pain seem to come in a politically correct form of bias, as befits the times. No one is “retarded” in today’s language, they are “mentally challenged”. No CP patient is therefore “malingering” today, they are merely “exaggerating”. This reminds one of the absolute rule that one never uses the word “lying” so today’s lawyers accuse other parties of dirty rotten “lack of candor”. See how much nicer that is than calling someone a liar.

However, we know a slap in the face when we see one. Just as one legal party who understands what the other side means when they allege “lack of candor”, we get the message when we are accused of “exaggerating” and we resent it terribly. We wish we were well enough to think clearly in a one on one conversation, to respond. We are NOT that well. It is just one more in a long line of degrading comments that we are somewhat unable to defend ourselves against. The playground bully will have his way once again, because we are really, really sick.

The institutions which permit their doctors to publish this kind of prejudicial abuse and inflict it on patients, should have a sign out front to alert any would-be CP patients what to expect. We would anticipate the clientele would turn around and leave. The myth of the “exaggerator” effect of a helpful spouse is not medicine, nor is it science. It is raw ignorance.

The greeting sign might read thus:

“If you have CP, you can come here and lay out several thousand dollars, but before you even get started, we know that your kind are exaggerators!!!” As Mark Twain said, “There are many humorous things in the world, among them is one person’s notion that he is less savage than other savages”. Similarly, the claims by doctors who have no measuring device for pain that a patient is exaggerating, are quite exaggerated.

There is no middle ground for severe CP patients, nor these authors. We either exist or we do not. We are either desperately ill, trying not to think of suicide; or, we are on the level of the person who claims to be a poached egg. Normal people don’t go around claiming they cannot stand the touch of clothing, cannot stand the sensation of their bowels filling, and cannot stand the agony of movement much longer. They also do not devote hard earned dollars to pain workups as a ruse. We are either exaggerating and need counseling; or, this minority of truly blind psychiatrists are out of their freaking minds and should consider counseling themselves.

Some things are not especially capable of being exaggerated. Take, for example, the color red. What if some PhD in art were to claim he had examined certain tubes of red oils, and found that the color red was exaggerated. We would think he was loco. There is ‘red’, and there is ‘not red’, but how do you exaggerate red? In the pain world, however, he would merely be displaying astuteness, supposedly. Central Pain is not Central Pain, it is an exaggeration. Of course, you can’t diagnose Central Pain without these pains being present, so the circularity in the whole thing is evident.

We like “multidisciplinary” pain clinics, but we dislike anyone adding themselves to the number to be paid by us unless they actually represent a discipline, and where is the “discipline” in being accusatory? We are starting to wonder if the “multidiscipline” should refer to the several types of discipline which ought to be inflicted upon the doctors who would embrace or originate two-bit philosophies, as if they were pronouncing some truth as a proprietary possession; not helpful, and reminiscent of shamanism. We have seen this sort of humbug elsewhere in the world. Maybe they should take off the white coats and put on some feathers, a cape of animal skins, drape leather bags of secret concoctions to their belts, with a couple of handpainted rattles thrown in, and tell us which spirits we have offended.

Blaming the patient is a cheap substitute for not reading the neurochemistry literature. One simply sniffs around among the entrails of the pain patient for a while and then in a deft move of psychic surgery, pulls out a briefly glimpsed, ill-formed “THING” which is declared to be “exaggeration”. No need to look closely. I have told you what it is, and may heaven help you if you dispute with me. I am a DOCTOR, and you have no idea how “weak” CP patients are (or how nutty namecallers can be).

We know we are weak. That is why we are there seeking help. We are absolutely devastated. But how does their pointing out the obvious, benefit us? And could I have another look at that “exaggeration” thing. It looked and felt a lot like Central Pain, and I don’t think you removed it at all.

The average person knows as much about how medicine really works as they do about the ritual rites of some ancient cannibalistic tribe and the voodoo which drives them.

Most psychiatrists at these clinics believe in helping us, not condemning us. My own pain psychiatrist, thank goodness, tried to get in and wrestle the pain with me. It felt like help, and it WAS help. Where did this recent absolutism and positivism in these few, critical pain psychiatrists come from? NOT from mainstream psychiatry, it would seem. Maybe it is a last ditch effort to maintain Freudian certainty in a morass of insecurity creeping in upon the profession. So volatile has brain chemistry made matters, that the psychology graduate may be assured of backing from the institution which trained him, but from nowhere else.

Because of advances in brain science, it is odd that dogmatically entrenched pain psychiatrists chain themselves to the altar of pain mythology, hanging on for dear life, when outside this area, psychiatrists have never been more humble about the standard diagnoses, like schizophrenia or depression because the PET scan and the functional MRI have identified organic causes for many mental illnesses, meaning they aren’t mental at all, they are chemical/anatomical. Not being able to do much patch clamping or other neurochemistry, most psychiatrists we know have become a bit thoughtful about the whole affair.

Brilliant psychiatrists such as Peter D. Kramer (who has corresponded briefly) are careful about even offering ADVICE (let alone condemnation) to patients, regardless of the diagnosis, because it is so easy to go wrong on the treatment. Kramer’s book, “Should You Leave” (a follow-up to “Listening to Prozac) is perhaps the most brilliant and the most cautious psychiatric book ever written, and is essentially an entire essay on whether a psychiatrist should EVER offer ADVICE, or should merely guide the patient to accessing parts of their own thinking where a solution is best found. Psychiatry is moving toward a specialty which can deal with uncertainty, but still aid the patient, It is a brave new world of neurochemistry. But meanwhile back in the pain clinics, it is apparently a brave OLD world of intuition and guessing.

Of course, Freud killed himself over pain in his jaw, but then maybe he was exaggerating.

Kramer’s descriptions of the state of the art in psychiatry are both touching and awesome for the depth of thought. And so we hoped he, or someone, might take a look at ineffable pain and offer a few tips to the damned. Dr. Kramer is in the middle of a book and declined the request to write something currently on pain, but left the possibility open in the future.

There is a temptation to review the arrogant rudeness and invite certain people to crawl back under the rock from which they emerged. What can be done to redeem them from anointing themselves with the awesome power of judge and jury.

We wish to baptize them into the Church of Capsaicin*, which will save their souls from the errant philosophies they heap on the heads of their helpless, captive patients. We hold our capsaicin services in Pain World, a branch of Reality World. There is nothing like a crash course in pain neurotransmission provided by Substance P (released by Capsaicin), your guide and medium to inner knowledge. Total immersion would be best, but even sprinkling can be enlightening. Can I see your capsaicin syringe please? Oh, not a full syringe–that’s perfectly okay, even a little will get the message across to you. Right this way to the NMDA tram where we will tour Pain World and you can go home and tell your friends how remarkable it was. Please fasten your seat belt and remember, it locks. Feel free to touch the animals because you are about to become one yourself. Don’t worry. Your own ride will be over in 30 minutes, but those agonized patients who wander freely here in the Pain Park are here for life. They make their own Substance P, their own Nav1.3 ion channels, and none of them have KCC2 any longer, so even pain inhibition is turned into pain excitation. Sounds remarkably like hell, doesn’t it. But then, hell is a core subject for students of the gospel of Pain.

One has to wonder if these people have learned anything recently from the revolutionary articles which have been published which finally show to the naked eye the dramatic immunofluorescent images by Bryan Hains, et al, which show even to the skeptic that CP patients are literally peppered with Nav1.3 ion channels, the membrane switches that upgrade a nerve cell into an engine of pain.

Because the chemical alterations in animal models of Central pain are so multitudinous, and it is clear that the Ph’D’s threading out the derailing of nerve transmission are wrestling with complicated algorhythms of chemical cascades which have gone wrong, one would think pain would have finally been elevated to the status of a disease, like any other disease. Unfortunately this is not the case. It is not actually us who have singled out pain as the one disease to be discussed in theological terms, it is the amateur Priests aka critical pain psychiatrists, who attend us. They will soon be back to trephining, opening little holes in the skull to let out the evil spirits. Wow, what great scientists they are to see all the theology in CP, but to utterly refuse to countenance it in say, gall bladder disease or gout.

Astonishingly, more than one author has now gone back to witch hunting amongst the neuropathic sufferers. Certain marks in the flesh of the patients somehow must appear before the eyes of the skeptical examiner which identify the exaggerating CP patient. We thought their disease was at the microscopic level, but these critical psychiatrists have superhuman powers of vision, it would appear. How else could they tell precisely who has the most Nav1.3 channels and who does not.

These “marks” just happen to be identical to the marks of malingering in back pain, etc., which supposedly differs but little from severe CP. This sort of CP bashing should come to an end. Pain clinics have a DUTY to correct this.

We would like to bid farewell to those, who have “discovered” that this exaggerating is going on, based on what they see “in their mind’s eye”. “Hit the road Jack, and don’t you come back no more.” We especially find it sophomorish that it should now be published in any journals as a warning to any who might assume that someone willing to spend hard cash at a clinic is a closet exaggerator, nevertheless. There the patients sit stupidly on the exam table, according to these authors, deceiving everyone, including themselves that they are in pain. You can never be too paranoid, it would seem. Exaggerators are everywhere.

We read the articles as saying, “Bow your heads, and congratulate us for ‘discovering’ that many pain patients exaggerate their pain. What qualifies us for this task is NOT that we have discovered any way to MEASURE pain, nor are we able to differentiate pain, and must rely on the patients words to know if they even HAVE pain, but from the way they talk about it, we have formed the ability to uniquely determine if they are telling the truth; and, having determined they are not, through NO OBJECTIVE MEANS, we feel justified in rejecting their behavior and the behavior of any who might attempt to be sympathetic.”

At first, we think these authors have to be kidding, but then we realize they think they have seen inside the CP patient, and also have developed some ability in themselves which “only those who are fit for their station” can see, to measure pain by gut instinct. However, from our vantage point, the emperor is looking kind of naked. We have seen movies of the flying monks, and bulletproof martial arts heroes, but we take this “ability to see exaggeration” as far more fictitious.

Basically, the old ideas on pain run something like this.

1) Pain is all of a kind.
2) The Doctor has had pain
3) Pain is part of life
4) Anyone who fights too hard against life is a fool
5) Gullible bleeding hearts often can be found surrounding pain patients
6) In our expert way, we doctors intend to stop excessive indulgence and coddling of pain patients as is our duty.

Do you believe these statements logically?

You can’t travel very far on these statements since they fly in the face of logic. Even the schizophrenics are getting a break now, what with the discovery of abnormalities in the hippocampus and elsewhere in the brain. Their mothers are no longer having their feet held to the fire for having “raised” a schizophrenic. No, the ability to visualize the changes in the brain on PET scans have gotten the mothers off the hook and now we have something rational to study. The mother accusers lost that fight bigtime but they are back! They cannot help their CP patients, so they have chosen to devour them instead.

They are launching forth with declarations that CP isn’t THAT BAD. How this was determined is never mentioned. Trust them. Disregard the glaring lack of double blinding in their studies as they come into the room. They have medical degrees and their words are down in print.

The most important thing to establish before an author begins to accuse a person of exaggerating is the baseline for evaluation. Exaggeration is always relative to something. The word means to “overstate” but if we do not know the baseline, we can’t really logically use the word exaggerate. If something is too tall, too high, too big, or too anything, what is the standard and how do we measure it. If we cannot, then maybe our effort should begin at finding a standard of comparision.

If I say I am six feet tall, and someone says I am exaggerating, they should have some idea of what 5 feet 11 inches is like. Therefore, we ask, what unit of pain measurement are these authors using, in order to declare we are exaggerating. Just as pH is the negative log of the hydrogen ion concentration, maybe pain level should be the negative log of the Nav1.3 ion channel concentration in the dorsal horn or the dorsal root ganglion. Without a unit, you can’t make a measurement, and without a measurement, you are out of order to speak of exaggeration.

The problem of course, is that these authors are using no unit at all. They are viewing pain as a unity, a singularity. They supposedly need not measure it to determine if someone is exaggerating, since all people with pain should act a specific way and any deviation is therefore exaggeration. My, how scientific! Perhaps this data could be spoken from the back of a covered wagon in a West Kansas wheat field, but what is it doing in a major, peer-reviewed journal???

Even little old me can tell the difference between the pain of a shower turned too hot and being immersed in gasoline and ignited. (The size of the flames is usually a good clue). However, these visionary authors feel no need to measure the Nav1.3 increase, the KCC2 decrease, or anything else. Instead, they view the degree of pain itself as standard, the bedrock, one-size-fits-all, exactly equivalent, standard and the degree of behavior following it can therefore be used as the measure of exaggeration. This is a case of getting the cart before the horse, of mistaking the result for the cause. Nice try boys, but you probably couldn’t locate a case of severe CP with both hands in bright daylight unless the patient told you of it, so you better listen to the rest of what they have to say. You believe they have pain sufficient to justify a visit to your clinic, but it is just too much of a reach to accept the fact that it really, really hurts. If it did, that would make you really, really impotent when you can’t treat it.

Without a baseline comparator, a patient might be exaggerating, understating, or he might just as easily be bullseyeing it with laser accuracy, and we would have no way of knowing which. In fact, it is EXAGGERATING to claim that one has the ability to discern what cannot be measured. So who is doing the exaggerating now, the doctor or the patient???

It is not that objective criteria could not be conceived. For example, someone undertaking to write an exaggeration article might quantify the percentage of body surface involved in the burning from light touch: or, the number of CP components present might be used as a scale. The patient might be asked to compare their CP with suffering which is familiar to other humans. Unfortunately none of this is done prior to laying down the big exaggeration claim.

Some authors, who are notable for their presumption, have begun to identify those who are “exaggerating” their CP and claim to be able to make this call without any objective findings, without any rational grouping, and without any comparative criteria such as is mentioned in the previous paragraph. We even have the “astounding” discoveries that the exaggerators have helpful, attentive mates or family, which probably makes the “exaggeration” greater. My, my, how those supportive family members do cause harm!

Examined from another viewpoint however, if a person WERE suffering terrible agony, and felt the family just didn’t get it, and the family was asking more than the CP person could do, would not the pain clinic be a place where the patient might attempt to get things out in the open? How would this activity be seen by a skeptical observer?

With this in mind, some new axioms are suggested that might put a stop to the nonsense of “reporting” what cannot be meaured. In other words, we need more science, and fewer opinion pieces and we need the journals to point it out when they decide to publish an opinion piece.

1. Central Pain is NOT like other pain. That is one of the basic diagnostic points
2. All who have Central Pain agree they cannot describe it.
3. Davidoff and others have shown that CP patients find it more disabling than paralysis.
4. Women who have given birth describe it as more severe than labor pains (AND, unlike labor, it never stops).
5. CP patients are the ONLY non-cancer pain patients in today’s world willing to line up for brain surgery in the hopes of some improvement. Does this willingness for have brain parts removed confirm or render preposterous the ‘perception’ that exaggeration is common in CP?
6. CP patients have NEVER been shown to come from any group that had any unusual characteristics or personality problems BEFORE the onset of Central Pain. This suggests they would not be likely to exaggerate AFTER CP occurred.
7. As early as S. Weir Mitchell in 1876, pain of central origin has been declared likely to give even the “bravest soldier the temperament of the most nervous girl”. This was different from nociceptive pain, which did NOT change the personality; however ghastly the wound.

Therefore what is observed in low back pain does NOT apply to CP. CP involves extensive brain dysfunction in the thalamus, lateral capsular nucleus of the cingulum, and the frontal cortex.

8. No one can tell if another is exaggerating if they have no way to compare it to a known entity, such as how a normal person would react to such a level of pain.

9. Those with the strongest emotional reaction, what is seen as exaggeration, may simply be those with THE GREATEST PAIN.

10. Means now exist to gain some objective measure of the degree of Central Pain (some are suggested above) and should be used BEFORE deciding if someone might be exaggerating. Other simple groupings might be the elaboration of the number of pain components which are present, and a description of the severity of each.

How is it possible patients were not subdivided into groups with differing percentages of the body surface in pain? Even burn patients are afforded this delineation. I know CP patients with pain in one finger only (with total numbness everywhere else) and I know others with pain in the entire body, the oral cavity, the nasal sinuses, all hollow organs of the abdomen, and throughout the dura surrounding the brain, (from injury to the quintothalamic tract). These patients are NOT equivalent and should NOT be grouped together in a blanket statement about exaggeration. Without the grouping, the totally injured person would be seen as an exaggerator and the one with CP in the finger would be seen as well adjusted.

In addition, tests should soon be available to determine the measure of increase in Nav1.3 ion channels or the decrease in KCC2 (chloride carrier) in a given person before deciding how severe their CP might be.
We would like to see psychological perjoratives and denunciations of efforts of helpful spouses, parents, and other concerned people ENDED where Central Pain is concerned, until the scientist has some means, however crude, of comparing or measuring the pain present before deciding, completely arbitrarily, who is EXAGGERATING.

Let the hunt for malingering be moved to an arena where people do not regularly take their own lives on account of the pain.

We also feel that no author should publish anything suggesting exaggeration until they have personally injected capsaicin* in a number of spots on their own bodies, simultaneously, in order to get a fix on what the commotion is all about in Central Pain. If they really believe in exaggeration, they could infuse capsaicin everywhere, by iontophoresis, in order to get even a clearer picture of who is exaggerating and who is not. I promise they will get an “exaggerated” pain response.

The exaggerator identifiers would also have to explain the very predictable creation of CP in rats by cord injury and explain how a rat is able to exaggerate by such acts as chewing off the affected limbs and other “subtle” hints that the rat is in agony. I have never done that at a pain clinic and therefore I should not be accused of exaggerating.

The Cotton Mather McCarthy’s of our day are loose in certain pain clinics. Exaggeration is easily spotted, they say. Just look for someone who “claims” to be in severe pain after injury to the central nervous system who has a supportive spouse, and your witch hunt is off and running.

As for the exaggeration police, we suggest you send secret agents among us to ferret out the exaggerators. Prime them with a good dose of capsaicin. No price would be too great to pay to expose those who evilly spend their money to come to you for help. Total body capsaicin is the best cover. Your agents will act so much like us as to be barely distinguishable. What a great way to insinuate yourselves into the inner workings of our society and add some authenticity to your study.

If Pat Wall were here, he would defend us. God rest his soul. We still have Jorgen Boivie and others. And last of all, we have those poor little rats, in whom CP has been induced, who are chewing their legs off in a vain attempt to escape it. Maybe the “exaggerator” identifying psychiatrists should spend a moment in the rat labs, seeing how easy it is to identify the CP rats. They might learn something. Exaggeration is a healthy thing. It means we are still interested in living.

*Capsaicin is extract of red peppers. Injection of a small amount under the skin yields a bit of allodynia, which informs interested researchers of what the bizarre pain of CP might feel like. It is not really a model of SEVERE CP, but it IS an eye opener, since it is very similar to the dull burning of dysesthesia. We haven’t heard any claims of exaggerating from those who have given capsaicin a try. They invariably say, “Wow, that really hurts”, but then, you never really know. Ever watch someone eat a hot red pepper on a dare and then see their eyes water as they grasp for a drink. Well, they might be exaggerating too. Let’s just hope there is no supportive spouse around to give them a second glass. That would really inflame the situation. Say, I just thought of a nice dinner to treat those psychiatrists to. All one dish.