Pain

Most Western medicine is end-organ driven. That is, if you have back pain, the problem is considered to be in the back; a pelvic problem must originate in the pelvis. Indeed, Western medicine names these problems by the end organ; thus, we have “lower back pain” and “pelvic floor dysfunction.” This model is called physicalism. If a patient experiences a physical problem, the problem must have a physical origin at the site of the problem. Of course, surgery and other traditional Western approaches can definitely treat many physical problems, but practitioners also find problems for which no, or only partial, solutions are available. Pain that is nonanatomical in distribution, for which there is no recent history of trauma, no evidence of a peripheral causative lesion and that resists traditional treatment should be considered to be of psychogenic origin.

That chronic pain can be psychogenic in origin is hard for most to comprehend. It makes sense that the cause of pain or tenderness (or burning or other somatosensory experience) must arise somewhere near the painful or tender area, but this is not always true. During a traumatizing event involving fear, rage, or other strong emotion, pain perception can be inhibited by norepinephrine released from the area of the brain called the locus coeruleus into the nociceptive (pain-perceiving) portion of the central nucleus (Ce) of the amygdala. Here, during an emotion-generating event, pain signals arriving from other parts of the brain are modulated. This is clearly seen under battle conditions where significant injuries may not be felt. Later, conscious recall of the traumatizing event activates the basolateral complex (BLC) of the amygdala, causing the release of norepinephrine. Just as in the encoding moment, the somatic pain experience is not elicited because of the release of norepinephrine (NE) and its effect on the Ce. Thus, thinking about the event does not cause pain. This is what makes psychogenic pain so confusing.

Nonetheless, the somatic components (pain, burning, temperature alterations, and tenderness) occurring in conjunction with a trauma are stored in the brain to be later experienced by exposure to subconscious stimuli. These subconscious stimuli do not produce an emotional response and the release of norepinephrine does not occur. This allows the co-encoded pain to be experienced.

This idea is not new, but the neurobiology is now better understood. Jean-Martin Charcot, Pierre Janet, Sigmund Freud, and Josef Breuer first described this more than a century ago, in the late 1800s. They were the first to suggest that subconscious stimuli could cause pain and other somatic symptoms. They believed the pain was co-encoded [Page 416]with a psychological trauma but cognitively dissociated from conscious awareness. Accordingly, pain relief would occur only when the trauma was brought to conscious awareness and treated.

The case in which a woman's hand was hurting for 3 months is illustrative. The patient was injured in a taxi accident in London, where the vehicle overturned. As the car tumbled, her hand swung wildly in the car. The back of her hand was badly bruised, but she did not experience the pain at the time of the accident. The pain and tenderness returned 15 years later, when she had decided to return to London to live. The physiology at work here can be explained as follows. During the original event, norepinephrine was secreted into the amygdala from the locus coeruleus. Flight was not possible during the event, and the four criteria—a highly emotional event, the possibility of being killed (meaning), the neurobiological landscape of the brain, and inescapability—were present, which led to a traumatization. NE release at the time of the event inhibited the nociceptive Ce from signaling pain to consciousness. From a survival point of view, this makes sense because her first priority was to escape from the overturned vehicle. Every time she would consciously recall the event, norepinephrine would be released, inhibiting the conscious awareness of pain. Her desire to return to London had enough overlap with the context of the event to stimulate the BLC regarding the event. NE was not generated because the thought of returning to London was not in and of itself threatening. She experienced pain, and she felt tenderness of the area, suggesting that local effects were being produced. She was not consciously thinking of the event, so her clues that would associate the event with the pain were absent.

...