Comparing pain to chess and music was intriguing. Intuitively, it seems that attention to pain is qualitatively different. Pain impinges on our attentions, while the other two activities are objects of attention. On the other hand, it is certainly possible to focus on pain or distracting one self from pain. The thesis of the article suggests that by directing attention towards pain, it gets worse, while directing attention away from pain can reduce it. This seems to be a testable hypothesis. Is there any study about this?
Yes, a lot of work has been done, and it is a hugely controversial area.
From my reading, the balance of evidence suggests that people can indeed exacerbate their pain by focusing on it, which is why I included the example in the article.
Whether training to ignore the pain makes it go away is harder to say. Some studies suggest that it does, some that it has no effect. Metastudies generally show no statistically significant effects—but I think people here already know to be wary of statistical significance as an end-all. One certain thing is that pain has its own rules, and utilizes several pathways that are not skill-like at all, which makes training it away somewhat iffy.
My colleagues who work on neuroscience of pain tend to be skeptical. Pain specialists I’ve spoken to tend to really like the approach; from what I hear, it has an unpredictable efficacy level (which could indicate that the effect is in large part placebo-based), but it often works extremely well.
A popular review that extolls the method is Morley et al. in Pain (80) 1999. Several self-help books on the subject are often recommended to patients by pain specialists; John Otis’s “Managing Chronic Pain” is very popular.
As for the somewhat-opposing view, check out this Cochrane review (Cochrane is generally a highly reliable source) which shows much smaller effect size (although there still is a positive effect): Cochrane Database Syst Rev. 2009 Apr 15;(2):CD007407.
Hmm. The notion that concentrating on pain makes it worse seems to contradict the finding that mindfulness meditation, which mostly involves concentrating on your feelings, increases pain tolerance even while it thickens the areas related to pain-related processing. E.g. Grant et al. (2010)
Zen meditation has been associated with low sensitivity on both the affective and the sensory dimensions of pain. Given reports of gray matter differences in meditators as well as between chronic pain patients and controls, the present study investigated whether differences in brain morphometry are associated with the low pain sensitivity observed in Zen practitioners. Structural MRI scans were performed and the temperature required to produce moderate pain was assessed in 17 meditators and 18 controls. Meditators had significantly lower pain sensitivity than controls. Assessed across all subjects, lower pain sensitivity was associated with thicker cortex in affective, pain-related brain regions including the anterior cingulate cortex, bilateral parahippocampal gyrus and anterior insula. Comparing groups, meditators were found to have thicker cortex in the dorsal anterior cingulate and bilaterally in secondary somatosensory cortex. More years of meditation experience was associated with thicker gray matter in the anterior cingulate, and hours of experience predicted more gray matter bilaterally in the lower leg area of the primary somatosensory cortex as well as the hand area in the right hemisphere. Results generally suggest that pain sensitivity is related to cortical thickness in pain-related brain regions and that the lower sensitivity observed in meditators may be the product of alterations to brain morphometry from long-term practice.
(For more on mindfulness meditation reducing the effects of pain, see e.g. here, here, here, or here).
On the other hand, mindfulness is a very specific way of paying attention to something—a non-judgemental approach where the unpleasant feelings are just observed as they appear and disappear. It seems reasonable to assume that other ways of focusing on pain might indeed make it worse.
Good question, and both your last paragraph and gregv’s answer are on the right track.
Mindfulness meditation is, above all else, training of attentional control. You choose what to focus at, and how to focus on it. Therefore, instead of focusing on “ohcrapithurtsithurtsithurts” (which would make the pain worse), someone with great deal of meditation experience can easily focus on other thoughts, or on how irrelevant the pain is (which trains the brain to make it irrelevant).
Or at least that’s the theory. Pain is a very complicated mechanism, and many caveats apply.
A side note on cortical thickness: IMHO, it is one of the most useless measures in neuroscience. Ok, fine, it can be a good preliminary note, along the lines of “this area here should be looked at in more detail,” but it doesn’t provide much more information beyond that. You can get increases in thickness due to outgrowth of the neuropil, or ingrowth of axonal inputs from the outside—and these in turn reflect an increase in excitatory or inhibitory or modulatory inputs (or some combination of the three). So in the end, you don’t really have any idea what’s really going on.
My guess is that the cortical thickening reflects an increase in the number of inhibitory synapses. The area gets larger because people get better at suppressing the activity within it.
This can also serve as an illustration of one limit (among many) of fMRI in general. fMRI (in most cases) measures blood flow/oxygenation increases in an area, which is related to neural activity. Neurons fire, they need energy, signals go out to increase blood supply. Area “lights up” on the scanner.
However, what kind of activity are you talking about? Activity of excitatory neurons, which activate an area, requires energy and oxygen, hence blood flow, hence it “lights up.” Activity of inhibitory neurons, acting to shut down or attenuate the actual functional activity of an area, also requires energy, which requires increases in blood flow, which makes the area “light up.” A bright spot therefore can mean “this area is somehow involved in the process I’m looking at,” but it doesn’t tell you if it needs to be activated or deactivated for the function to proceed. As you can imagine, this severely limits interpretation.
Right, I think it depends on how the “mindfulness” is directed. One teacher (Eckhart Tolle) suggests concentrating attention on (sorry for fuzzy terminology) internal energy in your limbs and a general sense of well-being. When pain impinges on this meditation, you notice and try to redirect your attention.
The thesis of the article suggests that by directing attention towards pain, it gets worse, while directing attention away from pain can reduce it. This seems to be a testable hypothesis. Is there any study about this?
Random anecdotal evidence: I used to do a lot of fire performance, and this was definitely true for that. Once you knew that the weather conditions were such (humidity makes it burn hotter) that you could hold a transfer til it went out on its own (and had the experience to do so), then you could just ignore the sensation, and barely feel it (since you didn’t have to track when you had to put it out yourself).
IF however, you had to put it out yourself (because you’re either not ready yet to hold it til it goes out on its own, or if weather conditions are bad or unknown), then you would have to maintain some awareness/focus on the feeling. The sensation would remain minimal, until it reached a point where you had to pay attention to it (to put it out), and then it would instantly jump to pain-level.
(Note for those who are interested: The first step with dealing with these sorts of painful sensations ISN’T to direct attention elsewhere, but rather to first to get rid of fear. Fear leads to attention, and maximizes pain. Lack of fear leads to the ability to NOT pay attention to pain.)
I’m not sure there is a study about directing attention to pain, but there is a video game being used to reduce pain, presumably by directing attention away from it.
Patients often report re-living their original burn experience during wound care, SnowWorld was designed to help put out the fire. Our logic for why VR will reduce pain is as follows. Pain perception has a strong psychological component. The same incoming pain signal can be interpreted as painful or not, depending on what the patient is thinking. Pain requires conscious attention. The essence of VR is the illusion users have of going inside the computer-generated environment. Being drawn into another world drains a lot of attentional resources, leaving less attention available to process pain signals. Conscious attention is like a spotlight. Usually it is focused on the pain and woundcare. We are luring that spotlight into the virtual world. Rather than having pain as the focus of their attention, for many patients in VR, the wound care becomes more of an annoyance, distracting them from their primary goal of exploring the virtual world.
Comparing pain to chess and music was intriguing. Intuitively, it seems that attention to pain is qualitatively different. Pain impinges on our attentions, while the other two activities are objects of attention. On the other hand, it is certainly possible to focus on pain or distracting one self from pain. The thesis of the article suggests that by directing attention towards pain, it gets worse, while directing attention away from pain can reduce it. This seems to be a testable hypothesis. Is there any study about this?
Yes, a lot of work has been done, and it is a hugely controversial area.
From my reading, the balance of evidence suggests that people can indeed exacerbate their pain by focusing on it, which is why I included the example in the article.
Whether training to ignore the pain makes it go away is harder to say. Some studies suggest that it does, some that it has no effect. Metastudies generally show no statistically significant effects—but I think people here already know to be wary of statistical significance as an end-all. One certain thing is that pain has its own rules, and utilizes several pathways that are not skill-like at all, which makes training it away somewhat iffy.
My colleagues who work on neuroscience of pain tend to be skeptical. Pain specialists I’ve spoken to tend to really like the approach; from what I hear, it has an unpredictable efficacy level (which could indicate that the effect is in large part placebo-based), but it often works extremely well.
A popular review that extolls the method is Morley et al. in Pain (80) 1999. Several self-help books on the subject are often recommended to patients by pain specialists; John Otis’s “Managing Chronic Pain” is very popular.
As for the somewhat-opposing view, check out this Cochrane review (Cochrane is generally a highly reliable source) which shows much smaller effect size (although there still is a positive effect): Cochrane Database Syst Rev. 2009 Apr 15;(2):CD007407.
Hmm. The notion that concentrating on pain makes it worse seems to contradict the finding that mindfulness meditation, which mostly involves concentrating on your feelings, increases pain tolerance even while it thickens the areas related to pain-related processing. E.g. Grant et al. (2010)
(For more on mindfulness meditation reducing the effects of pain, see e.g. here, here, here, or here).
On the other hand, mindfulness is a very specific way of paying attention to something—a non-judgemental approach where the unpleasant feelings are just observed as they appear and disappear. It seems reasonable to assume that other ways of focusing on pain might indeed make it worse.
Good question, and both your last paragraph and gregv’s answer are on the right track.
Mindfulness meditation is, above all else, training of attentional control. You choose what to focus at, and how to focus on it. Therefore, instead of focusing on “ohcrapithurtsithurtsithurts” (which would make the pain worse), someone with great deal of meditation experience can easily focus on other thoughts, or on how irrelevant the pain is (which trains the brain to make it irrelevant).
Or at least that’s the theory. Pain is a very complicated mechanism, and many caveats apply.
A side note on cortical thickness: IMHO, it is one of the most useless measures in neuroscience. Ok, fine, it can be a good preliminary note, along the lines of “this area here should be looked at in more detail,” but it doesn’t provide much more information beyond that. You can get increases in thickness due to outgrowth of the neuropil, or ingrowth of axonal inputs from the outside—and these in turn reflect an increase in excitatory or inhibitory or modulatory inputs (or some combination of the three). So in the end, you don’t really have any idea what’s really going on.
My guess is that the cortical thickening reflects an increase in the number of inhibitory synapses. The area gets larger because people get better at suppressing the activity within it.
This can also serve as an illustration of one limit (among many) of fMRI in general. fMRI (in most cases) measures blood flow/oxygenation increases in an area, which is related to neural activity. Neurons fire, they need energy, signals go out to increase blood supply. Area “lights up” on the scanner.
However, what kind of activity are you talking about? Activity of excitatory neurons, which activate an area, requires energy and oxygen, hence blood flow, hence it “lights up.” Activity of inhibitory neurons, acting to shut down or attenuate the actual functional activity of an area, also requires energy, which requires increases in blood flow, which makes the area “light up.” A bright spot therefore can mean “this area is somehow involved in the process I’m looking at,” but it doesn’t tell you if it needs to be activated or deactivated for the function to proceed. As you can imagine, this severely limits interpretation.
Right, I think it depends on how the “mindfulness” is directed. One teacher (Eckhart Tolle) suggests concentrating attention on (sorry for fuzzy terminology) internal energy in your limbs and a general sense of well-being. When pain impinges on this meditation, you notice and try to redirect your attention.
Random anecdotal evidence: I used to do a lot of fire performance, and this was definitely true for that. Once you knew that the weather conditions were such (humidity makes it burn hotter) that you could hold a transfer til it went out on its own (and had the experience to do so), then you could just ignore the sensation, and barely feel it (since you didn’t have to track when you had to put it out yourself).
IF however, you had to put it out yourself (because you’re either not ready yet to hold it til it goes out on its own, or if weather conditions are bad or unknown), then you would have to maintain some awareness/focus on the feeling. The sensation would remain minimal, until it reached a point where you had to pay attention to it (to put it out), and then it would instantly jump to pain-level.
(Note for those who are interested: The first step with dealing with these sorts of painful sensations ISN’T to direct attention elsewhere, but rather to first to get rid of fear. Fear leads to attention, and maximizes pain. Lack of fear leads to the ability to NOT pay attention to pain.)
I’m not sure there is a study about directing attention to pain, but there is a video game being used to reduce pain, presumably by directing attention away from it.
http://www.hitl.washington.edu/research/vrpain/
Edit: From the page: