Pain and Somatic Symptom Disorder

What did we think we knew about pain historically?

Pain is a reactive response and the result of damage

The worse the damage, the worse the pain

There is a single pain centre in the brain

Where the pain is = where the problem is

What is evidence against the traditional view of pain?

Pain is not proportional to the amount of damage/injury

• People can have severe pain while being uninjured

• People can have severe injuries without pain

• Pain can be bad with minimal injury

Stress makes pain worse/pain is connected to emotional state

Pain can be felt in a location other than the site of the problem, or a part not even there

Pain can be felt after the problem has been “fixed”
Pain can improve just when you expect it could (placebo)

Pain can occur when you expect it could (nocebo)

What is part of the reason for phantom limb pain?

You have a map of the body in your brain. Internal representations of that part do not disappear when the limb does, resulting in perceptions associated with that part.

How do you test for pain?

Subjective—need to ask

Pain is meant to be a ______ to _____. Once it ______ , it ______.

Alarm system; get you to do that in the short term; serves that function; goes away

What are the mechanistic descriptors of pain?

1. Nociceptive

2. Neuropathic

3. Nociplastic

What is the Nociceptive description of pain mechanisms?

Pain due to actual or threatened tissue damage, causing activation of normally functioning nociceptors

What is the Neuropathic description of pain mechanisms?

Pain caused by lesion or disease of the somatosensory nervous system

Can occur centrally (SCI pain, MS, post-stroke) or peripherally (post-herpetic neuralgia, diabetic neuropathy, entrapment neuropathies)

What is the Nocioplastic description of pain mechanisms?

Pathological change in the function of nociceptive pathways

Pain without: evidence of activation of normally functioning nociceptors and without: evidence of neuropathy

WHat is chronic pain?

An unpleasant sensory and emotional experience associated with actual or potential tissue damage that lasts beyond the time expected for healing (3-6 mths).

Related more to NS rather than tissues

Pain is no longer serving a helpful alarm function—that alarm is now the problem

Not a “psychological problem” - an issue of neuroimmune system dysfunction

What is complex regional pain syndrome (CRPS)?

A budepest/valencia criteria dx including

Pain

Sensory changes

Temperature/skin color changes

Swelling/sweating

Weakness, tremor, dystonia

Hair/nail changes

Somatic symptom disorder is _____ and _____.

Not designed to be explanatory; just there to try to encompass people who have a clearly psychological/pathological response to ongoing symptoms of some type

Who are overrepresented in pain problems?

Women

Due to

• Puberty

• Hormones

• Psychosocial stressors

• Inequities

What is the overlap between PTSD and pain, and why might this be?

20-30% of individauls with PTSD have persistent pain, and 15-50% of individuals with chronic pain have PTSD

For most people, symptoms happen then go away. Both disorders have what is intended to be a normal response to a threat that instead persists (state becomes trait)

Shared neuroanatomy and neurobiology

Role of ACEs/early life stress in contributing to health outcomes and physical conditions, including in pain circuitry

People with PTSD have increased reactivity of CNS compared to controls who have been exposed to trauma

What is the pain meds trajectory? How does this affect sufferers?

Works really well for some, and not at all for lots of people

Very confusing for sufferers, money, surgical procedures, wanting a fix

What is pain?

An unpleasant sensory or emotional experience associated with, or resembling that associated with, actual or potential tissue damage. It helps to

• Warn us about potentially harmful stimuli

• Help us adaptively react to these stimuli

• Protect us while we heal

• Teach us to use the information provided by this system for future protection

What are Somatic Symptom disorders in the DSM?

Somatic Symptom Disorder - distress related to one or more somatic symptoms resulting in persistent thoughts, high anxiety, or excessive energy devoted to this symptom

Illness anxiety disorder - I.e., “hypochondriasis” - preoccupation with having a serious illness/persistent worries about health disproportionate to symptoms (>6 months)

Functional neurological symptom disorder

Factitious disorder imposed on self or another - falsification of physical signs, symptoms, injury, etc in absence of obvious external rewards

How does reassurance relate to pain treatment?

Reassurance is not reassuring—provides short term relief, but ultimately keeps them stuck

What are the systems that chronic pain sufferers are embedded in?

Stigma and stereotypes

Shame

Systems that are hard to navigate and potentially harmful to the individual