Does Pain Always Hurt?

If you want to understand how a complex system works, and you don’t have the design specs or user’s manual, one way to get some insight is through reverse engineering. This often involves breaking one part of the system and seeing what happens. If you want to apply this technique to understand the pain system, you can’t just go out and break people, but you can find people who are already broken and try to find out why.

That is why pain scientists are interested in the rare cases where the system has gone totally haywire, such as congenital insensitivity to pain, allodynia, or phantom limb pain. These cases are a rich source of insight.

I recently read about a very bizarre example of pain system brokeness called pain asymbolia. I’m not sure what the takeaway is, but it is definitely thought provoking.

Pain asymbolia patients can feel pain and describe its quality and intensity. But they don’t consider it unpleasant, or feel very motivated to do anything about it! How can pain not be unpleasant? That sounds like a contradiction in terms. Like watching a Twilight movie, but it doesn’t suck. How can pain not hurt?


Feeling pain and being in pain

To understand pain asymbolia, it is useful to contrast it with congenital pain insensitivity. People with this condition are born without functioning nociceptors, and therefore do not receive any warning signals from their bodies at all. Their other sensory signaling is intact, so they can feel a knife cutting through their leg. They just don’t feel any associated pain. So in order to protect themselves from harm, they have to memorize the sensations that occur with tissue damage, and then take immediate action when they sense them. In other words, they have to create their own pain alarm system from scratch.

Pain asymbolia patients have functioning nociceptors, and can therefore experience pain in vivid detail. They can describe the location, intensity and character of a painful stimulus, whether it is strong or weak, burning, stinging, stabbing, etc. They just don’t consider the pain unpleasant and they are not motivated to avoid it. In fact, they may giggle or smile as the stimulus is being applied!

It appears that pain is like a dish composed of separate ingredients. In pain asymbolia patients, for some reason the “ouchness” is missing. Like a cake that has no sugar, the whole point of the experience is lost. The technical explanation for this omission is that the “sensory-discriminative” dimension of pain is intact, while the “motivational-affective” dimension is missing. Apparently this dimension is provided by the insula and the parietal operculum, because pain asymbolic patients have almost invariably sustained brain damage in these areas.

What about the reverse problem – can we have the motivational-affective part of pain without the sensory- discriminative part? The sugar without the cake? In his book Feeling Pain and Being in Pain, Nicola Grahek discusses some examples that seem to qualify, such as one patient who could not locate or describe the character or intensity of pain caused by a precise laser to his hand. All he knew was that there was some vague, undefined badness between his shoulder and hand that he wanted to avoid.

So what?

So is any of this knowledge relevant to people without brain damage? I think it’s useful to know that the unpleasantness of pain can be separate from its character or intensity. My personal experience is that the intensity of pain is not identical to its unpleasantness. Of course there is a correlation, but there is often an observable disconnect.

For example, I find that I can tolerate a good degree of pain in my knee or foot without getting distracted, but even a slight disturbance in my neck or upper back drives me nuts, and gets all of my attention until the problem is solved. I recall one time when I had some sort of (thankfully temporary) illness that for some reason caused a huge amount of nervy pain to wander around all over my back for a few days. Although it certainly wasn’t any fun, there was definitely something about it that didn’t bother me as much as it should have. And it had a peculiar character as well. I almost felt that it didn’t belong to me, as if there was pain in the air and I just walked into it. Sometimes I would tell my wife: “Wow this really fucking hurts!”, as if I was more impressed than aggrieved. But let’s face it, I did a lot of whining as well.

My clients seem to have quite different attitudes towards pain. Some can go for years with nonstop serious pain and they don’t really seem very bothered by it or motivated to cure it. Dealing with pain is a just low priority in their life. The motivational aspect of pain isn’t as strong for them. Others will go to great lengths to deal with seemingly minor annoyances, such as tightness, asymmetry or just a vague sense of wrongness in certain areas.

I have noticed that some of my clients who suffer the most pain also seem to have the highest pain tolerance. I recall one client who hurt all over. I pressed at one point and said “I’m sorry does that hurt?” She was proud of being tough and said “you can’t hurt me.” I said “no you are incredibly easy to hurt. You just don’t care that much when you do.”

I wouldn’t call her a pain asymbolic, but perhaps we are all on a spectrum, where some of us have brains that tend to add less unpleasantness to the pain recipe than others. Perhaps learning to cope with pain involves developing some ability to modify the recipe.

This reminds me of a saying associated with Buddhism, which draws a distinction between pain and suffering: “pain is inevitable, suffering is optional.” The suggestion is that mindfulness cannot be expected to remove pain, but it can lessen how much we suffer from it. I have heard similar ideas from pain experts like Bronnie Thompson and Neil Pearson. I think this is a powerful message for people dealing with persistent pain.

What do you think? Have any good pain stories? Share in the comments.

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14 Responses to Does Pain Always Hurt?

  1. Hi Todd,
    Thanks for the interesting post. Indeed, I suspect (as do a number of others) that much of the brain’s processing for painful and non-painful aversive events is similar. What makes a stimulus painful may have less to do with which specific regions, and more to do with when and how (e.g. in what context) they are active. I discuss some of this in my recent paper if you’re interested
    Cheers ~dave~

  2. In years of practicing combat sports, my training partners and I developed an appreciation for various types of pain. As beginners, all we knew was that something HURT and it was time to stop. As we became more skilled at interpreting the subtle pain data, we learned to differentiate between pain that could be ignored and pain that needed to be responded to immediately.

    For example, the pain of minor abrasions might be very intense, but didn’t really matter… while the far less-intense pain of a joint lock required immediate submission or countermeasures. Interestingly, the abrasions represented real tissue damage, while joint locks rarely resulted in actual injury… though the potential for damage FAR exceeded any abrasions we’d acquire. We had therefore learned to “prioritize” different types of pain based upon potential performance/health impairment as opposed to simple pain intensity.

    • Hi Jason,

      Thanks for stopping by. VERY interesting thanks for sharing. Yeah abrasions suck. I play soccer on artificial field grass, which is great for everything except sliding, which basically rips your skin off. Awful.

      Reminds me of something that Barrett Dorko mentions in his workshop – that a prolonged pinch can bring very intense pain, even though there is never really any danger of lasting tissue damage.

  3. Todd,

    I have participated in medieval armed combat with the Society for Creative Anachronism for over a year and investigating my relationship to pain is a constant endeavor. Being struck very hard with rattan sticks (basically bamboo), even in armour, is painful and the pain is a motivating factor to improve,but I find it intriging how repeated exposure to intense strikes seems to trivialize it my response to the sensation. I was struck hard enough last night on my chest to make me take a few deep breathes, but I was back in the action rather quickly.

    I am interested if other martial artists have a similar experience.

  4. I suspect, though I am not sure how to confirm this, that pain intensity varies in large part due to past experiences associated with a particular pain. In the world of BodyTalk for example, an active or emotionally charged memory will affect how any subsequent, similar pain is perceived.

  5. Todd,
    It amazes me how you always bring up such topics that have been swirling around my head, and just when I think they won’t be addressed, here you come along with this post and the Comfort Hypothesis, for example. I have worked in the rural/farming community for years, and only times they stop is when something prevents them from doing their job, like if they can’t raise their arm to feed the livestock or can’t quite lift their leg up enough to get up in the tractor, then they may decide that the pain is real enough to do something about it. Good work and thank you for this timely post.

  6. As far back as I can remember I have not experienced pain as everyone else. When as a child playing with my cousins I just thought that they were wimps when it came to pain.I am now 58 and have amazed doctors when I don’t take the pain pills they give me after surgery or giggled when going through physical therapy. At times when I’ve worked in offices I’ve bumped into the desk and when someone would ask didn’t that hurt and I’d say yeah rub it and just tell them I didn’t hit it as hard as it looked. I broke my ankle one time and no one could figure out that I teared up when it first happen but at the hospital I asked if I could have a punch card to work on getting a free coke from the cafeteria. I had been in the week before for a spider bite. Its a total different from what I have seen and told. I wake up from surgery and they try to give me pain pills. I refuse them stating that I feel a soreness but not a pain. I joke a lot when I get hurt and that is my way of dealing with what I feel, which isn’t much. I just recently realized that my situation actually has a name, which I heard on Criminal Minds….love that show. Thank you Dr. Spencer Reed for the information. Anyway that is some of my story. Thanks for listening.

    • On another note. I have never, to my knowledge had any kind of brain injury but I did work with Shetland ponies breaking them for the carousel. Got thrown a few times but that never bothered me and we had a farm that I helped out at too for awhile.

    • OMG!! I heard about this also from Reid on Criminal Minds!! thats so cool!! I Really wanted to know about a person that had that kind of medical condition, thats so wired.

  7. I have experienced this to some extant. I can tell you that it is not a desirable condition.
    I was beaten up a lot as a child. And all of a sudden one day my crying stopped and the cane or the object I was being hit with made no difference to my emotions. So much so that that time on I stopped giving importance to pain even when it was required. I have lived with multiple fractures and let them heal themselves more than once in my life. It is also difficult to convince people that I am in need of medical attention because they do not see the pain on my face! On numerous occasions I have ignored pain and have not stopped activity till I was literally immobile. It scares me sometimes.
    It is astonishing though, that of all doctors I have met in my life, and I have seen scores of them for various problems, only one told me that I need medication to start feeling and appreciating pain again. Even doctors seem to be ignorant when it comes to this condition!

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