Hamlet. Then is doomsday near! But your news is not true. Let me question more in particular. What have you, my good friends, deserved at the hands of Fortune that she sends you to prison hither?
Guildenstern. Prison, my lord?
Hamlet. Denmark’s a prison.
Rosencrantz. Then is the world one.
Hamlet. A goodly one; in which there are many confines, wards, and dungeons, Denmark being one o’ th’ worst.
Rosencrantz. We think not so, my lord.
Hamlet. Why, then ’tis none to you; for there is nothing either good or bad but thinking makes it so. To me it is a prison.
Hamlet. Act II, Scene II
William Shakespeare, 1603
We’ve been talking a lot about meaning at noi HQ over the past week or so. How meaning influences pain; the meaning of stimuli, the meaning of the environment, the meaning of the things we hear and say and the meaning of pain itself.
There’s a rich vein of research going back decades looking at the important relationship between meaning and pain – I’ve picked a few interesting papers to look at below.
The famous American WWII Physician, Henry K Beecher, wrote in his 1956 paper Relationship of significance of wound to pain experienced
“There was no dependable relation between the extent of a pathological wound and the pain experienced. No significant difference was found between the pain of sudden injury and that of chronic illness. The intensity of suffering is largely determined by what the pain means to the patient.” (emphasis added)
In the same paper he also wrote “…the indiscriminate administration of powerful analgesics to all injured individuals is unsound” sadly, a message that is as relevant today as it was over 50 years ago.
In a 2004 paper that the authors considered to be “the first experimental proof reported in the scientific literature that meaning (other than painfulness itself) influences the subjective experience of pain.” Arntz and Claassens reported
“… we have now reasonably solid experimental support for the widely held idea that meaning influences the experience of pain… the present experiment demonstrated that the meaning people attach to a stimulus influences its experienced painfulness.
The present findings are not only of theoretical importance, as they support the hypothesis that higher order psychological processes influence the experience of pain, but also of clinical importance, as they suggest that correction of dysfunctional interpretations of pain might help to reduce the burden the experience of pain poses on many people “
From a clinical perspective, Arntz and Claassens suggest there are obvious implications:
“Patients might easily misinterpret the meaning of their pain, e.g. assume more tissue-damage or a more catastrophic consequence of the underlying process than there actually is. Clarification of their interpretations and correction, if based on misunderstanding, should, according to the present study, lead to a reduction of pain.
…chronic low back patients often interpret their pain as stemming from an injury to their back and consequently are over-concerned about what physical movements they can still execute without causing a fatal damage to their backs (Vlaeyen and Linton, 2000). Recently developed treatments focusing at such misinterpretations are extremely successful, not only in reducing fear and avoidance, but also in reducing the pain experience (Vlaeyen et al., 2001, 2002a,b).”
Lewandowski et al (2005) demonstrated that a guided imagery process, changed the meaning of pain for participants, with a significant shift from “pain is never-ending” to “pain is changeable” noted after imagery along with reports of reduced pain.
Benedetti et al (2012) demonstrated that changing the meaning of experimentally induced pain influenced the experience via endogenous opioid and cannabinoid systems:
“Here we show that when the meaning of the pain experience is changed from negative to positive through verbal suggestions, the opioid and cannabinoid systems are co-activated and these, in turn, increase pain tolerance.
We induced ischemic arm pain in healthy volunteers, who had to tolerate the pain as long as possible. One group was informed about the aversive nature of the task, as done in any pain study. Conversely, a second group was told that the ischemia would be beneficial to the muscles, thus emphasizing the usefulness of the pain endurance task.
Our results indicate that a positive approach to pain reduces the global pain experience through the co-activation of the opioid and cannabinoid systems. These findings may have a profound impact on clinical practice. For example, postoperative pain, which means healing, can be perceived as less unpleasant than cancer pain, which means death. Therefore, the behavioral and/or pharmacological manipulation of the meaning of pain can represent an effective approach to pain management.”
So, where does this meaning come from. I think the Bard answered this when he had Hamlet pronounce “there is nothing either good or bad but thinking makes it so.”
Whose thinking? The person-experiencing-pain’s thinking. The therapist’s thinking. Society’s thinking. There must be opportunity for potent therapeutic benefit here with education, narrative and imagery as powerful modalities.
Arntz A and Claassens L (2004) The meaning of pain influences its experienced intensity. Pain 109 20-25
Beecher HK (1956) Relationship of significance of wound to pain experienced. The Journal of the American Medical Association 161(17) 1609-1613
Benedetti F, Thoen W, Blanchard C, Vighetti S and Arduino C (2013) Pain as a reward: Changing the meaning of pain from negative to positive co-activates opioid and cannabinoid systems. Pain 154 (3) 361-367
Lewandowski W, Good M, Braucker CB (2005) Changes in the meaning of pain with the us of guided imagery. Pain Management Nursing 6(2) 58-67