When we have a sudden awareness, it has become fashionable to speak of it as an “epiphany”, which comes from the idea of speaking up, or clarification. CP doesn’t have any epiphanies because the wires are crossed. Read on.
There was my relative, speaking of some mundane thought he had once entertained, calling it an “epiphany”. He had just begun teaching at a local college, so I guessed academia had its privileges to speak in any trendy way it wants. The word “epiphany” is old, and in antiquity applied to something major, when the mind decided to really “speak up”. Now the term has been broadened considerably. An epiphany can be as trivial as realizing you like one brand of potato chips better than another.
Still, that is how we learn sometimes, as the result of little, crystallizing events. We suddenly notice something. On other occasions we simply climb up the plane of awareness and knowledge gradually, until we are educated in some area. Apparently, the more slowly you learn something, the less likely it is to qualify as an “epiphany”.
In like manner, Central Pain knowledge ought to come from our own bodies. Unfortunately, our bodies are untrustworthy in CP. Since we usually pay ourselves the “epiphany” compliment only when we learn something, we don’t really have a word for when we suddenly DIDN’T learn something.
“Epi” means “up” and “Ana” means “not”. If we stay consistent with the Greek, the word for suddenly “NOT learning something” would be “Anaphany”. You won’t hear that word, We don’t amaze ourselves with what we just didn’t learn. Only CP people have anaphanies, because CP will make you think one thing is happening while it is secretly doing something else.
CP will invent new pains, for which there is no name, to confuse you. Mix a little of this and a little of that, hook them up to the wrong input and, baby, you have no idea what is happening except that you are suffering. The wires are crossed, and some have been cut entirely. This is figurative talk, since we have already said the pain system is NOT line wired, it is made of sequences of chemical events. The injured cells quit making a molecule essential for an accurate signal (see “The Smoking Gun?”–this website) Something sabotaged your beautiful alarm system. Your doctor will not find this intriguing. You are speaking of his close friend in a disparaging way.
One medical area where people learn rapidly and accurately is pain. It is so helpful to the clinician because it makes him/her feel like a “real doc”. If he has learned to listen carefully, he will usually know what is wrong with the patient before any tests are run. This is part of the art of “clinical medicine”. It was pushed very hard by Sir William Osler, the great internist who laid down the law at Johns Hopkins. “If you listen to your patient closely enough, he will eventually tell you what is wrong with him”.
This is where pain comes in. What a performer. It is so precise, so intense, so clear, that even the worst patient historian on earth hands the clinician pearls of wisdom. The doctor is pleased to receive laser accurate descriptions of where the pain is, when it started, what makes it worse, what makes it better, etc. Pain reassures the intelligent doctor that he really is intelligent.
Physicians get spoiled by this, and proud. A gynecologist is likely to recognize endometriosis (Painful periods in young life, which improved after a year or so, then got worse again and crampy, and are now accompanied by increased flow–Bingo! The doctor is thinking endometriosis.) If there is also pain with defecation, he almost assuredly knows endometriosis is there. He will still do the laparoscopy, but the pain has sent him a message, and he pats himself on the back when the image of the lesions comes to his eyes through the scope. What a marvelous diagnostician he is. This is what pain does for the ego. The Doctor’s “ONE TRUE NORTH”.
EXCEPT in CENTRAL PAIN!. There, pain is maddening, and shows that the “Doctor has no clothes, he is a fraud!”. His old friend, his reliable hunting companion, his backup voice, his listening power, just deserted. In CP, the angel on the shoulder will desert the Doctor on his hunt, right when the bull elephant is bearing down on him and a backup shot is essential. The doctor will then find his gun is not loaded, and it is all so ugly and humiliating getting trampled and having his diagnostic skills smashed to bits by a pain disorder, of all things. Both the patient and the doctor have had a CP ANAPHANY. Words made things worse, instead of better.
THIS CAN’T BE PAIN, CAN IT! It is too treacherous and too misleading. Yet, all of this wonderment shows what a beautiful job the brain customarily does of integrating NORMAL pain. There is nothing else in the body like it. Nothing so clear and so easy to dimension. But what if the nerves that do the integrating and dimensioning become injured, what happens to the massively complex apparatus that shaped pain so clearly? In injury, its complexity becomes its Achilles heel. All those backup, refinement systems add to the confusion, not to the clarity.
The doctor will look amateurish, the patient will sound like he is lying, and there is nothing satisfying about any part of it to either of them. Once the doctor does stumble onto the correct diagnosis, there will be no satisfactory treatment, so the whole thing will leave a bad taste in the mouth. Give him a hot appendix anytime. (Pain in the midline, moving down over 12 hours to the right lower quadrant of the abdomen, pain at McBurney’s point–appendix) Pain to the right shoulder–gall bladder; Pain to the left shoulder–heart attack….what a great doctor and he owes it all to pain!
The sixty-four dollar question then is. If CP is so all fired bad, why in the heck can’t the patient give a better history for it and a clearer description. The answer is that by its nature, Central Pain is not clear at all. The parts where it hurts are usually unclear, the components of the pain are unclear, and why the patient is suffering practically to the point of madness is unclear. What is missing from this is the normal operation of the thalamus, the thing that makes sense of pain for us and does such a marvelous job.
Neurologists have noticed for years the oddest behavior if certain parts of the brain aren’t functioning correctly. Then, they must work from what is missing. For example, in the case where the person knows there is severe pain in the room, but does not know who has it, when it is, in fact, the patient himself, the doctor can then conclude there is probably something wrong in the cingulate gyrus.
Pain, being important to survival, is very well integrated. It is so well integrated that at first gloss it seems there is nothing to integrate. Feeling within himself this pure clarity, Descartes concluded pain was like pulling a rope to ring a bell for the servant sleeping on the floor above. “Bell rope” or “Line wired” as it was called. Except that is not how pain works at all. It works like it was designed by a committee, and that is not intended to be blasphemous.
Pain is reminiscent of the man who discovered quantum physics and announced he had discovered the universe was not arranged according to the principles of common logic.
Pain is the most complex operation of the brain. Admittedly, since no one knows how the brain really works, that statement cannot be refuted, but experts tell us this and we will not dispute it. Nevertheless, a large part of the brain is devoted to processing pain, and the chemical pathways are absolute nightmares of complexity. Why is all that gobbledegook necessary?–to perform a massive integration into one very clear signal about pain in a normal nervous system.
The many characteristics of pain are integrated so well by the thalamus that the signal seems as clear as Descartes’ bell, and the patient feels it. and for normal pain (nociception) permits the patient to give the doctor a laser accurate pain history. This spoils the doctor and he is unable to get used to nerve injury pain (neuropathic) which is more like listening to someone describe which of many foods affect digestive funciton in subtle and varied ways, usually unintelligible.
Significantly, it is this very characteristic of CP history, the patterned unusualness, which caused Dejerine to say the diagnosis was very easy. The patient did not lose touch entirely, it had become “uncertain”. The pain was not equal everywhere, it was worse at the “ends” of the nerve supply. Deep pressure did not cause pain but light touch did. Etc. Etc. Dejerine wrote famous books on hysteria, and knew it well in many forms, but he said there should be no problem in distinguishing CP from hysterical pain, because the history in CP was so unique. Easy for him to say.
Roussy agreed with him, saying if there is disturbance of “superficial sensibilities” (touch, temperature. pain). and “atopoesthesia” (loss of the ability to perceive in the mind the precise location of the skin surface or skin topography unless touched), and if the burning is “centripetal” (worse on the distal extremities), the patient has Central Pain. This was Roussy’s “three-legged stool” on which the diagnosis of Central Pain rested.
Even S. Weir Mitchell, back in 1876, had discovered touch pain is instantaneous in peripheral nerve injury, but in pain of central origin manifests a delay of twenty seconds or so before light touch elicits worsened pain. (Mitchell’s delay) He didn’t think CP was such a hard diagnosis either. The personality also changed and the “bravest officer would become as nervous as the most fragile girl”.
Another identifying feature is “BOIVIE’S PARADOX”. Stated simply, it means that “Paradoxically, one must LOSE some of one’s ability to feel pain in order to become a candidate for the development of SEVERE Central pain”. In practical terms, this is nothing more than Roussy’s “centripetal” pain, for it is on the distal extremities where touch sensation is most impaired, where CP will be also be the most severe. Sometimes the loss of sensation is subtle and requires the use of thin filaments, known as von Frey hairs, to detect that subtle loss, even though the burning there may be severe.
Less well worked out are the mental changes, such as lack of concentration and lack of working memory, but these are frequently present in CP. Not enough has been written about this, but the CP patient must cope with it nevertheless.
Of course, the story doesn’t stop with a diagnosis, however unique and easy it may be to make for the well informed. Few doctors today, even the experts, would argue with the statement of pain specialist, Richard Chapman, “CP can take many curious and dreadful forms, many or most of which go unrecognized for what they are. It can fool patients as well as providers
