Real pain deserves real treatment


When a patient comes to us and describes confusing symptoms that don’t seem to fit into any immediate category, we can see it in two different ways: as a challenge, we can rise to, a riddle to solve … or we can see it as an opportunity to denigrate the patient, to imply that they are malingering or that it’s “all in their head.” This tendency is amplified when we are dealing with patients of color or females; interestingly, even if we are of color or female, that’s how implicit bias works. It has become extremely popular lately to claim that chronic pain patients who have conditions like fibromyalgia and complex regional pain syndrome are just malingering or have “functional” pain, as a result usually attributed, when it comes to women, of childhood abuse. These doctors all seem to have an agenda, and that is to insist that almost all causes of severe chronic pain are just psychological problems and not “real”… all in their heads, as they used to say.

Even as a young medical student, I had trouble reconciling this concept with what we know about objective reality. Not a thought goes through someone’s mind that is not the result of ions moving across a membrane through a voltage-gated, ligand-gated, mechanosensitive channel or other similar mechanism. All psychological issues have a physical origin. I say this not to proclaim a deterministic viewpoint without free will but to explain that thinking of the brain in terms of “hardware” and “software” is not accurate. Computers do not alter their physical structure the way an organic brain does. Even the new “neuromorphic” chips don’t, though they can simulate this process to a degree. Patterns of brain activity, when repeated, can reinforce the pathways that led to the initial pattern, making a repeating circuit more likely. This is how we learn to walk, drive a car, and solve algebraic problems. Sigmund Freud knew this when he developed what we know now as psychology.

Dr. Freud was a neurologist, but those who came to follow him later moved away from medicine toward a separate discipline dedicated solely to the mind. Psychology. This discipline of the mind came to expand to great prominence in most Western nations, and with that expansion came a form of medical pareidolia. Pareidolia is when the pattern-matching systems make what I will call a Type 2 error. Type 2 errors happen when a null hypothesis that is false is incorrectly not rejected. In the case of pareidolia, it involves seeing something, usually in a complex image, that is not truly there. This can happen when we mistake a garden hose for a snake or see animals in clouds. It can also happen when a new discipline tries to explain all complex behavior in accordance with its theories. This clearly happened with Freud, who saw all mental illness as the result of some childhood trauma or event.

Many of Freud’s theories have now gone the way of balancing the humors, which is useful to get us started thinking in the right direction but not accurate in the end. That fact has not slowed other “experts” from making the same error. Just because it is possible for a person to suffer from a conversion disorder that causes physical symptoms, like psychogenic dermatitis and even pain. It doesn’t mean every patient with those symptoms should be diagnosed with psychogenic pain syndrome or somatization disorder, conversion disorder, functional neurological symptom disorder, or central sensitization disorder. The latter of which is often used inappropriately in patients who actually have central pain syndrome. Somatization disorder is when someone has multiple symptoms, such as fatigue, GI upset, and headaches. These are also all symptoms of many autoimmune disorders, including lupus, rheumatoid arthritis, and Lyme disease.

The first two are autoimmune disorders, which are usually more common in women than men, and there is no diagnostic test that is 100% accurate. It is estimated that 20 to 30 percent of individuals with RA may have seronegative RA, meaning that tests for both rheumatoid factor (RF) and anti-cyclic citrullinated peptide (anti-CCP) will be negative. So, what happens when a doctor gets these results? Well, that depends. Just like surgeons are likely to see a surgical solution to a problem while an internist might see a medical one, doctors who are primed to see functional neurological disorders like conversion disorder will be prone to diagnosing this condition. Especially when the patient is female. That is because we have persons with medical degrees giving lectures that attribute almost all severe chronic pain to psychological conditions, advocating that these patients be denied any effective medical treatment, going so far as to argue that treatment makes them worse.

The suffering patient becomes more desperate for relief; their behavior closely mimics “drug-seeking behavior” when, in reality, they are relief-seeking.

Many of this new crop of pain “experts” also treat men and women differently, talking at length about how women with a traumatic childhood cannot be treated with certain medications because their experience obviates any diagnosis but psychogenic pain syndrome. Especially when it comes to someone with pain “all over.” This symptom is often diagnosed as fibromyalgia, also called non-joint type rheumatism, coded as M49.7. Fibromyalgia occurs in an estimated 2 to 4 percent of the population, or about 12 million Americans. But in the crusade to get rid of all opiate medications, the new temperance movement is lecturing around the country that there is no real fibromyalgia or really any serious chronic pain syndrome at all. Claiming instead that they can identify trauma in every case and that this trauma is causative.

This is, of course, a non-sequitur. Hardly anyone has a childhood devoid of all traumas. They are also ignoring the fact that many autoimmune and other diseases can cause someone to hurt “all over.” There are over 100 autoimmune diseases affecting up to 12.5 percent of the population. One of them is rheumatoid arthritis (RA), which has a 20 to 30 percent seronegative rate; how do we know that’s what they have? Out of a total of 9,784 adult patients diagnosed with seronegative RA, 564 were found to have spondyloarthritis (SpA). Of those, 44 patients were found to have inflammatory bowel disease. But strangely, only 67 percent of these diagnoses were in females. I say strange because  Autoimmune diseases are more common in women than men. Sjogren’s syndrome 9:1, systemic lupus erythematosus 7:1, RA 3:1, systemic sclerosis 3:1. Psoriatic arthritis, on the other hand, is 1:1 and ankylosing spondylitis, a subset of the spondyloarthritis category, is 1:3, so more common in men.

My question is this: if RA is three times more common in women, how is seronegative RA diagnosed only two times more in women? Could it be because women are more likely to be diagnosed with psychogenic pain or conversion disorder? And with the latest push to insist that pain patients just need tough love, how much more common will episodes of medical pareidolia become? And there is another issue. Many of the major proponents of trauma, only chronic pain syndrome, also use the term centralized pain syndrome or central sensitization syndrome. By this, they mean a heightened sensitivity to pain stimuli, which, in all fairness, many victims of childhood trauma display. But this should not be confused with true hyperalgesia and especially not opioid-induced hyperalgesia (OIH). Many conditions cause hyperalgesia, but true OIH is quite rare.

Opiates can also create a slightly increased sensitivity to pain, but again, this should not be confused with true hyperalgesia, which can, on rare occasions, be triggered by opiates, causing excruciating pain when administered. This is believed to be due to the upregulation of NMDA receptors and the activation of microglia and astrocytes, which contribute to neuroinflammation and increased pro-inflammatory cytokines. Hyperalgesia is recognized from history and signs on physical examination, like allodynia, where any stimulus, even a light touch, causes pain. These patients often need more pain medication than patients without hyperalgesia. OIH is when opiates trigger this condition, as described above. OIH is easy to recognize. Reduce the patient’s pain medication and see if they get worse or better. If they get relief, it may have been OIH; if their pain gets worse, they almost certainly did NOT have OIH.

But all over America, patients who have hyperalgesia and need pain medication treatment are being told that because their pain is from hyperalgesia, they can’t get pain relief. They are taken off their effective treatments and, when they suffer horribly and beg for help, are labeled as drug-seekers. Central pain syndrome is a long-recognized consequence of injury to almost any part of the CNS and can be caused by stroke, MS, tumors, epilepsy, trauma, and even Parkinson’s disease. The pain can be lacerating, aching, pressing, or “pins and needles,” affecting a large portion of the body or just a single limb or even a hand or foot. Pain can be constant and moderate to severe, often getting worse with any stimulation, including touch, movement, temperature change, especially cold, and even emotions. There can even be bursts of sharp pain like that caused by a nerve injury or dental procedures. They can also experience numbness, burning sensations, and loss of touch sensation.

This can happen months or even years after head trauma or micro-stroke. Imagine going in a year after a head injury and trying to explain that you are having these symptoms and being taken seriously. Especially with a new crop of experts insisting that almost all chronic pain has a psychogenic origin. Well, we don’t have to imagine. Just look at the case of Ryan Larkin. Ryan was the son of a Navy Seal and went on to become one himself, serving as a combat medic and volunteering to serve back-to-back tours in Iraq and Afghanistan. He served on four heavy combat tours between 2008 and 2013, where he also worked as an explosives breacher. Seals are multitalented. He was also qualified as a sniper. These are the only Navy guys that Marines like me revere. The breacher position put him near to the powerful blasts used to blow open doors and walls.

These continuous shocks to the brain are often ignored by the military and VA but often cause visible changes only on biopsy, being invisible to CT, MRI, and even PET.

This is called astroglial scarring and is readily apparent on microscopic staining. When Ryan went home, his family noted that he was anxious and confused, plagued by nightmares, but he still taught breaching classes to new Seals, again putting him close to multiple explosions. When his symptoms became severe, including excruciating headaches, he was diagnosed with PTSD and, over a two-year period, was placed on over 40 different prescription medications. These either made him feel worse or did not help at all, and he became disillusioned with the explanation that it was PTSD and, thus, “only in his head.” He got worse and was designated operationally unfit, and getting angry and continuing to complain got him labeled mentally unstable.

This is the favorite refuge of a defensive physician. We don’t know what it is, so it must be nothing. Ryan felt abandoned by the nation he had dedicated his life to serving and felt like he was a drain on his family. Ryan told his family that he wanted his body donated to traumatic brain injury research and took his life. On autopsy, the brain damage was obvious. A real physical problem that would have probably given him the respect and dignity of treatment and compassion. Unlike those designated “in the mind.” Ignoring what our patients tell us, acting like they are just making things up, and blaming everything on some childhood trauma does nothing to treat the underlying problem. And Ryan is not alone. After initially saying that there were no injuries, the US military now admits that 64 troops suffered from TBI during a missile attack in Iraq.

And it is not only the warrior who suffers; it is also their families and, sometimes, complete strangers. Eighteen people were killed in a mass shooting in Maine by Army reservist Robert Card, age 40. After his death at his own hand, he was found to be suffering from TBI. Showing significant degeneration and white matter inflammation. The dangers of refusing to believe what your patient tells you is happening are not always so stark. Most often, some woman traumatized in their youth are traumatized again when their pain is disregarded and she is treated with condescension. Many of these victims choose a much quieter way out, harming no one but themselves but leaving the world a much poorer and sadder place without them. It is time to stop ignoring what is obvious. These people have real pain and deserve real treatment.

L. Joseph Parker is a distinguished professional with a diverse and accomplished career spanning the fields of science, military service, and medical practice. He currently serves as the chief science officer and operations officer, Advanced Research Concepts LLC, a pioneering company dedicated to propelling humanity into the realms of space exploration. At Advanced Research Concepts LLC, Dr. Parker leads a team of experts committed to developing innovative solutions for the complex challenges of space travel, including space transportation, energy storage, radiation shielding, artificial gravity, and space-related medical issues. 

He can be reached on LinkedIn and YouTube.


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