The Pain Chronicles

by Melanie Thernstrom

  “It’s not broken,” he pronounced cheerfully.

  “Oh . . . Umm, how do you know?”

  “It would hurt a lot.”

  “Well, it does hurt. That’s why I’m calling . . .” I said, feeling less certain.

  “It would hurt more,” he said definitively.

  Upon reflection, I decided that perhaps it didn’t hurt as much as I had thought. For the next few hours he seemed to be right, but I still couldn’t walk, and then—even as I lay there quietly—the pain grew. It was as if Luke’s assurance had put the pain in a box called not-even-broken that contained it for a while, but then the pain welled up and began to seep through the walls of the construct.

  I called him back.

  “It doesn’t hurt the way a break would,” he said. His certainty reframed the sensation once again. By the time the pain overflowed again, Zach had come over. “Why didn’t you go to the doctor?” he reproached me. “You are so star-crossed.” I began to cry.

  Two of the toes were fractured. I knew I would never be able to call Luke about a medical problem again. Indeed, at times in our friendship after that when I felt that Luke was dismissive of my chronic pain, the dismissal did not succeed in dismissing the pain. I just felt more alone with it. It was the Placebo Dilemma again. Expectation may rival nociception, but it’s impossible to make use of that fact, because as soon as you know your relief is only placebo, your expectations collapse. The genie is ingenious; he never falls for the same trick twice.

  THE ANESTHESIA OF BELIEF

  At times, when my chronic pain was tormenting me, the sight of the scar from the pain toleration test—a slightly darkened square of skin beneath the round face of my watch—both reassured and reproached me. Here, I’d think, is the ultimate proof that my mind can control pain. Yet how to make it do so with my real pain, the pain that wasn’t experimental? The scar continued to fade so that after a few years it was visible only in certain lights, and the testament to my modulatory system seemed like a relic in which my faith was waning.

  I thought of a story I had read of a 1930s Thai Buddhist monk named Sao Man who had a disciple who was racked with pain from malaria. Sao Man declared that “instead of trying to relieve physical symptoms, monks should go to the root of distress and cure their minds” and “observe the pain without reacting, for thereby they would realize the truth of suffering.”

  Observing my pain is exactly what I want to do. I want to watch my mind at work as it generates pain, and then change it, the way a computer programmer can fix a glitch in the code or Vermeer might have painted over some of those clouds. I want to conduct the neurons of my brain as if they were an orchestra making discordant music. Those areas generating pain—pianissimo! Those areas that are supposed to be alleviating pain—fortissimo! Down-regulate pain-perception circuitry. Upregulate pain-modulation circuitry. Pronto.

  For most of history, the idea of watching the mind at work was as fantastical as documenting a ghost. You could break into the haunted house—slice the brain open—but all you would find would be the house itself, the architecture of the brain rather than its invisible occupant. Photographing it with X-rays resulted only in pictures of the shell of the house, the skull. The invention of the CT scan and the MRI were great advances because they reveal tissue as well as bone—the wallpaper as well as the walls—but the ghost still didn’t show up. The photographs they produce are static. Consciousness remained elusive.

  A newer form of MRI, functional magnetic resonance imaging (fMRI)—as well as a related technology, positron emission tomography (PET) scans—used with increasingly sophisticated software, aspires to watch a living brain at work. The films show parts of the brain becoming active under various stimuli by detecting areas of increased blood flow connected with the faster firing of nerve cells. For the first time in history, one can give a subject a painful shock and observe the person’s brain creating an experience of pain.

  “There is an interesting irony to pain,” Christopher deCharms, a neurophysiologist and pain researcher, told me. “Everyone is born with a system designed to turn off pain. There isn’t an obvious mechanism to turn off other diseases, like Parkinson’s. With pain, the system is there, but we don’t have control over the dial.”

  Dr. deCharms has collaborated with Sean Mackey to develop a science fiction–like investigational technique whose goal is to teach people to control their own “dials”: to activate their modulatory systems without the stress of fleeing a shark or the deception of a placebo. Usually, brain imaging involves subjects who are scanned and researchers who analyze the scan. But what if the functional imaging machine could be equipped with an internal screen so that the subjects themselves could watch a scan of their own brain activity in real time, as their brains respond to pain? Would seeing their pain-modulation circuits at work enable subjects to learn how to control them more effectively?

  Using real-time functional neuroimaging (real-time fMRIs), Dr. deCharms and Dr. Mackey asked volunteers, over the course of six sessions, to try to increase and to decrease their pain while watching a screen that showed the activation of the part of their brains involved in pain perception and modulation. Traditional biofeedback has proved that individuals can be trained to control autonomic bodily functions—such as heart rate, skin temperature, and even rhythms of electrical activity in the brain previously considered beyond volition—by using measurements of those functions. But such measurements only indirectly reflect the brain’s activity. By contrast, Dr. deCharms and Mackey’s technique, which they term neuroimaging therapy, allows subjects to interact (in a sense) with the brain itself.

  The hope of neuroimaging therapy is that regular practice will strengthen the ineffective modulatory system so as to eliminate chronic pain, the way long-term physical therapy can eliminate muscular weakness. The scan would actually be the treatment, the subject his or her own researcher.

  In preparation for the scans, subjects are trained in three types of pain-control strategy: changing their attention to the pain (to focus on or away from the pain); changing their assessment of the pain (to perceive it as more or less intense); and changing their perception of the stimulus (as a neutral sensory experience instead of a damaging, frightening, and overwhelming experience).

  Although functional imaging studies have shown that distraction reduces pain, Dr. deCharms believes that paradoxically, an alternative approach to relieving pain is to focus directly on it, which he believes can activate the pain-modulatory system. He personally feels that for chronic pain sufferers, “the technique of distraction may not provide much benefit, because it takes you away from your pain for a few moments, but as soon as you stop distracting yourself, the pain is there again—unchanged.”

  He had recently suffered from a bout of neck pain himself and decided to see if neuroimaging therapy could help. But when he tried to focus on the pain in the scanner, he found it curiously difficult to do. “Even though it felt like the pain in the scanner was all I thought about—and all I talked about—I wasn’t really focusing on it. The mind will do anything to avoid focusing on pain.” Yet, when he succeeded in focusing on it, he “could feel pain melt away. I perceived myself as upregulating the pain-control system. It was a feeling similar to a ‘runner’s high.’”

  Dayna—a middle-aged woman who had been unable to work because of back pain for several years—told me how she discovered that trying to distract herself from her pain with positive imagery actually worsened her pain. “I would picture horseback riding and hiking and all the fun, fun things I used to do,” she told me. “In the scanner, I could see that these things were causing an increase in my brain activity because I associate them with a sense of loss—with knowing I can’t do them anymore. I realized I needed to think of some new things.” She tried, instead, to focus on accepting and even embracing pain. “I had an image of myself dancing with the pain,” she said, and as they began to dance, she felt her pain transform from a stalker to a partner.


  Please let it work for me, I thought.

  Distraction had always been the most successful pain relief technique for me. Once, when I first had pain, I curled up in bed and cried. I had often done this when a romantic relationship ended, and the indulgence always made me feel better. But this time, when I finished crying, the pain was not only not better—it was worse. “Pain is not dissolved by tears, it is watered by them,” I wrote in my diary. After that, when I had too much pain to do anything productive, I went to a movie or walked to a bakery and bought a marshmallow Rice Krispies treat. But I had never tried to focus calmly on the pain itself.

  In one sense, neuroimaging therapy is simply a high-tech way to learn the ancient religious technique of meditation—by trying to make the process more transparent. But as Dr. Mackey pointed out, “it takes Buddhist monks thirty years of sitting on a mountain to learn control of their brains through meditation. We’re trying to jump-start that process.”

  I had looked at pain through the premodern lens of metaphor, religion, and magic; I had looked at pain through the modern lens of biology and disease. Both had proved inadequate. I wanted to understand pain through a new paradigm, a postmodern paradigm, as it were, that would use the magic of science to see the science of magic—and to find treatments that would draw upon that understanding.

  Lying on my back in a large plastic fMRI machine in the Stanford University lab, I peer through 3-D goggles at a small screen. The machine makes a deep rattling sound, and an image flickers before me: my brain. Me. I am looking at my own brain as it thinks my thoughts, including these thoughts.

  “It’s the mind-body problem, right there on the screen,” Christopher deCharms commented later. “We are doing something that people have wanted to do for thousands of years. Descartes said, ‘I think, therefore I am.’ Now we’re watching that process as it unfolds.”

  The screen shows activation of the rACC—the part of the limbic system that gives pain its emotional valence. The pain of pain, as it were, is the way it’s suffused with a particular unpleasantness—the sadness, anxiety, distress, and dislike that researchers refer to as dysphoria—a reaction so fierce that you are instantly compelled to try to make the stimulus cease, not in five minutes, not in five seconds, now. You can feel heat or cold or pressure, and note them simply as stimuli, but as soon as those stimuli exceed a certain intensity, the rACC activates, riveting your attention, filling you with dysphoria, and causing you to try desperately to put an end to it.

  The rACC is represented by a 3-D image of a fire in which the height of the flames corresponds to the degree of rACC activation. Subjects undergo five thirteen-minute scanning runs, each consisting of five cycles of rest followed by intervals during which they try to increase rACC activation and then decrease it.

  “Increase Your Pain,” the screen commands as the first run begins. I try to recall the mental strategies in which I had been instructed for increasing pain: Dwell on how hopeless, depressed, or lonely you felt when your pain was most severe. Imagine that the pain will never end. Sense that the pain is causing long-term damage.

  I picture the pain—soggy, moldy, or perhaps ashy, like smokers’ lungs. “Pain spreads out and pollutes the brain,” John Keltner had told me. “It actually poisons and infects your brain.”

  In three months, it would be ten years since the day I went swimming with Kurt and first acquired pain. What had it done to my brain? The Apkarian study suggested that 1.3 cubic centimeters of the gray matter of the brain is lost with each year of chronic pain. If I multiply that by ten . . . On the screen, the flames of my rACC explode. I feed the flames further by thinking of descriptions of the burning of heretics in Foxe’s Book of Martyrs.

  “Decrease Your Pain,” the screen commands.

  The suggested pain-reduction strategies do little to quell the flames. Tell yourself it’s just a completely harmless, short-term tactile sensation. I try to suffocate the pain with banal positive imagery of “flowing water or honey” and to picture myself in a “favorite vacation spot such as the mountains or the beach.”

  “Every pain-free moment competes with the onslaught of the chronic pain experience,” John Keltner had told me. “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.” But my mind keeps slipping back to the auto-da-fé, and the rACC fire flares.

  What if I were a martyr? I think of the story of Rabbi Akiva, who recited a prayer with a smile on his lips as the flesh was being combed from his bones for defying the Roman prohibition on Torah study. “All my life,” he explained to the puzzled governor orchestrating his execution, “when I said the words, ‘You shall love the Lord your God with all your heart, with all your soul, and with all your might,’ I was saddened, for I thought, When shall I be able to fulfill this command? Now that I am giving my life and my resolution remains firm, should I not smile?”

  “Fortunate are you, Rabbi Akiva, to be martyred for the sake of Torah,” the Talmud cheerfully concludes.

  During my next Decrease Pain interval, I focus on myself as a martyr. (Jewish? Christian? Witch?). Fortunate are you, I tell myself, to have this opportunity to lucidly recite a prayer of some faith while being burned at the stake. Fortunate are you to be so persuaded of your faith to see this opportunity as fortunate . . . My rACC activation respectfully subsides.

  But there was a twist, I recall, in the case of witches. Witches were sometimes believed to have insensitive areas, called devil’s marks, which could be discovered by sticking pins in them. A lack of pain could constitute proof of sorcery! As soon as I focus on the need to feel the pain of the pinpricks to establish my innocence, my rACC helpfully flares. Soon I have the strategy down. Heretic-martyr: rACC low. Heretic-witch: rACC high.

  I try to recall theories of the physiological mechanisms thought to account for the belief-induced anesthesia of heretic-martyrs. Perhaps they are in a trance—a state of autosuggestion or self-hypnosis. Or perhaps they benefit from “counterpleasure”: if their pain serves a higher psychological goal, they might experience it as strengthening, rather than damaging, their ego. In Sacred Pain, Ariel Glucklich theorizes that intense pain can cause both a massive release of beta-endorphins and a sense of disassociation, which frees one from the anxieties and desires that normally constitute the self. He terms the resulting euphoria “hyperstimulation analgesia.”

  One might expect the experience of pain to compel a unique focus of attention on the body. But religious devotees insist that during certain rites, this focus paradoxically metamorphoses into its opposite: a feeling of transcending or being freed from the body. Ascetics describe the moment during mortification when pain becomes no-pain—when, as a pilgrim put it, “Pain, having become so intense, began to disappear,” or, as a mystic wrote, “At one moment everything is pain; but at the next moment, everything is love.”

  How does pain cause the brain to create this sense of dislocation from one’s own body? The Canadian psychologist Ronald Melzack (the coauthor of the McGill Pain Questionnaire) theorized that each person has a unique “neurosignature” (the neural relay of the thalamus, cortex, and limbic system that constitutes the neuromatrix). The neurosignature creates what he calls a “body-self neuromatrix” that integrates the continuous flow of sensory input into a conscious awareness of oneself. Intense pain, he speculated, overwhelms the neuromatrix with an excess of sensory information, interrupting the neurosignature and arresting the body-self template. Although the sensation of pain continues to register, it can no longer be processed. One remains aware of the pain but ceases to experience that pain as belonging to oneself—or, indeed, ceases to experience a self for pain to belong to. This phenomenon is “either terrifying or exhilarating,” Ariel Glucklich writes, depending on whether it was sought or not.

  I remember watching the impassive face of the devotee at Thaipusam as the priest threaded the fishhooks with the dangling limes t
hrough his back and how he had said the pain no longer belonged to him. The god freed him from pain.

  Distracted by thinking about hyperstimulation analgesia—and then distracted by thinking about Tracey’s theory of the modulating effects of distraction—I watch as my rACC activation dwindles to nothing.

  COGNITIVE CONTROL OVER NEUROPLASTICITY

  The results of my scan, Sean Mackey tells me a few days later, indicate that I have significant control of my brain activity. A week later I am scanned again, in the sleek office at Omneuron, a Menlo Park medical-technology company Christopher deCharms founded to develop clinical applications of real-time functional neuroimaging. This time, it feels easier to control my rACC with less reliance on elaborate fantasy; I am interacting more directly with my brain.

  This learning effect was demonstrated by a study they published in the prestigious Proceedings of the National Academy of Sciences. The study showed that while looking at images of their own brains’ activity, subjects can learn to control the activation in a way that significantly regulates their pain. The first phase of the study looked at thirty-six healthy subjects and twelve with chronic pain. In the scanner, the healthy ones tried to modulate their responses to a painful heat stimulus. The chronic pain patients, however, worked to reduce only the pain they already felt. The chronic pain patients who received neuroimaging training reported an average decrease of 64 percent in their pain rating by the end of the study. Moreover, the benefit of the study continued after it was over: a majority of the pain patients reported that they continued to experience a reduction of pain by 50 percent or more. Healthy subjects also reported a significant increase in their ability to control the pain during the study.

  “One big concern we had,” Dr. Mackey says, “was: Were we creating the world’s most expensive placebo?” To make sure that wasn’t the case, he trained a control group in pain-reduction techniques without using the scanner (as in his previous experiment) to see if that was as effective as employing a multimillion-dollar machine. He also tried scanning subjects without showing them their brain images—and he tried tricking subjects by feeding them images of irrelevant parts of their brains or feeding them someone else’s brain images. “None of these worked,” Dr. Mackey says, “or worked nearly as well.” Traditional biofeedback also compared unfavorably: changes in pain ratings of subjects in the neuroimaging therapy group were three times as large as in the biofeedback control group.