Pain Control Using fMRI

A couple of days ago, the NYT ran an article  on the use of real-time functional magnetic resonance imaging (fMRI) to treat pain and perhaps a host of other symptoms like addiction and depression.  The technology works like a kind of high-tech biofeedback:

Here’s how Omneuron uses fMRI to treat chronic pain: A patient slides into the coffin-like scanner and watches a computer-generated flame projected on the screen of virtual-reality goggles; the flame’s intensity reflects the neural activity of regions of the brain involved in the perception of pain. Using a variety of mental techniques — for instance, imagining that a painful area is being flooded with soothing chemicals — most people can, with a little concentration, make the flame wax or wane. As the flame wanes, the patient feels better. Superficially similar to an older technology, electroencephalogram biofeedback, which measures electrical feedback across multiple areas of the brain, fMRI feedback measures the blood flow in precise areas of the brain.

By giving users feedback about their pain, the technique attempts to create a visual representation of an individual's pain.  That's pretty impressive!  But imagine if we could make interpersonal judgments of pain.  That could really change the way we identify malingerers and the way we calculate damages in court.  As I've noted, I think that new neurotechnologies may someday move us in that direction.

Comments

[Daniel Goldberg]

Cross-posted from PrawfsBlawg comments:

As I've mentioned to Adam over email, I'm skeptical of the claims that fMRI provides objective evidence of pain. As far as I'm aware, fMRI measures correlates, which is not equivalent with the qualia under investigation. Evidence of pain is certainly not the same as the experience of pain itself, especially because evidence may be of varying quality.

Judy Illes et al. refer to this erroneous conflation as a "neurofallacy," and specifically the neurofallacy of "neurorealism." I don't necessarily agree with Adam that the neurotechnologies may move us in that direction, if only because I agree with Searle that there is an ineluctably subjective feature to consciousness (and a fortiori pain) that, IMO, by definition could not be captured by objective instrumentation.

One question which I am answering in my dissertation is why we feel the need to seek objective evidence of pain.

[Anibal]

The explanatory gap- the chiasm between what we feel or sense and the udnerlying physical suubstrate that produce it that we cannot use to explain the very subjetive phenomena- is still at the center in the philosophical debate, and i think nobody actually can elude it, though, nobody knows what will happen in the future.

But in response to the question, my humble opinion, is to remove the burden of mankind which is pain and suffereing. Any way to objectivize pain and then treat it, could help us too much.

Neverthless, neuroimaging has many promises to make come true. And i don´t think as Coltheart (2006) that neuroimaging data cannot distinguise between competing psychological hypothesis. Pain is a psychological state and because what the brain does is the mind, we have to pay attention to the "pain matrix" located in the brain, and felt becuase the brain.

[Adam Kolber]

(Cross-posted reply to Daniel): I absolutely agree that fMRI measures correlates. I just think that if we have sufficiently reliable correlates, that's all we need! If I look at an X-ray and see a large fracture in a person's leg, I can make a pretty good inference that the person X-rayed is in pain. Does the X-ray measure pain? That's an interesting question. Does a thermometer measure temperature or just a correlation between heat and the properties of mercury? I appreciate this inquiry but I don't need to settle it in order to make the claim that fMRI (or the next neurotechnology) can allow us to make more objective inferences about people's pain than we can now.

[Daniel Goldberg]

More cross-posting (with a few edits)!!

(Adam -- this is a great conversation, so thanks for posting on it)

"I absolutely agree that fMRI measures correlates. I just think that if we have sufficiently reliable correlates, that's all we need!"

Need for what? And what is the criteria for sufficient reliability?

"If I look at an X-ray and see a large fracture in a person's leg, I can make a pretty good inference that the person X-rayed is in pain."

I'm less certain of the quality of the inference. It's not unheard of for even large fractures not to result in much pain. In addition, because people's pain responses are so different, what would be agony for one person might simply be a dull ache for another. Thus, while you might be jsutified in drawing an inference of pain writ large, assessing the level of the pain (which is crucial to effective treatment) is another matter entirely. This demonstrates the roughness of the correlation, and, tracking Patrick's suggestion, the excessive caution that is needed in inductively moving from the identification of a neural correlate to a conclusion that the subject of the neuroimaging is experiencing the phenomena asserted.

My own personal opinion is that both scientists and the media generally do not exercise the caution warranted. It becomes all too easy to elide the notion of correlation with ontology, as Illes et al point out.

"Does the X-ray measure pain? That's an interesting question. Does a thermometer measure temperature or just a correlation between heat and the properties of mercury?"

I think there's an easy answer to the first question: no. That does not mean it fails to provide indicia of pain, but the measurement of pain, if it exists via X-ray, is an exceedingly rough heuristic.

"I appreciate this inquiry but I don't need to settle it in order to make the claim that fMRI (or the next neurotechnology) can allow us to make more objective inferences about people's pain than we can now."

I respect your position, but I'm less sure that it doesn't implicate some key premises in your argument. What, for example, would it mean to draw some "more objective inferences about people's pain"? And how exactly would neuroimaging permit this? My point here is that fMRI does not do anything more than enable us to garner information about neural correlates of pain. This, of course, is no mean feat, but interpretation of the meaning of the correlation is still required both on an aggregate and on an individual level, and there is a significant danger, IMO, in presuming that blood oxygenation levels tell us a great deal about a person's pain qualia.

Bear in mind, I'm not remotely opposed to the use of fMRI to improve diagnosis and even treatment of pain. But I do think it is crucially important to identify what we are actually measuring (and what we are not measuring), in large part because I am going to argue that it is primarily our cultural attitudes towards subjectivity that lie at the heart of our consistent problems in adequately treating pain. Thus, thinking that objective evidence of pain will permit better treatment, while not necessarily false, raises a number of questions regarding why we need what we deem to be objective evidence of pain in order to treat it adequately.

[Patrick S. O'Donnell]

Cross-posted from PrawfsBlawg:

Hilary Putnam has offered arguments against even the notion (the picture) of psychophysical correlates (as is typically understood) in his latest writings and the assumption that "psychological states must be pared down to an 'internal core' before they can be metaphysically and scientifically [and legally!] legitimized" is likewise arguable and a topic Putnam has also addressed.

As Bennett and Hacker explain: "The observed neural phenomena that are concomitants of a person's suffering pain...are not forms of *pain-behaviour.* [Keeping in mind that the 'primary grounds or evidence for the ascription of psychological predicates to another are behavioural.'] They are *inductively* correlated with being in pain. The correlation is an empirical discovery, which presupposes the concept of pain and its nexus with criterial, non-inductive evidence for the application of the concept of pain to *a living creature* (not to its brain)." We cannot ascribe psychological attributes to the brain, and I think it is mistaken to believe that "the 'access' which introspection gives each person to his own mental states and processes *is* a limited access to processes going on in his brain," such that the fMRI is somehow going to give us a truer, more objective picture of the experience of pain, one whereby we can detect, for instance, "malingerers." I rather agree, again, with Bennett and Hacker: "The sense in which there is literally any such thing as 'getting inside another human being' is: examining the interior of his body and brain--for there is no such thing (save figuratively) as getting inside his mind. This is not something we cannot do; rather, there is no such thing to do." Getting inside another person's brain, literally or through images of one sort or another, does not tell us what a person is thinking or feeling. "Moreover, given that we can and do establish that different people enjoy or suffer the same experience, differences in the underlying neural processes would not show that, despite their sincere avowals to the contrary, they do not really have the same experience. To think otherwise would be to suppose that someone might sincerely avow pain, groan and scream, but, nevertheless, that a brain scan migh show that the person was not in pain at all. But that is absurd. All that would thus be shown is that a neuroscientific theory, which assumes neural uniformity across different individuals, is false. For the criterial (logically good) evidence for being in pain, which is required for the non-inductive identification of the pain of others, is presupposed by inductive evidence correlating pain with neural states and events, and accordingly overrides it."

Sunny Auyang has also reminded us how the experience of pain is not merely a raw sensation but something close to an emotion" "Besides the ouch the pain has an *affective aspect* that determines its unpleasantness: how badly it hurts and disrupts other mental processes." Indeed, this helps to account for the fact that "mental concentration can sometimes block pain."

The criteria for identifying pain are not located in the head.

See M.R. Bennett and P.M.S. Hacker, Philosophical Foundations of Neuroscience (Malden, MA: Blackwell, 2003). For a counter-argument, i.e., specifically with regard to pain, please see Galen Strawson's Mental Reality (Cambridge, MA: MIT Press, 1994), 215-250.

[Anibal]

Philosophers and scientists have been debated about the nature of pain since antuiquity. For example, Aristotle recognizes pain as an emotion and only ´till nowadays, we can describe pain as an "homeastatic signal" send from peripheral nerve cnduits or tissue in damage to alert the organism to prevent doing what it was doing, because compromise its integrity.

The criteria for identifying pain is in the head, although genetics some factors of personality mix with some enviromental ones, and even the way patients interact with their physicians would create certains variations in the subjective realm.

Rescuing some forms of behaviourism today, to say that to adscribe pain we have to pay attention to "pain behavior" is an anachronism.
Many convergent studies and methodologies ranging from neuropharmacology, physiology, point to the circunscribe pain receptors, c-fibers and delta fibers or large unmylienated pathways trasmiting pain sensation to the thalamus, anterior cingulate cortex (the so called pain matrix)... and that depending on their enhancement in the pattern of activity measure in terms of some hemodynamic parameters, these correlate well with the state of pain and how the telecenphalon or frontal cortex can modulate its feeling sensation.

In the near future, neurotechnology will be cpable to unmask depecetive individuals such as those that intentionally produce false symptoms (e.g.malingerers). Those that today not recognize that the mind is not more than the physiological operations of the brain in concert with the body and in interaction with the enviroment via the outcomes the organism produce, are blocking the advancement of knowledge, because how do we understand and explain something that has not physical grounds?

[Tooth-Grinding]

How can an MRI treat addiction when addiction has so much to do with what happens outside our bodies? I think addiction is so rampant in our society that there will never be a worthwhile treatment option that doesn't highlight the environmental component of addiction

[x-ray fluorescence]

Hi,
The criteria for identifying pain is in the head, although genetics some factors of personality mix with some environmental ones, and even the way patients interact with their physicians would create certain variations in the subjective realm.