A Multidimensional Approach to Pain – Dr Chris Hayes

From Genesis 3 to contemporary pain services

12 MINUTE READ

from Luke’s Journal 2018 | Pain & Faith | Vol.23 No.1

Modern neuroscience highlights the fact that the experience of pain is much about the brain and nervous system. 

Two people may have the same bodily structural change, such as a lumbar disc prolapse, and yet one reports pain while the other does not. This discord is explained by the understanding that an interpretation is made at the level of the brain about the degree of threat – the greater the perceived threat the more likely the person to experience pain. Hence, pain can be seen as part of a response designed to protect us from danger.

Humans appear to experience pain in ways that the rest of the animal world does not. Our highly developed minds and complex social networks create ample opportunity for amplification of the pain experience. The way that we experience pain seems to relate to the unique way our consciousness has evolved. 

In this article I will attempt an exploration of foundations in neuroscience and interpretation of Genesis before examining the building that is a modern multidimensional approach to pain.

Genesis 3

In considering the evolution of human consciousness, where better to start than Genesis 3? But before going back to the ancient wisdom, a little more contemporary neuroscience. The book Thank God for Evolution by Michael Dowd1 makes for interesting reading in this controversial space. Dowd explores parallel unifying ideas in the Biblical account and modern scientific understanding. He proposes a ‘quadrune’ brain with each of the 4 layers being fundamental to our evolutionary development. 

  • Firstly, at brainstem level, is the so-called ‘reptilian’ brain. Primary functions relate to sustenance, sex and fight/flight or freeze mechanisms. These powerful drives relate directly to our ancestors’ success, or otherwise, in passing on genetic material to future generations.
  • Secondly comes the ‘old-mammalian’ brain. Dominant functions relate to social bonding and interaction. Think breast-feeding, skin contact and development of more complex social networks. The mid-brain and limbic system are key structural components.
  • Thirdly comes the ‘neo-mammalian’ brain, with the capacity for critical analysis and scenario testing. Structurally, this correlates with development of the cerebral cortex. On the one hand a blessing, on the other a curse when we consider the challenges we now experience with rumination and seemingly never-ending cascades of thought.
  • Lastly, related to development of the frontal lobes, specifically it seems the medial pre-frontal cortex (or 3rd eye in certain traditions), is our human capacity for transcendence, for higher consciousness, for salvation or enlightenment. 

My life as an inhabitant of Planet Earth is clearly enhanced if I am aware of and grateful for the fourfold structure of my brain. I can become better equipped to tackle the challenges of my reptilian brain or ‘lizard legacy’ if I recognise that it developed in a bygone age for a specific purpose that does not necessarily align so easily with life in contemporary times. In observing the chatter of my ‘monkey mind’ I can be grateful for its analytical capacity, as well as reflective about its potential for harm and need for transformation. Learning about the potential for any of the brain areas to be dysfunctional in terms of contemporary life and its ability to lead us into temptation is an essential aspect of spiritual growth. 

“Improving relational dysfunction… can often be part of the journey of recovery from chronic pain.”

Now, back to the beginning, and a Genesis 3 perspective on the evolution of human consciousness. Clearly Genesis can be interpreted in many ways along the spectrum – from literal to allegorical. Perhaps a multitude of meanings does not make any single interpretation less true. However, it is interesting to consider Genesis in terms of evolutionary brain theory. From this perspective the tree in the centre of the garden may equate to the developing nervous system and the serpent our ‘reptilian’ brain. The knowledge of good and evil that comes with eating the fruit refers to the evolution of the human brain to the point of self-awareness. At face value it seems true that we have a capacity to differentiate good and evil that is unique amongst living species on Earth. There came a fall from the state of innocence represented by the garden, and there were consequences. Enmity grew between the serpent and the offspring of the woman. What better metaphor for our very human struggles with our basic drives. Pain was amplified. Presumably pain exists even in the idyllic state of Eden. 

However human brain development meant that pain became more multi-faceted. A social aspect crept in. The woman’s desire would be for her husband but he would rule over her. Or perhaps equally, the man’s desire might be for his wife and she might decline his advances. Relational pain followed the increasing complexity of human interaction and expectations. The earth itself became cursed and the ecosystem put under threat as a consequence of the evolving human brain. What better depiction of our current state of ecological crisis? We also became aware of our impending death in a way that the rest of the animal kingdom is not. 

Finally, we were banished from the garden with cherubim and a flaming sword guarding the path back. Devastating as this picture is, it also raises the hope that a return to Eden is possible. Perhaps the garden remains deep within each of us. The return to this state of innocence is possible but only by way of the sword. We need to die to self. We need to be prepared to become like little children before we can enter the Kingdom of Heaven. Perhaps this is the Christ-like path that Jesus opens for us?

Multidimensional approach

Let us now return to a multi-dimensional approach to pain. We need to recognise that pain has a role even in an idyllic world such as Eden. If I touch a hot saucepan, pain allows me to quickly withdraw my hand before too much damage occurs. An acute pain response such as this is clearly a protective gift.

However the evolution of the brain and humanity’s fall from innocence meant that pain became a more complex gift, if indeed it remains a gift at all. The experience of pain amplified. Cognitively, our expectations, beliefs and fears have great potential to increase the experience of pain.

In the modern world, an extensive social security capacity, along with technological advance, has contributed to disability rates unseen in societies where basic requirements for food and shelter are more difficult to attain. This disability can be seen as another factor contributing to the amplification of pain.

Neuroscience clearly shows that reduced physical activity adds to nervous system sensitisation and increased pain intensity. Environmental degradation, mono-cropping and production of refined high caloric foods add a nutritional layer to nervous system sensitisation and amplification of pain. Pain is no longer the simple experience of the Garden of Eden.

“Relational pain followed the increasing complexity of human interaction and expectations.”

Contemporary treatment of pain follows this multidimensional framework and often benefits from the input of multiple health professionals. A biopsychosocial approach is recommended. Recently this has been inverted and the term ‘sociopsychobiomedical’ coined. This recognises, in the context of chronic pain, that the sociological and psychological factors are generally more important than the biomedical in formulation and treatment.

I work as a pain medicine physician at Hunter Integrated Pain Service, John Hunter Hospital in Newcastle. Our team have found the term ‘whole person’ approach2 to be more suitable than ‘sociopsychobiomedical’ in our discussions with patients. We then differentiate the holistic into five component parts illustrated by the guiding hand shown below left. Making change in any of the areas represented can help to retrain the nervous system and reduce the experience of pain. Behavioural change is the key that can unlock neuroplasticity, bioplasticity and beyond, to whole person plasticity. As human beings, we have the capacity to change at any stage of life if we choose to do so (see figure below).

Biomedical treatments such as medication and surgery can play a role in changing us for the better. However, they tend to be more effective for acute illness or injury and much less so for chronic conditions. Hence the standard approach to treating chronic pain involves medication deprescribing and avoidance of surgery, except for very carefully selected indications.

The mindbody aspect recognises that what we think and feel has great capacity to change our physical state. Unhelpful beliefs and expectations can very directly impact our physical state – in part via nervous, immune and endocrine systems. Activation of the stress response rather than the relaxation response can contribute powerfully to negative health outcomes. On the other hand, activation of the relaxation response can be a strong contributor to healing.

The term ‘connection’ is multi-faceted and hence very useful. At one level it refers to connection with the people around us. Improving relational dysfunction such as that described in Genesis 3 can often be part of the journey of recovery from chronic pain. At another level there is environmental connection. This may be in need of restoration as we think of the ecosystem damage resulting from human behaviour. Spending time in a natural environment can be beneficial in calming an aroused neuroimmnue system. Connection can also be used as a term to introduce discussion of deeper purpose and spirituality. There is a body of research that correlates this deeper connection with well-being and longevity.

Addressing activity is a fundamental aspect of treating pain. The seemingly natural response is to rest in the face of pain. This can have brief benefit at the time of an acute injury. However, mobilisation becomes important at an early stage. From a pain perspective, and particularly in the context of chronic pain, maintaining, or often increasing, activity helps to wind down a sensitised nervous system and reduce pain intensity. 

Nutrition is coming to be recognised as a component part of the treatment of chronic pain, just as it is for other chronic conditions, including diabetes and heart disease. A Western diet, high in refined food and sugars, produces low-grade bodily inflammation which can spill over to contribute to nervous system sensitisation and pain. Changing to a diet high in plant-based whole foods with reduced amounts of refined products and sugars has an anti-inflammatory effect that can contribute to pain reduction over time.

“Healthy individuals live in healthy societies, inhabit healthy ecosystems and recognise the spiritual connectedness of all things.”

To use a de-identified brief case history, Sophia was a 30-year-old woman experiencing chronic pain and fatigue when she was referred to our team. When she attended our introductory education seminar, she particularly noted the importance of psychological aspects and nutrition.

While awaiting a multidisciplinary assessment with our team, she started working with a local counsellor and changed her diet to reduce refined foods and increase vegetable intake. When she attended the assessment two months after the education seminar she had lost 5kg in weight. At the multidisciplinary assessment she reported that her pain and fatigue began when she was 13 years old.

She was diagnosed with fibromyalgia and chronic fatigue syndrome by a rheumatologist the following year. When asked what else was happening at the time of pain onset, she said that her parent’s marriage had ended and her father moved interstate. As the eldest of five siblings, she took charge of her brothers and sisters while her mother returned to work.

In Sophia’s words “my childhood ended”, “the weight of responsibility settled on my shoulders”. Sophia was able to recognise the possible link between her teenage emotional burdens and the pain and fatigue. Her therapeutic approach involved ongoing nutritional focus.

She lost another 5kg over the following six months. She started a regular walking program. She continued to work through the mindbody impact of her childhood experiences. After six months of disciplined attention to her recovery plan, her pain and fatigue had both reduced by 80%.

In attributing cause to her improvement, she felt that all aspects of her whole person plan were important, however, the mindbody aspect seemed most fundamental. She had been able to work through to forgiving her father for leaving the family home and his subsequent lack of contact and support. The anger and negative emotions suppressed at that time were brought to her conscious mind and released. Some time later she was able to re-establish contact with her father. There was a degree of healing of family connections.

Healthy individuals live in healthy societies, inhabit healthy ecosystems and recognise the spiritual connectedness of all things. The path to healing can be longer or shorter. A metaphoric return to the garden can often play a part. This incorporates a dying to self, a letting go of unhelpful cognitions, a mindful simplicity, a healthy connection with others and the planet.

The ancient biblical book of Genesis offers intriguing insights into a multidimensional approach to pain for the modern era.


Dr Chris Hayes 
Chris enjoyed discussion of spirituality around the family dinner table as a child. After marrying Cate they attended churches from various denominations. They have a shared interest in the spiritual dimensions of healing. Chris has an ongoing fascination with the intent of Biblical writers and how ancient wisdom can inform modern life and health care. Chris trained in anaesthetics before plunging into pain medicine. He has been Director of Hunter Integrated Pain Service at the John Hunter Hospital in Newcastle since its foundation in 1997. He is currently Dean of the Faculty of Pain Medicine, Australian and New Zealand College of Anaesthetists. 


References:

  1. Dowd M. Thank God for Evolution. 2009 Penguin Random House
  2. White R, Hayes C, White S, Hodson FJ. Using social media to challenge unwarranted clinical
  3. Variation in the treatment of chronic noncancer pain: the “Brainman” story. J Pain Research 2016;9:701-709.

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