Ever wonder why what should be rewarding, ie light touch, is hugely punishing in central pain? What is regulating reward and punishment. What is in control of aversive learning. More on Witting et al in Pain. 2006 Jan;120(1-2):145-54.
Some have spoken of the Holy Grail of Central Pain as anything objective which would let the medical world know that those with CP are not only NOT faking, but are dying of pain.
The hammering and battering and accusatorial challenge by doctors against those with central pain reflects several things: stupidity in questioning patients; the unavailability of a vocabulary for the sensations of the central pains; the invisibility of chemical reactions at the synapse; and the assumption that any physical discomfort MUST conform to the pain which normal people feel.
In other words, it derives from pseudo-religious notions about pain and suffering, which have always evoked the most profound questions about religion. Pain has paradoxically been at the central nexus of most religious idea. It is one of those complicated things mankind slips into their hip pocket with the assumption it is well in hand, when it is among the most incomprehensible. When medicine, however detached scientifically it imagines itself to be, considers pain, it does so in the religious context of the topic. In other words, it is God or Nature’s will so the patient should just endure. Cures should go to something like diabetes, not pain, it seems.
It does not seem to register that this is directly contra to the very heart of medicine and the Hippocratic Oath, which is to “relieve suffering” and to “see that your patient suffers no injustice”. What could be more unjust than to greet a patient with severe central pain, and then cut them apart as a malingerer, exaggerator, and making a big deal out of nothing (or at least nothing more severe than the doctor has experienced–on that count we would be glad to pay for the capsaicin so they could speak with real authority. Severe pain is as far from nothing as one can get.
That most CP patients have severe spinal injuries and if they wanted attention could focus on that, does not seem to register. What does it say when someone who is paralyzed is MORE concerned about their pain? Pain makes a perpetrator of injustice out of too many doctors, who fail to read the literature, do not understand the chemistry of hypersensitization and vainly imagine that their own root canal, which they bravely endured, is about as bad as pain gets. Such an attitude will cut the heart out of the severe CP patient, who forgoes talking about the problems of being paralyzed, forks out a very large amount of cash (which they probably do not have) in the hopes of relief of the terrible burning. This is a moment of shame for medicine.
On the other hand, CP patients do an abysmal job of explaning the multiple components of their unique pain, so that the physician can tell whether the sensation is neuropathic, mechanical, or somatic. It does absolutely no good and greatly confuses the issue to speak of such things as “neuropain”. That word would have to have a prefix to mean anything, such as “John Brown’s neuropain”, and then it still wouldn’t mean anything. Patients must discipline themselves to recite which central pain they are speaking of (burning spontaneous or evoked burning, muscle pain, pins and needles, bladder or bowel pain, lancinating pain etc.). Until diagnosed by a true expert, a patient should not assume that their pain IS neuropathic nor that it is NOT. If we are to get at the heart of things on PET scans, the patient MUST learn to be specific.
The real Holy Grail would be something to cure CP, but we chose this title to empahasize that the CAUSE has not yet been discovered. Six months ago, we would have declared that the artifact was well in hand. There was very strong evidence that the painfulness of pain was mediated by the insular cortex. Frankly, this discovery was revolutionary. It is still likely to be true, since there is now evidence that central pain is more a matter of cortico-cortico communication than it is thalamo-cortical. (see below)
Dr. Francis Crick
