The Pain Chronicles (32 page)

THE MAGIC TAKES PLACE IN YOUR HEAD

Techniques such as prayer, meditation, and hypnosis are designed to alter pain perception by manipulating either expectation or attention, or both. The placebo response is created by expectation, which activates the pain-modulatory system, but for people who don’t respond to placebos, techniques of controlling attention can alter pain perception. Even for those who do respond to placebo, that response is often short-lived; over time, the brain often catches on and the placebo loses its power.

On the other hand, learning to control attention in order to change pain perception is a skill that can be developed. When Thomas Aquinas insists that “the contemplation of divine things suffices to reduce bodily pain,” and Kant suggests contemplating Cicero, they are talking about a form of controlling attention. Hypnosis is an extreme form of controlling attention by which the brain is able to exclude from consciousness all unwanted external stimuli, including pain. The nineteenth-century practice of mesmerism seems to have been a form of hypnosis. With hypnosis, subjects enter a state of autosuggestion by which they willingly grant authority to the hypnotizer to direct their attention and perceive only what the hypnotizer tells them to perceive. When the hypnotizer instructs them to feel no pain, their brain ceases to generate an experience of pain, even—in the case of mesmerism—under the ultimate test of surgery.

In China today, surgeries are still sometimes performed using acupuncture alone, which in this context is theorized to function like hypnotism. The British neuroscientist Patrick David Wall (who, along with his colleague Ronald Melzack, first developed the gate-control theory of pain) told the story of watching surgeries performed using acupuncture in the mid-1970s in China.

The patients at the hospital had been prepared for the surgery by a long course of training and had trusting personal relationships with the acupuncturist. And indeed, Dr. Wall could detect no signs of pain as the incisions were made. But when he noticed that the surgeon cut into one woman’s thigh
before
the acupuncture needles had been inserted, he began to wonder if the mechanism of pain relief that was at work was actually akin to hypnosis. The woman, confident of not being hurt—and protected by that confidence—continued calmly chatting.

His theory was confirmed by a horrifying incident with another patient. In the midst of his surgery, the patient suddenly broke free of the trance. His chest had been opened in order to remove part of his lung. Although the operation required a major incision in a nerve-rich area, the patient betrayed no distress. But then, at the end of the operation, after the doctor removed a surgical drain from inside the chest, the patient screamed and struggled to get off the table. He was held down and continued screaming and crying.

What had gone wrong? Dr. Wall believed that prior to the surgery, the acupuncturist had carefully rehearsed each step of the surgery with the patient, assuring him that each of the steps would be painless. But the acupuncturist had neglected to mention removing the drain, so the patient had responded to the procedure as he ordinarily would—with alarm and agony.

Although the surgeries were performed only on patients who had passed the training, there were others for whom acupuncture failed to have any effect. Not everyone, it turns out, can learn to achieve a trance; only some people are “highly hypnotizable.” The explanation for this has long remained elusive. Do such people simply have greater abilities to concentrate, to focus attention, to perceive only what they want to perceive?

Recently, neuroimaging has provided some clues toward an explanation, showing that the brains of the highly hypnotizable are actually different from those who are not. An area of the brain (known as the anterior corpus callosum) that is involved in attention is about a third larger in those who are highly hypnotizable. Moreover, highly hypnotizable people turn out to have above-average abilities, in general, to control pain, because they are better able to filter out unwanted stimuli.

When I began researching pain, I assumed that the patients who told me their pain could be alleviated by hypnosis, acupuncture, meditation, or any other alternative treatment must not be in real pain. I was wrong. Some of the patients with the most severe conditions were helped by these kinds of techniques. For example, one of the worst forms of pain is central pain: pain caused by pathology of the central nervous system itself, common to multiple sclerosis, spinal cord injuries, and certain types of brain tumors and strokes that affect the thalamus. Holly Wilson (who was paralyzed by a botched surgery) told me that the only time she is free from the burning pain of the spinal cord injury she refers to as her “shadow” is when she’s under hypnosis. Lily—a sixteen-year-old dying of a rare genetic disease at a children’s hospital—recalled the one time her pain momentarily disappeared. With her wasted body curled in a fetal position, hooked up to a cadre of machines, Lily had a chart a thousand pages long; she had spent much of the last six years living in the hospital. A team of renowned specialists consulted regularly on her case. I had thought she would want to tell me about the care she had received from the distinguished, compassionate head of the pediatric pain service whose practice I had been observing. But the memory that made her face light up was a woman who once worked for the hospital in a clerical capacity but then moved away. “She laid her hands on me,” Lily said with great feeling.

“She didn’t even touch her,” Lily’s mother explained with equal enthusiasm. “She simply held her hands above her!”

On assignments in Africa I had been baffled by the testaments to pain treatments that appeared to have nothing to do with medical science. In Rwanda, a man with a pattern of burn marks encircling his forehead told me that he had undergone a traditional treatment for migraines that had cured his chronic headaches.

“Didn’t it hurt?” I asked, trying to keep the horror from my voice. I had had a series of migraines during that trip, and worryingly, I was down to my last pill of Zomig, my favorite migraine medicine. I suspected there was no Zomig for sale anywhere in Rwanda.

“The more the treatment hurts, the more powerful it is,” my translator said. “The treatment only hurts once, whereas the headaches used to hurt him every day. You should try it. If that headache medicine you take worked, you wouldn’t have to take it all the time.”

“I don’t take it all the time,” I said peevishly. I’d
like
to take it all the time because my occipital neuralgia gives me continual migraines, but my insurance pays for only six tablets of Zomig a month, each of which costs twenty-nine dollars. At home, I hoard the pink tablets, each wrapped in its own foil, but once in a while I use them all up, and then, during the next headache, I have to stumble to the pharmacy to buy an extra one. I always feel vaguely ashamed on these occasions and pay cash and crumple the receipt.

In the context of Africa, a $29 headache is obscene—an obscene overvaluing of my pain and undervaluing of the pain all around me. Yet at times, when I encountered Africans—people missing shoes, teeth, limbs—it would strike me that many of them seemed less discontented than I. Perhaps they thought of pain as part of the fabric of life, whereas I expected my life to be physically painless, and I endlessly grieved that it wasn’t. I needed a cure for my pain, or I needed a cure for my belief that my pain needed to be cured.

When I asked John Keltner which alternative treatment works best, he shrugged.

“In my Zen way,” he said ironically, “I’d say you’re asking the wrong question. They can all work equally well because the magic isn’t in the technique; the magic takes place in your head.”

It’s because the magic takes place in your head that such disparate interventions as ritual scarification, Zomig, hypnosis, and opioids can have the same effects. The variety of alternative techniques might be thought of as the array of props in a religious rite: it is not the lighting of the candles, the pouring of the wine, or the recital of the blessing that makes the Sabbath sacred. Each may—or may not—lead the way into the sacred space, the place where magic happens.

Yet do the effects of magic moments endure? Aren’t you the same pained person the minute you stop meditating?

Dr. Keltner paused.

“Every pain-free moment competes with the onslaught of the chronic pain experience,” he said. “Pain is supposed to be the warning for something that is literally life-threatening. With chronic pain, every experience, every movement, every situation gets inappropriately stamped and experienced in the mind as life-threatening. We’re not supposed to be exposed to danger all the time, and we’re not supposed to be hearing an alarm bell all the time. You can see how pain has the potential to make someone go insane.”

The devastation of chronic pain is the way in which, over time, it “spreads out and pollutes the brain.” He drew an analogy to phantom limb pain: if you cut four fingers off a hand, the neural area in the brain (the homunculus) that represents the remaining finger tends to grow, expanding into the areas that used to represent the other four fingers. The homunculus’s remaining finger eventually swells to encompass the space once occupied by all five digits.

In the same way, he said, “pain is such a persistent, relentless experience, it actually poisons and infects your brain. Pleasure and relaxation are at a disadvantage compared to pain because, while pain dominates and imprints on consciousness, they are typically quiet, subtle states. People need to find a way to have experiences that are not only pleasurable but are as important and riveting as pain. Religious experiences can be that powerful, but unfortunately, doctors can’t prescribe religion. But by whatever technique—sex, intimate conversation, listening to music—people need to create moments when their attention is sufficiently drawn away from pain that they are almost pain-free, so that they can begin to recondition and reclaim their brains.”

A LESS DIRE NARRATIVE

For some, simply knowing that the brain creates and controls pain provides that control. The writer Susan Cheever told me that when she developed back pain, her doctor diagnosed her with—in short—aging. She was in her early sixties, showing signs of arthritis and scoliosis. But she had always been outstandingly healthy, athletic, and youthful-looking, and she did not care for the idea of these things changing. She decided to consult with John Sarno. After examining her, Dr. Sarno authoritatively declared, “This pain is not being caused by your arthritis or scoliosis or any other mechanical problem.
It is being caused by your brain
.”

The truism struck her as a revelation. “I know all about being led astray by my brain,” she said wryly. The next time she felt leg pain, she thought of Sarno’s theory of TMS—how repressed negative emotions cause pain and muscle tension. She told herself that the pain was not caused by problems in the disks of her spine: “It’s caused by my brain, distracting me from my unacknowledged grief and rage.” She noticed that crying relieved her pain. She enrolled in his workshop and began the long project of “reeducating a certain part of my brain to think about another part of my brain in a different way.” The day of a friend’s memorial service, the pain vanished from her leg and reappeared in her upper back. “I thought,
Oh,
come on
—this is so obvious.
”

When she told Dr. Sarno how difficult her childhood had been as the daughter of the troubled writer John Cheever, he expressed surprise at how well she was doing and attributed it to the power of her imagination to transform emotional pain and loss into her own writing. He enjoined her to use that power to transform her experience of bodily pain.

She became aware of the way that each time she felt the sensation of pain, she began to embellish it into an ominous narrative. At the first pinch of a headache, she would begin to write an internal story whose opening scene was a cloudy afternoon in Central Park and whose end was her death by brain tumor. “I have an apocalyptic imagination,” she said. “Sarno gave me a much less dire narrative. Instead of thinking,
Maybe this is the first sign of my death
, I started thinking,
Maybe this is nothing.
Maybe this is psychosomatic. And when I did, my pains vanished. Poof.”

She opened her hands with the same gesture as the priest in the Batu Caves: as if pain were something one might, simply, let go of.

I felt very envious.

Even though I knew that one of the four types of pain is psychogenic pain, the simplicity of Susan’s story surprised me. But I knew that although Dr. Sarno’s model doesn’t work for everyone, he wouldn’t have become popular unless it worked for some. I’ve heard other doctors express skepticism about his doctrines, but since pain is a perception, there is no such thing as fraudulent pain relief.

I was half tempted to consult with Dr. Sarno myself, but a telling characteristic of TMS is that the location of the patient’s pain continually shifts. My pain was nothing if not stable. The right side of my face and forehead always hurt; the left side felt fine. My neck was never fine. Sometimes I pictured myself in my coffin, the pain finally fled, and the image would both comfort and alarm me.