pain – Becoming Human

Endorphins

These days, we know quite a lot about the correlation between levels of the various neurotransmitters and emotional state. We still know next to nothing, though, as far as I can tell, about the mechanisms which regulate neurotransmitter concentrations in the body. Pharmaceutical treatment of mood disorders merely takes the deficits as a given. Whilst, however, there may conceivably be instances in which the underproduction is biologically determined, it is perfectly clear that in most cases depressed neurotransmitter levels are simply a consequence of underlying neurosis. Since neurosis has a variety of effects on the body, simply remedying a single expression of it does nothing to address pathologies which are not vectored by means of the neurotransmitter in question, and may have unintended consequences.

Individual neurotransmitters tend to have a variety of surprisingly unrelated functions. Nowhere, however, is the adaptive role of a neurotransmitter more mysterious than in the case of endorphins. Endorphins were first discovered as the body’s own “endogenous morphine”, as discussed in Candace Pert’s book Molecules of Emotion which I reviewed on this blog. Thus endorphins are produced in response to pain and they act as analgesics. But endorphins are also produced in response to love and orgasm. What on earth is the link?

I don’t pretend to know the answer, but if endorphins procure us a state of bliss then it is tempting to wonder if, although we tend to suppress pain, being more aware of it would not in fact bring us more joy. It is often said that there is no pleasure without pain, but might this be quite literally true at the biochemical level? Indeed, it is awareness of pain, not pain itself, that triggers endorphin production. This is clearly the case because the body has ways of suppressing psychic pain which do not rely on endorphins. Additionally, endorphins are produced in response to acute pain and endeavor to allow the body to continue to operate under temporarily stressed circumstances; the body’s own painkillers become less effective once the immediate crisis is past, when the experience of pain serves the role of prompting appropriate remedial action in response. By contrast, falling in love raises endorphin levels over a prolonged period.

How then can we experience the bliss of raised endorphin levels if we are not in pain, and have no pain to bring into consciousness? Well, as I argued in an earlier post, vicarious experience and direct experience are much harder to distinguish than we realize. The mere fact, therefore, that pain is a constant of the human condition gives us access to it, an access we can embrace or, on the contrary, shy away from. When we are fully engaged with the collective human experience, and not only our personal experience, pain as well as pleasure abound. This is the natural state of things, and our responsiveness to it is natural also. But usually we are closed to the pain of others because we are closed to our own pain, and we are closed to that pain because we irrationally fear its long-lost power to overwhelm the ego.

John Sarno’s work on the etiology and treatment of psychosomatic disorders

I have been troubled all my adult life by disorders termed, which generally meant dismissed as, psychosomatic. These are disorders for which no physical etiology can be found, although they may have observable physical manifestations. From a psychological point of view, they have also recently been classified as somatoform disorders. As such, I was very interested to discover recently John Sarno‘s work on the subject.

Sarno’s basic premise is that just as emotional conflict can give rise to neuroses, so it also can give rise to pain and other physical conditions. This linkage may be direct, with Sarno positing that localized pain is a result of ischemia ordered by the central nervous system. Such emotional conflicts may also, via mechanisms which are presumably diverse, but which Sarno does not elucidate, result in afflictions to which non-psychological factors also contribute, whether in terms of their etiology or their clinical development. A key feature of Sarno’s posited diagnosis of tension myositis syndrome (TMS) is the variability in its lifetime expression. As such, it is an umbrella diagnosis or metadiagnosis for a variety of syndromes which have in common a non-progressive character. For a fuller discussion, read his 2006 book The Divided Mind.

I suffered in my early teens from clinical depression and situational urinary incontinence. By my mid-teens, this was replaced by muscular fasciculations, which I was convinced for a long time had to be a manifestation of a degenerative condition. Muscular function remained mechanically and electrically normal however, and much later this was officially classified as “benign fasciculation syndrome” (although it has receded, I am not fully free of it to this day). I went on at college to develop chronic fatigue syndrome, which at one point resulted in my being almost unable to walk. I also suffered at that time from migraines and back pain, and peri-orbital migraine was a regular occurrence for many years afterwards. During all this time, there have been no notable biochemical abnormalities observed.

Now I have not been monitoring bodily symptoms against my emotional state for many years and so I cannot provide a full account; it has changed immensely for the better, but I have still had my share of annoying things, in particular abdominal pains, and six or seven years ago Achilles tendinitis. Around May last year I developed plantar fasciitis on the left foot; it took a year to heel but then almost immediately the right foot developed the same symptoms. It has been quite debilitating as strenuous effort has tended to worsen it. All this led me to seek effective relief from the pain in various ways, a subject to which I will return.

Sarno’s notion, therefore, is very appealing. Indeed, given the importance of physical complaints, so called “hysterical conversion“, in the early development of psychoanalysis, it is not quite clear why attention has mostly been subsequently restricted to behavioral neuroses, especially outside of the Reichian tradition. Even if the mechanisms remain obscure, it is attractive to view psychosomatic disorders as somatic forms or expressions of neurosis.

However, I suspect the brain is less involved in mediating this relationship than we think. Sarno claims that the pain is directly generated by the brain as a diversion from unwanted emotions which threaten to break through into consciousness. I fancy this is otherwise: the brain is involved, certainly, in the repression of emotions, and by preventing their expression it prevents their discharge. The bodily symptoms, however, do not necessarily require neurological involvement and may arise on the basis of pure biochemistry. This is illustrated by research on the role of myofibroblasts in the mechanic regulation of connective tissue (see here). To me, the idea that the brain is busy, like some cranky old Wizard of Oz, devising ways to present consciousness with ever-new diversions seems crude, and it is not required to explain Sarno’s clinical outcomes. Variation in the site of pain may have simple biomechanical explanations.

So Sarno’s work is pathbreaking and liberating, definitively contributing to a shift in understanding of psychosomatic disorders, but it nonetheless needs to be taken with the necessary pinch of salt. Sarno offers, in The Divided Mind, no epidemiological data to back up his claim that the syndrome chosen by the brain is a matter of fashion (in a Kuhnian perspective, it is of course much more plausible that it is the diagnosis and corresponding collection of statistics which is driven by fashion, rather than the patient’s symptoms, especially since many of these diagnoses are evidently imprecise). He also offers no evidence to back up the conjecture that local ischemia explains the pain or that this is cerebrally induced (and if so, how). Indeed, the locus of pain is not discussed either, and some statements suggest Sarno does not have a deep understanding of myofascial biochemistry.

Sarno follows the usual path of airbrushing Reich out of the history of psychoanalysis, although it should be obvious that Reich was the first to look at the body and mind as a whole. However, his major error is to follow Freud’s mistrust of the id and misplaced trust in the superego. Freud, as we know, viewed repression as in many ways akin to a virtue upon which civilization depended. Sarno also paints a picture of the “childish, primitive” unconscious as the enemy within, even referring to it, with patent ideological bias, as the “dregs of evolution”, contrasting it to the “ethical and moral” conscious mind, a view hardly conducive to integration and well-being, and one which even Freud would have struggled to maintain (Nietzsche of course having demolished it comprehensively). His negative views of the moral quality of children are particularly depressing in their Calvinist overtones.

Several of Sarno’s statements in relation to brain neurology seem completely wrong: for example he attributes “rational, civilized” behavior to the neocortex, labeling it “that part of the human brain that has been added in the process of evolution”, even though the neocortex developed in the first mammals. The attempted equation between brain structures and Freud’s threefold division of the mind is presented as fact, whereas it is not a notion entertained by any mainstream psychoanalyst or neurologist. Indeed, Sarno oscillates gaily between the unconscious/preconscious/conscious model and the id/ego/superego model as if they were the same thing.

All this aside, this is a book which opened my mind to what now seems like an obvious fact but has long gone unnoticed, namely that the mind does not simply affect the body in vague, unspecified ways but perhaps in very specific ways where a direct link can be drawn between emotional circumstances and pain. It is pretty clear now to me what the circumstances were which led to both episodes of plantar fasciitis, and I am inclined to agree with Sarno that this knowledge is immensely emancipatory.

Sex, pain, and the death instinct, revisited

As I mentioned in a previous post, I have been reading a book by Joachim Bauer entitled Warum ich fuehle, was du fuehlst (“Why I feel what you feel”), which is basically a mixture of science and conjecture about the function of the human mirror neuron system. It turns out that the same neurons fire when we perform an act ourselves and when we see it performed by someone else, and this, it is argued, lies at the basis of our ability to experience empathy and to intuitively read the emotional state and intentions of the other.

A leitmotiv of the book is the idea that social interaction performs an essential role in neurobiological development. Famously, though probably apocryphally, Frederick II is said to have conducted an experiment whereby children were raised without hearing human language; deprived of this stimulus, they are said to have died. Perhaps more believably, controversial experiments on macaque monkeys have shown that, deprived of social contact, they develop psychosis. This conclusion is not new, but it appears we are starting to uncover some of its neurobiological foundation.

Controlled scientific experiments cited by Bauer in the book show that social exclusion can generate pain in the same centers that register physical pain. We have for some time known that the perception of physical pain is not a simple function of external stimulus, but also factors in, and fundamentally, psychological aspects – what that pain means, or is thought or feared to mean, to the perceiver. Now further we know, and this is backed up in a 2005 paper by Naomi Eisenberger and Matthew Liebermann, entitled Why It Hurts to Be Left Out, that purely social factors can induce pain which is similar in all respects to “physiological” pain (indeed, it is physiological pain).

Interjecting a couple of points of my own here: firstly, pain is something we are wired to avoid. Indeed, we avoid it instinctively, even if we are consciously prepared to confront it knowing it has certain benefits (or more accurately, is a by-product of processes which have such benefits). The greater the pain we experience, the more we privilege its avoidance over any rational assessment of the benefits to ourselves of enduring it. Secondly, what is already true for physiogenic pain is true, of course, a fortiori for psychogenic pain (or perhaps I should call it “sociogenic pain”), namely the pain we actually experience is a function of our psychological state at the moment of the stimulus. There are common features, perhaps, but there is no standard human response to life events which modify our social constellation such as bereavement, loss of ones job, retirement and so on. Just as touch, which might otherwise procure pleasure, will feel painful when applied at a point where we have open wounds, so also the same life event will be experienced by some even pleasurably whereas it might have the most excruciating effect on others. In medicine this is called hyperalgesia.

Indeed, this is true to such an extent that it leads to a necessary qualitative distinction in any discussion of psychogenic versus physiogenic pain. Certain life events, such as bereavement, are probably universally painful in at least some degree, and therefore comparable to fractures, burns, stings and so on. In other words they signal to us a real and universal need to bring the healing resources of the body to bear on the wound inflicted. The vast majority of situations and events which cause psychogenic pain, however, are not like this at all – our reaction to them is intensely personal and someone else’s reaction to the same events could be totally different.

As I am in the business of giving personal development suggestions in this blog, and not just describing things, allow me then to say that it is extremely important to make this distinction. There are many things in the world in relation to which vast swathes of the population are in a neurotic state. It is thus statistically common to observe a similar reaction to these things in many people. Nonetheless, this does not make these things natural or inevitable sources of pain. They may even be natural sources of pleasure.

This is likely the case in many instances where many people – men and women – experience sexual jealousy. There are many grounds to suspect that observing ones partner and other people one loves being sexually intimate with others, or to learn about it or hear of it, is in fact naturally pleasurable, and was experienced as such in our Urwelt. Just to cite a few: there is the vicarious experience of pleasure which I mentioned before; the social bonds which it creates to the new sexual partner; the prospect of half-siblings improving the life chances of ones own offspring; the prospect of ones own enhanced sexual gratification as a result; and so on. Perhaps most convincingly, there are people who enjoy it. There are not many who enjoy objective sources of physical pain.

Nonetheless, many people experience this as pain. What to do? It is easy enough to say that one should stick out the pain and eventually it will die down and be replaced by pleasure. However, as any sufferer from chronic pain will tell you, this is not even necessarily true, much less is it a sufficient motivation to endure a potentially long and painful journey to a seemingly uncertain destination.

I do not have a simple answer either, but I think some reflection on what causes this hyperalgesia may point the way. Already when it is understood that the person suffering from jealousy experiences physical pain, it becomes clearer than it might otherwise have been that their reaction to this experience is, to a significant degree, outside of their control. Anger or recriminations in relation to it are pointless. Indeed, worse than pointless – such a reaction invites the sufferer to feel guilty, deny their pain, or submit to the other, refreezing and reinforcing the factors which led to the experience of jealousy in the first place.

Jealousy is felt as alienation – a withdrawal behind the defenses of the ego and a loss of the sense of contact with the world, a sense which was clearly tenuous to begin with. Alienation in childhood becomes self-fulfilling prophecy in adulthood. The cycle can only be broken by showing empathy and connection – not by withdrawing it and leaving yet another victim abandoned carelessly on life’s highway.

And this really brings me back to the essentiality of social contact, of touch and of sexual expression also. It appears that there is nothing in humanity’s basic repertoire of interaction which is merely “nice to have”, which we can ignore or neglect without fear of consequences. The idea of freedom without community – cultivated the world over as a spiritual value – is in fact a nonsense, or at best something which is only possible on the basis of a very strong foundation of community in the past.

Bauer tells familiar stories and some less so. That the passage into retirement is an explanatory variable for mortality rates. How couples seem so often to die in close proximity to each other. But also of how persons condemned for their crimes by the community to expulsion, voluntarily take on themselves the duty to die. The biological stress engendered by social exclusion is a self-destruction program, eerily like (though Bauer does not make the connection), Freud’s posited death instinct (Reich’s response to which I discussed here). And I guess this makes some sense, both because there does, after all, appear to be such an instinct in the animal kingdom* (though this certainly does not mean that Freud’s treatment of it was correct) and because it is something that many character types may intuitively understand – not only masochists.

Persons experiencing jealousy have an injured sense of connection to the world, such that they need to hold on to symbols of that connection and turn particular people (often partners, but also kids) into such symbols. They respond to perceived threats to those symbols – perceived through a magnifying lens of paranoia – with self-destructive behavior, just like those on whom the tribal shaman has pronounced a curse.

All too often, fearful of the intensity of this reaction – which is truly akin to a reaction to a life-threatening situation – and burdened anyway with their own sense of shame and guilt, their partners will apologize, try to reassure, try to salvage the fragile trust which existed, or seemed to, before. It is in the nature of things that this is not possible. This type of connection to the world is too tenuous and artificial to be anything more than a band-aid on a gaping wound. What the jealous partner needs in such moments is empathy, grounding, and connection – not desperate attempts to re-become a shattered symbol, but the shattering of the symbolic and its replacement by the real.

Genies do not go back into bottles. In such moments we can meet as demons to each other, or both decide to meet as humans. Almost everything in life that generates emotional pain has great potential for healing, but it is a potential which almost always goes unexploited because the insecurities are not just on one side, but on both. When we decide to meet as vulnerable, hurting beings it may just be that we finally realize we are not, and cannot be, alone.

Notes

* Illustrated at cellular level by the process of apoptosis, and also observed in many cases of post-traumatic stress disorder where the underlying monotrauma results from a direct human agent.

Why therapy hurts

When we stop telling ourselves that life has it in for us, and start believing in the possibility that the universe may, in fact, be on our side, we often only then start really to feel pain. Many people start to feel this pain, are afraid of it, feel nothing has worked, and then give up.

Why do we only feel our pain more as therapy progresses? Because the negative mantra had become an anesthetic, dulling us to the pain, but also to joy and possibility. Continue reading “Why therapy hurts”