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Pain

Stephen and I were happy twin toddlers: playful, affectionate, curious, beginning to string words into sentences when, Mum said, "Anthony just went quiet." I became miserable, irritable, anxious, inattentive and solitary, and stayed that way.

Constant pain from a botched and unnecessary medical intervention caused me life-long emotional, cognitive and social damage. It comes from a spot half way up my back, to the left of my spine where there is a scar. The muscle beneath that scar (the latissimus dorsi, trapezius, erector spinae and multifidus muscles all overlap at that point) is atrophied and the muscle around it is a little bulky.

It starts soon after I engage those muscles, when I sit or stand. It's "tonic" pain: constant, rising and falling only slowly in intensity. The longer I'm up, the more it hurts and it takes hours for the pain to resolve after I lie down.

Most people in chronic pain experience periods of intense pain (like an endometriosis flare or moving an arthritic joint) between periods of less or no pain. With me, the pain is nearly always present and when the intensity changes it changes very, very slowly and predictably. Pain, for me, is like a trait. My perspective may be very different from yours, very different, even, from most chronic pain sufferers. This tonic pain, this lens through which I experience the world, distorts everything that matters.

It slows my thinking speed, reduces my working memory capacity, impairs my concentration and undermines my self-control. It increases the intensity, frequency and duration of negative moods and negative emotional events, and it numbs my social feelings. It isolates me from others and leaves me disengaged from my surroundings.

I've searched the pain science journals, textbooks and other literature to see if pain affects others in this way:

Cognition: The negative impact of pain on mental processing speed, working memory capacity, attention control, impulse inhibition, emotion regulation and other cognitive processes is well-attested in the pain literature.

Mood and emotion: Science has focussed on misery (depression) and, to a lesser extent, anxiety and it pays least attention to irritability and neuroticism (exaggerated reactivity to negative affect) in pain, but it has found all of these are amplified by pain.

Social feelings: I'm not aware of any scientific research into the impact of pain on social feelings (empathy, compassion, shame, guilt, rejection, affection etc.) but pain obliterates my social feelings. Here, Michael Schatman, editor-in-chief of the Journal of Pain Research, recently told me, "I agree with you regarding the lack of study in this area."

In 2004 I read an fMRI brain study that found the distress of physical pain shares grey matter with the distress of rejection — a social feeling. I don't know whether that's been confirmed but it might explain, neurologically, how physical suffering can interfere with social feelings.

After I lie down the pain slowly recedes and, in time, social feelings begin to emerge, but I'm usually alone and asleep by then. In my dreams, I feel others' feelings and respond with my own. I love my dreams.

When I rise the next day and the pain begins, social feelings fade again into impotent, vague notions, distant memories, not the visceral affective guardrails I need to successfully navigate society.

Emotional facial semaphore and intersubjectivity: Don't read these three bullet points and the following two paragraphs unless you can do so carefully, attentively. Skip them. Move on to "Inattention" which you can read with half a mind and little care and interest and still, easily get the gist. This section explains a disturbance of affective contact, the symptom, autism, in me.

• When I make eye contact, I can't convey appropriate feelings by facial expression. I can't return a timely, sincere smile when suffering is swamping my sensorium. Failure to display a timely sincere (Duchenne) smile elicits distrust in the observer.
• The human male (but not female) face in pain activates the human observer's amygdala. The amygdala is involved in, among other things, the processing of fear and aggression.

• People in pain are excessively reactive to negative affect so, when I'm in pain, negative facial expressions from others, like distrust, fear and aggression, hurt a lot ... so much that I can't look at you for fear of seeing that face.

If we make eye contact when I'm in pain, you will see my pain and my failure to display a timely sincere smile, and I will see your emotional response: distrust, fear and aggression. It's an ugly emotional moment for both of us but especially so for me.

So, the interplay of emotional facial expression, the universal semaphore of displayed, exchanged feelings, is disabled in me and its absence marks me out as remote, shifty and strange and I miss important social cues. No one is studying the impact of pain on emotional facial semaphore or intersubjectivity.

Inattention: The present is usually so toxic, I retreat into distraction and absent-mindedness. My surroundings are still available to that part of me that drives my car and opens the fridge door but conscious, deliberate me is mostly absent and lives by glimpses.

Death is preferred over prolonged severe pain but even mild to moderate pain, if continued long enough, will bleed life of its pleasure, transforming the individual into a sufferer whose overriding goal is to drive this experience from consciousness." — Kenneth L. Casey. 2019.

The impact of distraction on pain intensity and unpleasantness is well-attested in the pain literature.

Inattention, poor eye contact, blunted social feeling, emotion dysregulation, negative mood states, significant cognitive impairments. This is a seriously disabling set of symptoms. I watch them come and go, rise and fall with the pain, day after day.

It's not been easy. The pain is awful, of course, and all that stuff above is too, but I'm also heartbroken and have been since I lost my family's affection and the world turned away when I was a toddler.

My family were very patient and kind and took good care of me and I am so grateful for that. But they couldn't give me sincere, spontaneous affectionate smiles and shared feelings. No one could. I've spent most of my life not being smiled upon and not sharing feelings. The heartbreak from this affective isolation never remitted in my childhood and only for a few moments in my adult life.

My family could have talked to me and listened to me, though. They could have engaged me in uncomfortable, clumsy, embarrassing conversations, which would have been enormously rewarding and helpful for me, but nobody did that back then with kids like me.

And then there's emotional contagion. You feel my pain. It hurts you to be around me.

Distress

Suffering. What is it, what does it do to us, what is its role in mental illness?

In 1968 Ronald Melzack and Kenneth Casey re-imagined pain as more than just a sensation, and this model underpins all modern thinking in pain psychology and pain neuroscience. They described three dimensions of pain:

1. sensory-discriminative: sense of the quality, location, duration and intensity of the pain
2. affective-motivational: unpleasantness and urge to escape the unpleasantness
3. cognitive-evaluative: cognitions such as appraisal, cultural values, distraction and hypnotic suggestion.

It is the affective-motivational dimension, the unpleasantness, that harms us.

Unpleasantness is also called "suffering", "discomfort", "torment", "anguish", "hurt", "negative affect", "negative valence", "negative hedonic tone", "aversiveness" and "distress".

I'll use "distress" and sometimes "suffering" here.

Distress is found in three classes of feelings:

1. It is a dimension of unpleasant homeostatic feelings like pain, hunger, fatigue and hyperthermia. Unpleasant homeostatic feelings torment us with distress until we satisfy them with specific behaviour (in pain: withdrawing and protecting, in hunger: eating, in fatigue: resting, and in hyperthermia: stepping into the shade).

Sheep respond to hunger, fatigue and hyperthermia by grazing and resting in the shade of a tree.

2. Distress also plays a role in negative emotions like grief, anger and fear, and

3. it is an essential part of some social feelings (e.g., empathy, rejection, shame).

Distress likely evolved first and was enlisted by homeostatic feelings, emotions and social feelings as they emerged later in animal evolution.

It is likely that just one neural network generates distress, and every unpleasant homeostatic feeling, emotion and social feeling employs this one distress network.

What does distress do to us?

I am studying the effect of distress on human emotion, cognition and social engagement and I have focussed on three causes of distress — hunger, sleep deprivation and pain — because each of these has a body of scholarship addressing its affective, cognitive and social impacts.

What I've found is, each of these distressing homeostatic feelings generates in humans the same set of clinically significant symptoms:

• negative mood states (misery, anxiety and irritability) and exaggerated reactivity to negative affect (neuroticism),
• slowed mental processing speed, reduced working memory capacity and impaired attention control, impulse inhibition and emotion regulation, and
• impaired social feeling/social engagement.

Until someone finds an instance of distress that does not cause this cluster of symptoms, I shall assume all intense distress, regardless of its cause, produces this syndrome.

This syndrome is found and is a major contributor to disability in all instances of serious, distressing functional mental disorder.

Look, for example, at the extract below from the "associated features" of schizophrenia in DSM-5-TR. Compare my underlinings in that text with the symptoms of suffering listed in the bullet points above.

All the elements of the distress syndrome, except neuroticism, are found in the DSM associated features of schizophrenia.

Individuals with schizophrenia may display inappropriate affect (e.g., laughing in the absense of an appropriate stimulus); a dysphoric mood that can take the form of depression, anxiety or anger; a disturbed sleep pattern (e.g., daytime sleeping and nighttime activity); and a lack of interest in eating or food refusal. Depersonalization, derealization and somatic concerns may occur and sometimes reach delusional proportions. Anxieties and phobias are common. Cognitive deficits in schizophrenia are common and are strongly linked to vocational and functional impairments. These deficits can include decrements in declaritive memory, working memory, language function, and other executive functions, as well as slower processing speed. Abnormalities in sensory processing and inhibitory capacity as well as reductions in attention are also found. Some individuals with schizophrenia show social cognition deficits, including deficits in the ability to infer the intentions of other people (theory of mind).

Eugen Bleuler in 1911 addressed neuroticism in his unmedicated schizophrenic patients:

Particularly in the beginning of their illness, these patients quite consciously shun any contact with reality because their affects are so powerful that they must avoid everything which might arouse their emotions. The apathy toward the outer world is, then, a secondary one springing from hypertrophied sensitivity." (p. 65)

Try to imagine a seriously functionally mentally ill person without this syndrome: without anxiety, irritability, misery or neuroticism; without slowed thinking, attenuated working memory or poor attention control; imagine they have healthy impulse-inhibition, emotion regulation and social engagement, too. Would you even call them ill? Eccentric, maybe, but ill?

What is distress doing in functional mental illness? What is its role?

Recently, a historian of psychiatry told me, "Suffering is central to serious mental illness. Whether it is the cause or the effect, or something of both, is an open question."

I'm sure it is an open question in his mind but the causal relationship between mental disorder and distress is not an open question in psychiatry.

In psychiatry, at least in its bible the DSM, it is always mental disorder that causes distress, never distress that causes mental disorder. Look at this from DSM-5-TR's diagnostic criteria for major depressive disorder:

The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

This formulation occurs throughout DSM-5-TR, and it has been a feature of the DSM since its third edition in 1980 when the lead author laid down new essential criteria for every diagnosis, including: the symptoms must be distressing to the individual or the symptoms must impair the individual's ability to function.

I believe distress, in mental disorder, is causing the same devastating set of clinically significant symptoms it causes in hunger, sleep deprivation and pain, and psychiatry, if it wants to address this devastating cluster of symptoms common to all serious, distressing mental disorders should find and treat the cause/s of suffering. While social and emotional distress must, of course, be addressed, the physical, extracerebral body should not be ignored. Look for nutrient deficiencies, hormone imbalances, inflammation, pain, fatigue, any kind of constant or recurring distressing homeostatic imbalance.

The features that distinguish one DSM entity from another — mania, psychosis, obsession, etc. — may be summoned by distress from a propensity in the patient's biological inheritance reinforced by life experience and social state (diathesis-stress, an old idea), so, eliminating ongoing distress may at least to some degree ameliorate these eccentricities, while resolving the seriously disabling affective, cognitive and social harms of suffering.

Inuring

You can suffer from an intense distressing homeostatic feeling and, if it creeps up on you by degrees and fades away slowly, if it follows a familiar, predictable temporal course that does not trigger alarm, or if it is constant—there all the time—you may not know it, while the distress still does serious psychological damage.

I always knew there was something wrong with me. I have an identical twin: a perfect control. He played and made friends and I did not. He was happy, attentive, affectionate, sensitive, witty and loquacious. I was not. I kept hoping and waiting for nature to sweep me up and usher me through all the developmental stages I'd seen him effortlessly glide through but it never happened.

Throughout my childhood I'd felt discomfort in my back but didn't pay it much attention until, when I was nineteen, I smoked marijuana for the first time and I saw clearly in that instant that this discomfort was muscle pain coming from a spot halfway up my back to the left of my spine, and I saw it was this that had been ruining me. I "saw" this because marijuana connected my feelings with my consciousness and cognitions, and marijuana reduced the pain's distress and intensity, and that sudden drop in distress and intensity, which I'd never experienced before, drew the pain to my attention.

I tried all the drugs and therapies but the most effective intervention was simply lying down for hours. Marijuana eased the pain but it took a serious toll in weariness and stupidity. And if I rubbed a spot on my back at the centre of the pain it sometimes helped a bit.

Three years later, at the beach, somebody touched me there and said, "What's that scar?"

I asked Mum and she told me I'd had a birthmark X-rayed when I was a toddler to accelerate the birthmark's involution.

If the pain intensity rises more rapidly than usual (from extreme exertion, say) or falls more rapidly than usual (from, say, smoking dope) then it comes sharply into consciousness. But when the pain's intensity follows its usual slow temporal course, when it creeps up on me and fades away slowly, I don't notice it. The distress, however, is undiminished and, when it is intense, it crushes me.

This sensory inuring or habituation might be a function of Melzack and Casey's third dimension of pain, the cognitive-evaluative dimension.

Pain science is familiar with analgesia caused by the excitement of sport or war where a player or combatant can temporarily experience no suffering and no awareness of pain in very traumatic injury, like a severed tendon or limb amputation. This is thought to be cognitive suppression of both the sensory and affective dimensions of pain.

Distraction, hypnosis and placebo, three more cognitive processes, can all modify both the affective and sensory dimensions of pain, or just the affective dimension depending on context.

I've never read an account of pain's sensory but not its affective dimension being suppressed by a cognitive process ... or by any other process for that matter. This may be addressed in the homeostatic feeling literature, I suppose. I've got a lot more reading to do.

I've just started listening to "Look again: The power to notice what was always there" (2024) by Tali Sharot and Cass R. Sunstein, and here are some quotes and notes:

"Your brain stops responding to things that don't change."

Proving my claim that hunger, sleep-deprivation and pain all cause the distress syndrome (incomplete)

Social feeling

Hunger impairs social feeling:

• One of Laurence Rees's informants for his book, The Holocaust, has this to say about life in a concentration camp: "The feeling of hunger is such an overpowering feeling that it covers up any other feeling, any other human feelings."

• Richard J Evans describing life in the Warsaw ghetto in his book, The Third Reich at War: "Hunger led to a deterioration in social relations ..."

• @UAExplainer posted this about hunger in Soviet Ukraine: "Communities and families fell apart; trust was broken. The social and political life of Ukraine was deeply scarred by the Holodomor."

Sleep deprivation impairs social feeling:

• A recent article in PLoS Biology by Simon et al. concluded sleep deprived people are less likely to be kind or generous.

Pain impairs social feeling:

There is no science on the impact of pain on social feelings. All I have for now is my own self-report, but I assume all intense distress, regardless of its source, impairs social feeling.

Irritability

Hunger causes irritability:

• Ackermans, M. A.; Jonker, N. C.; Bennik, E. C.; de Jong, P. J. (2022-01-01). "Hunger increases negative and decreases positive emotions in women with a healthy weight". Appetite. 168: 105746. doi:10.1016/j.appet.2021.105746. ISSN 0195-6663.
• Weinreb, Linda; Wehler, Cheryl; Perloff, Jennifer; Scott, Richard; Hosmer, David; Sagor, Linda; Gundersen, Craig (2002-10-01). "Hunger: Its Impact on Children's Health and Mental Health". Pediatrics. 110 (4): e41–e41. doi:10.1542/peds.110.4.e41. ISSN 0031-4005.

Sleep deprivation causes irritability:
I haven't started searching the literature again for irritability in sleep deprivation but, for now, just look at any sleep-deprived toddler.

Pain causes irritability:

• Thomas Dormandy in "The Worst of Evils", Ch 18: an 1819 account of a man suffering from a stone in the bladder: "The patient's social and professional life became increasingly restricted. He noticed with alarm that, perhaps because of his frayed temper, he was shunned by former friends and business associates."
• Kenneth L. Casey, "Chasing Pain" 2019 p. 70: "... pain that is more severe and prolonged often has serious behavioral consequences such as misdirected anger ..."

I assume all intense distress, regardless of its source, amplifies irritibility.

Cognitive dysfunction

Hunger impairs cognitive function:

• Weinreb, Linda; Wehler, Cheryl; Perloff, Jennifer; Scott, Richard; Hosmer, David; Sagor, Linda; Gundersen, Craig (2002-10-01). "Hunger: Its Impact on Children's Health and Mental Health". Pediatrics. 110 (4): e41–e41. doi:10.1542/peds.110.4.e41. ISSN 0031-4005.

Sleep deprivation impairs cognitive function:
I haven't started re-searching the literature for cognitive dysfunction in sleep deprivation yet. It's there. I saw it in the 2000s. For now, just ask yourself how quick and sensible you are when you've had a sleepless night, or how safe you would feel in the hands of a sleep-deprived airline pilot or surgeon.

Pain impairs cognitive function:

• Moriarty, Orla; McGuire, Brian E.; Finn, David P. (2011-03-01). "The effect of pain on cognitive function: A review of clinical and preclinical research". Progress in Neurobiology. 93 (3): 385–404. doi:10.1016/j.pneurobio.2011.01.002. ISSN 0301-0082.
• "But middleton was now seriously troubled and weakened by the pain of an arthritic knee and his staff were conscious that this reduced his ability to concentrate on the battle." — "Overlord", Max Hastings. Ch. 9.

I assume all intense distress, regardless of its source, reduces cognitive prowess.

Footnotes and references

I'll populate this with citations if I ever get journal access again.

Scratchpad (ignore)

• The anterior cingulate cortex embodies pain affect. [1]
• Thomas Beddoes (1806) "A Manual of Health, or the Invalid Conducted Safely Through the Seasons", p 75:

  "Upon examining a particular child it has occurred to me many scores of times to ask the parent, 'Pray, have you any more children?'

  " 'Yes but they none of them complain.'

  " 'Be so good as to bring them. I would wish to examine them myself.'

  "A child roars when suffering from a sharp pain but when pain creeps on them by degrees, when they find themselves in dull pain, they will rarely complain, and yet that is when I need to see them."

  Quoted on page 166 in "The Worst of Evils: The Fight Against Pain" (2006) by Thomas Dormandy.

• "When depression is well marked its exact form varies greatly — grief finding causes for unhappiness in the past, fear which seeks them in the future, and a simple sense of wretchedness about the present seem the primary types." ... "In part, the mood expresses the individual temperament as determined by the interaction of inborn constitution with the sum of experience, remote as well as recent." — Mapother, Edward (November 13, 1926). "Discussion on Manic-Depressive Psychosis". British Medical Journal: 872-879.

• "... even when opium does not abolish pain, the pain no longer preys on the person's mind." Diocles of Carystus, a contemporary of Galen quoted in Thomas Dormandy, "The Worst of Evils: The Fight Against Pain" (2006), Ch. 2.

• "The image that guides me is what I call 'tracing autism'. I first heard this term used by a mid-career psychiatrist and brain imager whom I met toward the end of this project. He tried without success to get me to understand the difficulty but also the sense of possibility that surrounds image-based neurobiological work on something like autism. He described how a person might have a very pure, identifiable and innate genetic lesion that disturbed their language functioning. Because of the person's language problems, the psychiatrist pointed out, people in their environment would react differently to them. So, this very small and innate molecular difference would radically alter that person's social surroundings. This environmental input might then lead to a measurable biological difference elsewhere in their brain which someone like this psychiatrist might measure—but now as a relation to these other levels, and one that looped back into them in its turn."—Fitzgerald, Des (2017) Introduction: "Tracing autism: uncertainty, ambiguity, and the affective labor of neuroscience". In vivo. Seattle: University of Washington press. ISBN 978-0-295-74191-8.

• "Glenn Close's family provided one of the first examples of the application of genetics in psychiatry. In 2011, her sister Jessie and nephew Calen volunteered for a research study at the McLean Hospital in Massachusetts led by Dr Deborah Levey, a psychologist at Harvard. A genetic analyisis of Jessie and Calilen's DNA using ROMA revealed that they shared a rare genetic varient resulting in extra copies of the gene that produces the enzyme that metabolizes the amino acid glycine, which has been implicated in psychotic disorders as it helps to modulate activity of the ecxitatory neurotransmitter, glutamate. Extra copies of this gene meant that Jesse and Calin were deficient in glycine, since their bodies overproduced the enzyme that metabolised glycine. When Dr Levy gave them supplemental glycine, Jessie and Calen's psychiatric symptoms markedly improved. 'It was like watching a patient's fever decline after giving him aspirin.' When they stopped taking the supplemental glycine their symptoms worsened.'

From Jeffrey Lieberman, "Shrinks" (2015), chapter 10.

Lieberman reads this glycine supplement as having addressed a brain chemical imbalance (which it did) and wonders about glycine's specific role in mental disorder. But glycene plays an essential role in every cell in the body. The glycine supplement addressed a chronic, background homeostatic distress.

• Robert Spitzer, main author of DSM III, defines mental illness: "In DSM III, each of the mental disorders is conceptualised as a clinically significant behavioural or psychological syndrome or pattern that occurs in an individual and that is typically associated with either a painful symptom (distress) or impairment in one or more important areas of functioning (disability).

"In addition, there is an inference that there is a behavioural, psychological or biological dysfunction, and that the disturbance is not only in the relationship between the individual and society. When the disturbance is limited to a conflict between an individual and society, this may represent social deviance, which may or may not be commendable, but is not, by itself a mental disorder." — Quoted in "DSM III: A history of psychiatry's bible" (2021) by Allan V. Horowitz, chapter 3.

• Allan V. Horowitz in "DSM III: A history of psychiatry's bible" (2021), chapter 6: "Some researchers go even further, claiming that a single dimension similar to the g factor in intelligence, that provides a summary measure of general mental ability, accounts for all types of psychopathology accross the lifecourse. 'Today's patient with schizophrenia was yesterday's boy with conduct disorder or girl with social phobia and tomorrow's elderly person with severe depression', psychologists Avshalom Caspi and Terry E. Moffitt assert."

Avshalom and Moffitt's proposal is in this 2018 American Journal of Psychiatry article. They discuss "the new idea that there may be one underlying factor that summarizes individuals’ propensity to develop any and all forms of common psychopathologies," which they call p.

This p factor is, obviously, distress.

Suicide

Compare rates in chronic pain, itch, dyspnea, etc., with suicide rates in mental illness.