The Pain Chronicles (22 page)

INTEGRATIVE AND DISINTEGRATIVE PAIN

“Pain upsets and destroys the nature of the person who feels it.” Aristotle’s epithet seems all too true: pain fills consciousness, blotting out the components of which the self is made. Yet such is pain’s peculiar relationship to meaning that this loss can take startlingly different—indeed, opposite—meanings.

Suffering is sometimes described as a state that poses a threat to identity. While some pain poses a grave threat, other pain paradoxically strengthens the sense of self. Chosen pain—the pain of childbirth, a tattoo, an athletic feat, an act of bravery on the battlefield—can be
integrative
, strengthening integrity. For religious devotees and participants in the mourning and coming-of-age rituals common to most cultures, pain’s dislocation of self is valued as a means of reshaping that self according to the religious ideals of the community. In a secular context, hazing rituals use pain to create “brothers” rather than discord. The pain of S and M fulfills deep erotic desires. The pain of self-mutilation may accomplish relief from a greater psychic pain or a sense of emptiness or numbness.

Chosen integrative pain differs profoundly from unchosen
disintegrative
pain: pain that cannot be reconciled with one’s sense of self, but undermines and destroys it, as the pain of surgery differs from the pain of disease, even when they result in the same tissue damage. The pain of surgery can be integrative because it furthers the goal of survival, whereas the pain of the progression of a disease brings us closer to the self’s dissolution. The pain of childbirth differs from the pain of miscarriage. Some women today elect to forgo anesthesia in childbirth and say that they are glad that they did.

“One word frees us of all the weight and pain of life: That word is love,” Sophocles wrote in the fifth century
B.C.E.
Sean Mackey, chief of the Pain Management Division at Stanford University and the director of Stanford’s Neuroscience and Pain Lab, recently showed that the pain of which Sophocles spoke can include physical pain. Dr. Mackey was struck by the parallels between the experience of early romantic love and the experience of addiction. Early romantic love involves overwhelming cravings for and emotional dependency on the beloved, obsessive thinking, a sense of energy, euphoria, and intensely focused attention, and piercing pangs of withdrawal. He wondered if both addiction to opioid painkillers and romantic love activate similar opioid brain systems. If so, does romantic love confer analgesia?

He and his colleagues recruited Stanford students who identified themselves as being in the first nine months of passionate romantic relationships. The students were asked to bring photographs of their beloved as well as of an equally attractive acquaintance. The students were then given a painfully hot stimulus while their brains were scanned and they were told to focus on a photograph of their lover or a photograph of their acquaintance. Love ameliorated the pain. When students were given a moderate-intensity pain stimulus, looking at a lover’s picture caused a 46 percent greater reduction in pain, as compared with looking at an acquaintance.

When competing with a high-intensity pain stimulus, however, love’s powers began to wane, reducing the students’ pain by only 13 percent. But the more passionately in love the students were, the more analgesic benefit they received. Students who said they spent more than half of the day thinking about their partners experienced more than three times the analgesic benefit than that of those who were less preoccupied with their partners. The imaging revealed that the photographs of their lovers activated brain regions involved with opioids as well as those involved with dopamine. (The dopamine regions are also activated in people with addictions.)

The study seems to raise the intriguing question of whether the effects of love could be nullified by giving the subject a drug that blocks opioids, such as the drug naloxone. Could naloxone be the romantic antidote that would close the wound of Cupid’s arrow—a condition whose pangs have tormented unrequited lovers from the beginning of time?

It is not only love, but community that balms pain. Researchers at Oxford University recently discovered that rowers who trained together were able to tolerate twice as much pain as rowers who trained alone. The rowers did a training session alone and a training session as a team; after each session their pain threshold was measured by seeing how long they could bear a blood pressure cuff squeezing on their arm. The men’s pain threshold generally increased after exercise, but it increased far more significantly after group training sessions than after single sessions, suggesting that for humans, it is not only running from a tiger that produces the flood of endorphins of descending analgesia, but also communal activities (a phenomenon that may shed light on the embrace of pain during religious rites).

In his book
Disease, Pain and Sacrifice
, the psychologist David Bakan refers to integrative pain as
telic centralizing
: pain that is interpreted as consistent with one’s
telos
or sense of purpose. Sacred pain is telic centralizing; secular pain is
telic decentralizing
. Torture maims the victim’s sense of self; thus “whoever was tortured, stays tortured” after wounds have healed, as Jean Améry wrote about his torture by the Nazis. The Nazis arrested and tortured him, hanging him by his arms, and then sent him to Auschwitz. He survived torture, but not the memory of it, and eventually he committed suicide.

Torture involves the deliberate creation of suffering, which may or may not involve physical pain. “Waterboarding”—favored by the Spanish Inquisition, the Khmer Rouge, and the Bush administration—simulates drowning in such a way that it creates the overreaching desperation to make the torture stop, which is torture’s hallmark. Confusion about the distinctions among tissue damage, pain, and suffering underlay the Justice Department’s argument that “the waterboard, which inflicts no pain or actual harm whatsoever, does not, in our view inflict ‘severe pain or suffering.’ ”

Rape is torture, even though it does not necessarily cause significant or enduring tissue damage. The torture of starvation only intermittently causes hunger pains. The torture of prolonged sleep deprivation or sensory deprivation (used by the British on IRA prisoners until the technique was outlawed) does not cause any tissue damage, but it can produce psychosis and long-term psychological damage. The forced lobotomies in the Soviet Union and America in the first half of the twentieth century involved little pain. And, of course, psychological tortures—such as the torture of knowing one’s loved ones are being tortured—require no physical pain at all.

Context stamps pain like a coin. Torture in one context may be part of an occasion for rejoicing in another. I heard a lecture on pain and suffering once in which the speaker showed a photograph of a Hindu devotee during the festival of Thaipusam with hooks in the flesh of his back connected to ropes that followers were
tugging on
, like the reins of a horse (a festival I would later witness). “You see, the man’s face is in repose,” the lecturer commented. “The piercing does not cause him suffering, because it strengthens, not weakens, his sense of himself and his bond with his community.” If the devotee is in pain, that pain is telic centralizing.

But for a Western person (like me) for whom pleasure and well-being are central, is physical pain inevitably disintegrative and telic decentralizing? Does faith play any role in shaping the experience of pain today?

THE RISKS OF RELIGIOUS BELIEF

In recent years, a number of studies have attempted to quantify the effects of religious belief on pain, health, disability, depression, and mortality in the context of chronic disease, with surprising results. A 2005 study led by Dr. M. Ojinga Harrison at Duke University Medical Center examined the role religion plays in modulating pain in African American patients with sickle-cell disease.

As a group, African Americans are strikingly religious: historically, the church has played a central role in helping its members cope with their plight, and a high proportion of African Americans continue to attend church and describe their faith as central to their lives. Sickle-cell disease has no cure. Despite recent advances, the lives of those afflicted by it are punctuated by disabling episodes of severe pain, lasting from a few hours to several days, which often require hospitalization and intravenous pain medications. But studies of sickle-cell disease have found that the frequency of pain crises is associated not with the severity of the disease but with the emotional state of the patient—with depression, anxiety, and other negative emotions correlated with greater pain. Those who attended church once or more per week were found to have both lower levels of psychiatric disturbance and the lowest scores on pain measures.

Larger studies have found that—for unclear reasons—people who attend religious services live longer and are generally healthier, less depressed, and less likely to be disabled. A famous nine-year analysis of more than twenty thousand adults in the United States, led by Robert A. Hummer at the University of Texas at Austin, found an astonishingly strong statistical correlation between churchgoing and mortality: Christians who attended church once a week lived an average of six years longer than nonattendees, while those who attended more than once a week lived an average of seven years longer. Even the timing of death seems to be influenced by religion: the devout are less likely to die before important religious holidays. African American Christians who attended church once a week lived eight years longer, while those who attended more than once a week lived fourteen years longer!

What about the devout who do not attend church? Curiously, “private religiosity” (prayer, Bible study, or self-described “intrinsic religiosity”) does not appear to yield any of the dramatic benefits of church attendance. Indeed, private religiosity turns out to be associated with both negative and positive health outcomes and both worsens and ameliorates pain and depression.

It appears that the concept of private religiosity is too broad and that, from a health perspective, there are helpful and harmful forms of faith. Some of the benefits of churchgoing are thought to stem from
cognitive reframing
—the ability to reinterpret pain and illness as potentially furthering spiritual health even while they threaten physical health. But while some people believe that illness draws them closer to God, others may interpret it as God’s punishment or abandonment, or they may begin to question God’s very existence.

An intriguing study published in 2005 in the
Journal of Behavioral Medicine
tried to distinguish “positive religious coping” (strengthening faith) from “negative religious coping” (struggling with faith), among 213 cancer patients with advanced multiple myeloma, at a particularly difficult juncture—shortly before undertaking a painful, debilitating, risky treatment regimen (high-dose chemotherapy and stem cell transplantation). The patients described themselves as having high levels of religious faith and relying heavily on their faith to cope with the crisis of their illness. But the study found that patients who employed “negative religious coping strategies” had significantly greater pain, depression, distress, and fatigue, while (in contrast to the findings of some other studies) positive religious coping yielded little to no benefit compared to those who were not religious.

Critically, however, it is not known whether religious conflict causes poor health outcomes, or whether poor health creates religious conflict. Or, perhaps, the two unhappily feed upon each other as pain and suffering create doubt, and doubt fosters further pain and suffering.

THE PHOENIX

If suffering occurs when there is a threat to the integrity of the person or a loss of a part of the person, then suffering will continue if the person cannot be made whole again,” writes Eric J. Cassell. Chronic pain poses a particular challenge, for “in acute illness the threat is perceived as distinct and limited, whereas in chronic illness the threat is ongoing, long-lasting, global (encompassing all aspects of the person’s life) and incapable of direct resolution.”

How can wholeness be restored?

“Most doctors are not up to the task of chronic pain,” John Keltner told me. Preparing himself for the task has been a process of extraordinary length—and one, in his mid-forties, in which Dr. Keltner is still immersed. Blessed with a patient wife, he began as a resident in anesthesia and pain medicine at the University of California at San Francisco (following a Ph.D. in physics), where he trained primarily in procedural pain interventions—injections and the like. Frustrated with their limitations, he decided to focus on trying to understand pain in the brain, and he moved his family to England to work on functional brain imaging at Oxford University. After two years, he decided he wanted to bring some of the academic insights into his practice, and (despite the lack of a trust fund to assist two decades of higher education and training) he embarked on another residency in psychiatry at the University of California, San Diego.

“You want to take advantage of all the physical tools that treat the body, but the part of pain pathology that continues to be less fully understood is the mindful part. Chronic pain is a devastating disease, a devastating diagnosis. Most people—including most doctors, who were trained in physical medicine—are stuck in the paradigm that the physical aspect of pain is the important one. Our understanding of the mind—of perception, cognition, belief—is not very far along.”

Dr. Keltner pointed out that the mind is a new field. Psychiatry is little more than a century old, and neurology, in the contemporary sense, only half a century.

“I have this faith—and at this point it is only faith,” he said, “that at the end of the day, mental therapies have the potential to be stronger interventions than physical interventions. My instinct is that ultimately there is more power in treating the mind, teaching the mind, healing the mind.

“Most doctors are normal people dealing with people whose lives are shattered. My patient isn’t saying,
I have repetitive strain syndrome
, he’s saying,
My life is ruined.
He’s a butcher who can’t chop anymore. I have an anesthesiologist with a pain that radiates down her arm who can’t do her job anymore. We’re taking a history and getting their rating of pain, but what they’re really saying is,
I’m losing my fiancé, I’m losing my house, I’m losing everything
, and we ignore that. We need to treat all those other things as well: to help them figure out a way to be—to address the total human experience of being incapacitated. How can we create an AA for pain?”

Although most physicians speak in a quick, efficient style, Dr. Keltner often pauses for long moments in the midst of a conversation, as if grappling with the issues anew. Dressed in rumpled, graduate-student-type clothes, he has an intense gaze, bright blue eyes, and a boyish air of physical vitality.

“Like all chronic disease, chronic pain involves a bifurcation,” he said. “There is the normal state, where you used to live, and you are conditioned to that state. Then you face a debilitating circumstance that lasts for months or years. When you’re in that second state, you hold on to expectations of that first life: you mourn that first life—you want it and want it a million times over. But people have to let themselves die and lose their old expectations. If they let it die, they can rise like a phoenix from the ashes and can have a new life. The doctor has to help them die and be reborn with a vital, rich life.”