It's All In Your Head (Goldberg)

I have been interested in pain for at least five years now, and I entered my Ph.D program with an eye towards doing some work on pain.  In doing some of my basic reading on the subject, I devoured Jean Jackson's phenomenal 2005 essay on stigma and chronic pain.  In that article, which has a wonderful bibliography, she noted the forthcoming research of Howard Fields, a neuroscientist at UCSF.  I was enthralled by her description of his theories, and I have literally been waiting for 2 years for the anthology containing his essay to be published.

The wait is over, and I cannot recommend highly enough the entire collection: Pain and Its Transformations: The Interface of Biology and Culture.  One of the aspects of studying pain I've always found so puzzling is why that virtually any clinical handbook or textbook on pain management will pronounce that pain can only be managed multimodally and through multidisciplinary efforts.  Yet there are virtually no truly interdisciplinary approaches to thinking about pain itself.  Most of the law, policy, and ethics' approaches tend to be focused on law, policy, and ethics, without any of the benefits of the integration that is possible through interdisciplinary work (One of the most common erroneous beliefs about interdisciplinary work is that it is really the sum of its parts; rather, such work is emergent in the sense that its lenses arise out of its parts without being reducible to them.  As such, it is, or at least can be, integrative, and is therefore not simply ethics + law + history of medicine).

This book proposes to begin the process of filling that gap by analyzing pain using an interdisciplinary approach, including ritual theory, art studies, music history, and religion.  I was most excited to read Fields's essay, and I was not disappointed.  His most interesting idea is that the presumed distinction between physical and mental pain is incoherent.  Why?

Without delving too much into the history of pain, the dominant biological model of pain over the last 40 years has been Melzack and Wall's gate control theory.  This theory works very well for many kinds of nociceptive pain, but is notoriously unhelpful in unpacking many kinds of chronic pain, such as neuropathic pain and phantom limb pain.  The latter is particularly difficult for gate control proponents to explain, as it is impossible to fit such pain into the gate control theory where there is by definition no organic insult to any tissue (this is because the limb no longer exists!). 

Fields argues that newer models of pain suggest, in point of fact, that pain does not exist in your hand, or your leg, or your back.  Pain is all in your head.  What he means is that our brains have a detailed somatic map, a representation of three-dimensional somatic space.  Pain is projected -- by the brain -- onto the relevant area of this somatic map.  This explains how there can exist phantom limb pain: such a phenomenon is "not surprising since the brain's representation of the limb is intact" (Fields, 43).  Fields concludes: "Once one understands and accepts the concept of projection, it becomes obvious that all pain is mental" (Ibid.)

I think this is phenomenal, and coheres well with the belief that many pain scholars maintain -- including myself -- that, despite our best attempts to dislodge ourselves, mind-body dualism remains an extant and active heuristic in Western conceptualizations of pain, and that this heuristic has deep consequences particularly for those who suffer from chronic pain.  The idea that "pain is all in your head" is either incoherent (to the extent it relies on a strong and dubious mind-body dualism) or means exactly the opposite of what the utterer usually intends.

Thoughts?   

Comments

[Kelly Hills]

Harumn.

It's interesting, and on the one hand I want to say yes, that's sensible. Our brain maps itself to the body we grow up with, which is why people who're missing a sense, for example, tend to use that area of the brain to overdevelop some other sense (the typical areas associated with hearing being diverted to increased tactile response, or whathaveyou).

But, I'm concerned that it might go too far the other way, as well - too far into the mind. I of course am very anti-Cartesian dualism (I probably could have just stopped at anti-Cartesian), but I'm afraid this goes too far into a primacy of the brain/mind, making the body a secondarily relegated object in the dynamic; this conflicts pretty badly with the more autopoietic view I have of the body.

Shantideva has a lovely piece in the Bodhicaryavatara that asks what it means to be "me", where is it that a person resides:
The flesh and skin are not the “I”,
And neither are the body’s warmth and breath.
Likewise, since it is a group of fingers,
The hand itself is not a single entity.
And so it is with fingers, made of joints-
And joints themselves consist of many parts.
The parts themselves will break down into atoms,
And atoms will divide according to direction.

I suppose I'm concerned that the shift is not to one that balances the body and brain, but to one that privileges the brain over the body (rather than the past privilege of body over brain).

[Daniel Goldberg]

Hi Kelly,

Yes, I can see how the post might be taken that way, but I don't think one has to read Fields as being a totalizing mentalist. You're absolutely right to note that we are embodied, and this is in no small part why I'm partial to some of Searle's work on consciousness (because he acknowledges the importance of material structure while arguing that it is quite compatible with the ineluctable subjectivity of mind). I doubt Fields would go so far as to deny embodiment and argue mentalism. I tend to think the idea is quite consistent with an emphasis on the body; it simply points out the flaws of trying to draw some neuroscientifically principled distinction between physical and mental pain.

It's not that we are only mental creatures, nor that the pain one feels in their arm is not physically embodied. It most certainly is, but its roots are in the mind. (At least, that's my interpretation of what Fields is saying).

[Kelly Hills]

Now, keeping in mind I've not read Fields's book... ;-)

Certainly the idea of drawing a difference between "real" (physical) or "imagined" (mental) pain is silly - it's all physical pain; our brain is just as much a part of the meaty flesh of our being as our fingers or heart or eyeballs.

But, what does it mean to be rooted in the mind rather than the body? Isn't the language itself being used emphasizing the split between the two? So even if the effort is to not speak about a dualism, you still end up underscoring just that?

[Daniel Goldberg]

A fair point, but I think that's more an unfortunate choice of terminology on my part. I suppose I would say the point is not that one does not experience pain in the body -- of course one does, but that the notion of pain existing in a physical location in the body contrasted with pain existing "only in one's head" doesn't make a darn bit of sense. For better or worse, all pain is mental even if there remain qualitative differences between different kinds of pain, and those qualitative differences inevitably and obviously are deeply connected to our own emboidment.

I'm also admittedly guilty of using some fairly provocative rhetoric here quite in purpose, and it's legitimate to point out that in so doing I may be legitimizing the duality. That is not my intention; I think Fields' analysis demonstrates its incoherence. Mind is not separate from body though it is not reducible to it, either, pace Searle.

[Patrick S. O'Donnell]

Howdy Daniel!

Does Fields provide us with empirical evidence of these so-called somatic maps? Does he have "pictures" of these three-dimensional representations? Where are these representations located? How did he find them? This would appear to make pain a matter of "perception" rather than "sensation," yes? Does Fields deny, then, that the "criteria of identity of a pain consist in its intensity, location and phenomenological features...?" Is Fields not recapitulating Searls here, who claims that "the pain-in-the-foot is literally in the physical space of the brain," and that "the brain forms a body image, and pains, like all bodily sensations, are parts of the body image." (To which, I think, Bennett and Hacker provide a devastating response.) This thesis is as strong or weak as "representationalism" in the theory of mind, for which it appears to be a species of, yes?

[Daniel S. Goldberg]

Hey Patrick,

The essay is intended for an interdisciplinary audience, so I think Fields is really summarizing a lot of what his research has found. He has published more than a few articles on these matters, some of which are in the reference list for the essay.

I'm not sure I agree that this makes pain a matter of perception rather than sensation; part of Fields' point, I think, is to trouble the distinction between perception and sensation, at least as applied to pain.

I also don't think Fields is committed to denying "criteria of identity of a pain consist in its intensity, location and phenomenological features..." As I remarked to Kelly, nothing Fields says commits him to arguing that we do not experience pain in a phenomenological sense as in the foot, the hand, or the arm. The traditional models of pain take a bottom-up approach. Fields is interested in how pain is modulated from the top-down, and his research suggests there are crucial and profound ways in which all pain is modulated in the brain.

I do think Fields is consistent with much of what Searle argues, which is fortunate, seeing as how Searle's perspective on subjectivity and mind is central to some of my claims re pain. I'm not sure I see the "devastating response" from Bennett & Hacker -- could you elaborate?

I'm not sure the thesis turns on the merits of representationalism, though it's surely friendly to it. In my work, I am not particularly interested in fleshing out the representationalism vs. intentionalism debate, not because it is insignificant in its own right, but because I do not think we need to decide that question to treat pain far better than we currently do. I do think we need to work harder to recognize the influence of mind-body dualism in our conceptualization about pain and work harder to excise it from the clinical gaze. And to that end, suggesting there is an irreducibly mental element to all pain, and that differentiating between "physical" and "mental" pain is nonsensical, is invaluable.

[ctw]

As a layman, I may be (uh, unquestionably am) missing some subtleties, but I don't understand the references to mind-body dualism in this context.

Based on minimal reading in this area, my concept of sensory processes involves the "body" (ie, the nerve sensors) registering effects from external causes and sending signals to the brain. Having read Humphrey's "History of the Mind", rightly or wrongly I have a mental image of something like your description of Fields's "somatic map" of the body. I envision that the brain takes the sensory inputs, relates them to areas on that "map", analyzes them - taking into account intensity, geography, history, et al (see, a multidisciplinary view!) - and determines an "appropriate" reaction, conveyed either directly to the impacted area of the body or possibly indirectly via the "map".

Perhaps biased by being a systems engineer, I see this process not in terms of mind-body dualism but in terms of an integrated system. Is this way off base?

Also, the mental-physical pain distinction with which I am familiar addresses the difference between "mere" mental anguish and "real" physical - ie, "ouch" - pain. This seems a fair distinction whereas given my "integrated system" view, the one I understand to be under discussion here makes no sense to me.

I am reminded of a TV documentary I saw recently about a surgeon (I think in Europe, possibly Portugal) who conducts surgery without anesthesia. The documentary was more along the lines of human interest reporting than scientific explanation, so it didn't address how that might work. But I wonder if it might be relevant to this discussion. Perhaps through some unspecified psychological technique, he is able to convince the patient (ie, the patient's sensory data processing brain) that the "pain" signals indicating trauma can be safely ignored.

Or perhaps he is simply a charlatan and/or the documentary was a hoax. Any opinions?

Thanks - Charles

[Daniel S. Goldberg]

Charles,

It doesn't sound to me like you're missing much at all. Note that, as Jackson argues, part of the reason the gate control theory has enjoyed such dominance despite its obvious problems -- problems that Melzack is only too ready to acknowledge and even embrace, to his everlasting credit -- is that it coheres really well with the mind-body dualism that I and others think remains prevalent in allopathic medicine.

Insult touches somatic tissue, nerve conduction flows to the dorsal horn, up the spinal "gate," and into the brain, which registers the signal, and produces the experience of pain. Given this model, it shouldn't be all that hard to see why many kinds of chronic pain, which usually do not have any identifiable organic insult, don't fit well at all.

I'm kind of partial to systems approaches myself, so I think your manner of describing mind-body interaction is pretty close to the models I tend to favor.

If anything, what you're missing is just how much the mind-body duality continues to pervade biomedical culture, including permeating patients and caregivers' views as well (chronic pain patients are often desperate to find proof of some organic insult).

Re psychology of pain, that's actually the subject of much of the book I reference above. The ability of many different kinds of persons, particularly spiritualists and religious adherents, to seemingly self-anesthetize suggests, as Fields notes, that to think properly about pain we need to go way beyond molecular and neuroscientific analyses.

[ctw]

Daniel -

Since you made the mistake of responding, I'd like to float one more thing by you. I just read a year-old critique of a Searle review of Humphrey's "Seeing Red":

http://blog.atheology.com/2007/02/25/seeing-red-understanding-consciousness

The relevant part of the critique is this argument (actually, my not-necessarily-accurate interpretation thereof). The "red" we "see" is only a creation of our minds. The "red" object actually has no color - it merely radiates (or reflects) light the wavelengths of which cause responses in the eye with which we have been trained to associate a concept we label "red".

This is the view I had even prior to reading this critique, so it is natural for me to consider pain analogously. Just as "red" is an association the brain makes between specific inputs from the optic nerve and previous experiences, "pain" is an association that the brain makes between certain types of inputs from the nervous system (stimulated, I assume, by what you call "organic insult" or some other phenomena) and previous experiences. Hence, in that limited sense, pain "is all in your head".

Since I don't know the lingo in this arena, this may not be syntactically coherent, but does it capture your basic view? Since it seems so reasonable to me, I find it hard to imagine an alternative view that would be reasonable but also incorporate some sort of mind-body dualism.

Thanks - Charles

[Daniel S. Goldberg]

Charles,

I'm not sure the analogy holds. I don't want to set up a strawman here -- few believe that pain is possible without mind. Those who do believe it, like Valerie Hardcastle, are typically referred to as eliminative materialists and are certainly the exception rather than the rule. Pain for many theorists, including Searle, is taken as a paradigm case of consciousness, and it is difficult if not impossible to conceive of pain qualia in the absence of consciousness.

That mind is a sine qua non for pain, however, says little about the connection between mind and body, nor does it necessarily imply that mind and body are fundamentally interrelated phenomena. Searle argues -- persuasively, to my mind -- that consciousness is not some ethereal Cartesian substance floating around that can exist in the absence of neurophysiological structure. He is quite happy to admit that without brain, there is no mind (though this is not to suggest his claim is uncontroverted). His key insight is that this argument does not imply that mind is reducible to brain, either.

In thinking about pain, the age-old duality between mind and body still grips allopathic medicine. You have organic insult, a series of neurochemical changes and electrophysiological signals occur, and voila -- we consciously experience pain (mind). This is, to use Fields' terminology, a bottom-up approach, and few believe that it is utterly useless and of no explanatory value. Indeed, it explains some kinds of pain very well (nociception, mostly).

Fields, however, starts with a different topology altogether: why focus on pain only from the bottom-up? An increasing corpus of evidence suggests that pain is modulated in crucial ways from the top-down, that our consciounsess, our mind, if you will, plays a crucial role in shaping, informing, and even causing or preventing phenomenological pain of all kinds, but especially pain that persists in the absence of tissue injury. This is in part why the evidence that some are apparently able to self-anesthetize is so crucial -- it absolutely shows how the mind's construction of meaning produces our very experiences of pain.

The empirical fact that so many think such pain is "not real" or "imagined" shows the stigma that we attach to experiences of mind, even when those experiences of mind undoubtedly produce embodied and phenomenological experiences "in" the body. The idea many have is that if it isn't visible "in" the body, it isn't real pain. Fields' analysis repudiates this idea, because of his argument that ALL kinds of pain are modulated in significant ways through our consciousness. If so, this certainly suggests that pain is absolutely "real" regardless of whether we experience organic insult or not.

Contrary to the idea that we can meaningfully differentiate between "somatic" pain (that pain associated with organic insult) and "psychogenic" pain (or pain that is mental or psychological), then, the top-down approach suggests a mental, psychological component to all pain experiences, one that goes well beyond the basic truism that mind is necessary for pain.

I hope that helps -- if it doesn't, I'd recommend taking a look at Fields' essay, as well as Jean Jackson's wonderful essay (http://www.blackwell-synergy.com/doi/abs/10.1525/ae.2005.32.3.332)

[ctw]

Daniel -

Thanks for your response which was indeed helpful.

The analogy with "red" was only meant to suggest that whatever the source of stimuli, it's the brain that creates "pain" just as it's the brain that creates "red". When I wrote the comment, I kept the analogy going by alluding to pain stimuli analogous to inputs from the optical nerve, but I didn't mean to preclude other sources: signals (somehow corrupted) from locations in the body other than the apparent one, signals from the body "map" resident in the brain, et al. In any event, the analogy should hold if we can "see" red even with no stimuli external to the brain. (Not to suggest that we can - I have no idea other than just now trying with seemingly little success.)

I find it interesting that consciousness seems so hard for even specialists to discuss, never mind explain. Your phrase "ethereal Cartesian substance" nicely captures the rather surreal tone of some of the few discussions I've read. I eagerly await progress in understanding the phenomenon.

- Charles