Sleeping, dreaming, hurting?

David Eagleman:

“So there’s one theoretical framework that says maybe dream content is about simulating and practising through different sorts of threats…” 

Maybe dream content is practising this stuff so that you can keep those circuits well oiled, that’s one hypothesis, so one of the consequences of the hypothesis is that people who live in, lets say war torn areas with a lot of violence around them might have an over representation of violence and fighting in dreams, but that study was done just a few years ago comparing people in really terrible areas in South Africa where there is a lot of violence to people somewhere in a wealthy neighbourhood where nothing ever happened and what they found was that there was no difference in their dream content in terms of the level of violence”

Eagleman goes on to say that other research has shown that the content of dreams is pretty consistent across time frames – we have basically the same dreams that our parents, and grand parents and great-grandparents had.

The hypothesis regarding dreams being for simulating and practising through different sorts of threats had me thinking about pain – can we hurt while sleeping and dreaming? (If you don’t want to keep reading, please skip to the comments if you have any direct or indirect of dream pain because I’m very interested in collecting people’s thoughts)

My initial thought was “no!” Pain is a conscious experience and by definition can not be experienced when ‘unconscious’ (I’m aware that the definition of, and distinction between, conscious/unconscious is a can of worms – and it’s one I’m not going to open here).

Checking out the literature didn’t really help – there isn’t too much at all on experiencing pain while you dream, but there were a few interesting nuggets.

Going back some way, in 1966, Nelson asked whether it is possible to tell if one is awake by pinching oneself. Nelson argues that “pain is a mark belonging to waking experiences and never to dream experiences“. However in 1967, Hodges and Carter, in the same publication refute Nelson’s claim and cite a plausible, conceptual example of a dreamer dreaming that he is being burned alive at the stake and awakening to tell his wife of the horrible pain experienced while in the dream. Further, Hodges and Carter propose that it would be possible for a dreamer to be observed moaning and writhing in their sleep and then awaken in a state of perspiration and exhaustion to report of a horrible dream. Both Nelson’s and Hodges and Carter’s arguments turn on philosophical ponderings however and do not provide any empirical evidence.

In 1993 Nielsen et al published some findings in Sleep based on the authors using themselves as the test subjects. They placed an inflatable cuff above the knee of the subject which was then inflated when measurements indicated that the subject was in REM sleep. After waking the subjects and seeking a report on any dream experience, 13 out of 42 reportable dreams included reports of pain sensations.

However, as pointed out in this excellent post from the neurocritic on the subject, the subjects were all primed with the suggestion of pain and were all experienced sleep researchers.

A 2002 paper from Raymond, Nielson et al collected data from the dreams of burns victims while in hospital and found a similar percentage of reportable dreams- about 30%, had an element of pain.

While Nielson and fellow researchers used first-person accounts to explore the subjectivity of pain during dreams, Mazza et al (2012) undertook a review of the literature on nociceptive processing during sleep using third-person observations of sleeping subjects. Mazza et al (2012) suggest that cortical processing of nociception is partly preserved during sleep and reflex behaviours in response to nociceptive stimuli are observable in all stages of sleep.

In one unique case, Mazza et al (2012) report on a subject using a motor activity (lifting an index finger), that had been trained during wakefulness to indicate the perception of a noxious stimulus, following 11 out of 20 stimulus occasions during REM sleep. They do not however, report on the subjective experience of the experiment participant so whether this person experienced pain during sleep is not known.

One very interesting article that came up in my search wasn’t about dream pain, but another complex, subjective phenomenon, that of phantom limb in amputees:

Normal body scheme and absent phantom limb experience in amputees while dreaming

“While dreaming amputees often experience a normal body image and the phantom limb may not be present… Six amputated patients underwent overnight VPSG study. Patients were awakened during REM sleep and asked to report their dreams. Three patients were able to deliver an account of a dream. In all dreaming recalls, patients reported that the amputated limbs were intact and completely functional and they no longer experienced phantom limbsensations. Phantom limb experiences, that during wake result from a conflict between a pre-existingbody scheme and the sensory information on the missing limb, were suppressed during sleep in our patients in favour of the image of an intact body accessed during dream…

So if REM sleep is a state of proto-consciousness (Hobson, 2009), i.e. a contextually (REM sleep) emergent property of self-sustaining systems (the related brain networks), the self as it appears in REM sleep dreams is no longer affected by waking experiences because it feeds from an embodied and functionally intact body scheme.” (Emphasis added)

Reading this I had two thoughts; 1. If, during REM sleep dreams, the “self” is no longer affected by waking experiences and “feeds from a functionally intact body scheme” would any influence of central sensitisation or pain related brain changes be negated during dreaming – do people with CRPS experience allodynic dreams? 2. Is pain also an emergent property of self-sustaining systems (probably as good a definition as any for pain), and does this suggest that pain, as is experienced in the waking state, is just not able to be experienced in a dreaming state?

I’m not convinced that the content of a dream can include the subjective experience that we label pain in a waking state. There is good empirical evidence that nociception occurs when we sleep and that this is “processed” in the brain to some degree, but I’m not persuaded that this is sufficient to be given a label of the subjective experience of pain, even if the nociceptive stimulus is followed immediately by appropriate nociceptive-avoidant behaviour such as withdrawal or other responses such as grimacing or moaning.

One key difference for me is that any reports of pain in a dream are necessarily after the fact. Reports of dream pain are always about pain; meta-comments on what the person remembered of the dream and any pain content. Obviously this is very different from asking a person to report on what they are feeling now, as they feel it. Is the memory of a pain experience pain itself, clearly not. Perhaps there are some answers to these questions in lucid dreams, but whether this is a real dream state or not has its own controversy.

As I sit writing this, I can recall a recent, severe pain experience at the dentist. I can recall what the ceiling looked like, what was being said at the time “this might hurt a little…”, I can recall my response as the ultrasonic scaler hit a patch of exposed dentine and if I really ‘put myself in the experience’ I experience, right now, a shivery, cringing motor output and, for want of a better phrase, a sickening feeling. But, and it’s a big but, I can’t experience the painfulness of the original pain at all (thankfully!!) even though the rest of the experience can be remembered quite vividly. Maybe this is what dream pain is like? All the remembered bits of a past pain experience, what you think pain should be like, but none of the painfulness of waking pain? I’ve never had the experience of dreaming that I was experiencing pain so I’d love to hear from anyone who has.

Let us know in the comments – have you ever dreamt that you were experiencing pain? What about reports from your clients?

 

-Tim Cocks

http://www.noigroup.com

 

Nelson J (1966) Can one tell that he is awake by pinching himself? Philosophical Studies; 17(6)

Hodges M and Carter WR (1967) Nelson on Dreaming a Pain. Philosophical Studies;

 

 

Get your think on and get up to date at a noigroup course, or immerse yourself in some brainy books with Explain Pain 2nd Ed and The Graded Motor Imagery Handbook

15 Responses to “Sleeping, dreaming, hurting?”

  1. Laura (@laurawhitburn)

    Great piece Tim, I too have wondered about this. My thought is YES, a reason being that for me the line between ‘physical’ and ‘social’ pain is very blurred (in terms of evolutionary purpose, felt sense, and associated brain regions) and I have certainly felt the pain of disconnect in dreams, so why not pain!?
    Very keen to hear others’ thoughts…

    Reply
    • timcocks0noi

      Hi Laura, thanks for dropping by and commenting. When we were discussing pain in dreams here at noi the point you raise was brought up too. In dreams, the experience of other unpleasant feelings/sensations seem to be more common than the experience of what we would normally label pain, based on some discussions I’ve had as well as the comments here.

      I think there is an argument that dream experiences are qualitatively different from waking experiences- do we know during the dream that we are feeling some such experience, or is it only upon wakening that we recall the dream content and associate some appropriate-seeming feeling or experience to it?

      I’ve been thinking about extreme cases of ‘sleep-walking’ where people have been observed performing all kinds of high level functions – the eponymous walking, eating, talking, even driving, but have no recollection of the events after. Is there anything ‘that it was like’ to be in this state? Is sleep-behaving something like a Philosophical Zombie (after David Chalmers)? If this is the case, then it might demonstrate that it is possible to have significant physiological, neurological and behavioural activity without experience – without ‘something that it is like’ because we are not conscious – we are “offline” from the world. Additionally, as there is no recollection of the physiological, neurological and behavioural activity the sleep-behaver can not retrospectively associate any experience or feelings to the activity that would make sense if the activity occurred in a waking, “online” state. Alternatively, does a dreamer who wakes with memory of the dream retrospectively associate an appropriate online experience/feeling to the memory of the offline neurological and physiological activity and only then have a dream experience?

      Like you, I’m very interested in others thoughts.

      Cheers
      Tim

      Reply
  2. John Barbis

    If one can experience, as part of the dream experience, anxiety, fear, and extreme sadness ( sense of physical and emotional loss) during a dream, why shouldn’t one be able to experience pain? Pain, not nociception, is just another manifestation of the brain’s (real or unreal) perception of a danger to the organism. I have watched our adopted dog (who had a rough early life experience) have some wretched dreams. If he was not experiencing pain during those dreams, it was a very close correlate to it. Anxiety, depression, PTSD, and pain all have their origins in the same limbic areas of the brain. I think that we all agree that emotional pain is a part of bad dreams. Why shouldn’t physical pain be a part also?

    Reply
    • timcocks0noi

      Hi John, thanks for sharing your thoughts.

      Following from the idea that pain is a conscious correlate of an animal’s perception of threat or danger to the body/tissues, and that consciousness is that state of being that we regain upon awakening (I’m borrowing from Antonio Damasio’s description of consciousness here) then it follows for me that the experience of pain requires consciousness – the very state that by its absence, we define sleep.

      I have no doubt that an animal can respond to nociception during sleep – withdrawal responses (I’ve seen this in dead cane toads!), probably even facial grimacing, moaning or other vocalisation, but I’m still not convinced that we can say that the unconscious animal is having the experience of pain.

      There’s a long discussed philosophical debate concerning brains in vats that is probably relevant here, but that’s a conversation that definitely needs some good Aussie shiraz.

      Thanks again for dropping by John,
      Tim

      Reply
  3. Gerry Daly

    Just some thoughts, from an outsider, on this interesting subject matter. I think the right questions were asked in the opening post. My approach to the subject matter would focus on the reasons why pain doesn’t seem to manifest whilst asleep. It might be interesting to research the ‘falling asleep event’ with chronic pain patients, to see if they report a sense of pain easing just as they about to succumb to sleep. Likewise, if the waking up event gradually re-introduces their perception of pain. It would seem that that different grades of sleep (half-sleep etc) allow their own grades of pain perception, but deep sleep seemingly doesn’t. That, of course, raises the question of the requirement for a pain perception in a non-conscious or unconscious state, which would in turn raise a question about the ‘purpose’ of pain perception to the conscious state. My personal intuitive overview of the relationships between lack of pain in the non-conscious, and pain perception in the conscious, suggests to me that pain perceptions are a ‘tool’, utilised to block or inhibit possible conscious reactions to a threat, and thus are surplus to requirements in the non-conscious state….even though the same actualised threats are active, and being responded to by the autonomic systems.
    With ‘dreamed sensations of pain’, it might seem that the template upon which the dream is constructed is merely one of memories, including memories of past painful events. On waking, the dreamed pain disappears, suggesting it was just an illusionary event. Also, as pointed out in the opening post, we seem to have a conscious defence against remembering actual previous pain….almost like we are not allowed to remember the intensity because of the fear it might create which might obstruct our current activities. This has been well recorded with expectant mothers not being able to recall the pain of previous childbirths, until they go into labour again. It’s a survival mechanism which somehow ‘denies’ the discouraging memory, and probably a good thing too ! My take on the ‘pain in dreams’ issue would be that the dream is a sub-conscious reliever of some consciously perceived threat, which must be expunged from the sub-conscious before the anxiety it might create becomes a threat in itself. Perhaps, it might be said that the ‘dream’ is an autonomic response to a consciously perceived psychological threat, which can only be responded to with a dreamed psychological response.

    Reply
    • timcocks0noi

      Hi Gerry, thanks for your interesting and thought provoking musings. I agree that being able to experience pain is certainly biologically advantageous, but I think it has motivational aspects to it as well as inhibitory – but that’s probably a very semantic point.
      I’m not sure if we have a conscious defence against remembering pain – perhaps pain is just not the kind of thing that we can remember in the same way that we can remember something that we saw or heard or read. That is, we can remember that we did experience pain back then, that it was unpleasant and that there is some activity/behaviour/place/surface etc etc to be avoided in the future, but we can’t re-experience the unpleasantness itself in an ‘offline’ remembered way?
      Thanks again for contributing,
      Tim

      Reply
      • Gerry Daly

        Thanks for reply. Just a few add-ons to throw into the mix……

        Your take on ‘offline’ attempts to remember the full experience of ‘previous pain’ is absolutely right. Seems we can’t remember pain as we would remember emotional or other experienced events, where we might have a recurrance of conscious reactions (crying, laughing etc) ….almost in confirmation of the original event, and thus a confimation of the lingering memory. With pain, we know it was an unpleasant experience, but can’t seem to recreate the intensity with any clarification.
        I listened to a podcast recently where Dr Patrick Wall suggested that we are unable to focus on the pain from two different injuries simultaneously. Apparently, we switch our attention between the two injuries depending on how we consciously prioritise each. Or, as I might see it, there is some controller (possibly the autonomic systems) choosing the priority unconsciously. If so, that might suggest that the pain perception is being manipulated unconsciously, whether in dreams, or in wakefulness, which, in turn, would suggest that pain perceptions are a utility, a tool, rather than an emergent conscious event with little definition of ‘purpose’….for me, there is little need of a continuous ‘warning purpose’ once we have already been made consciously aware of an actualised threat. I’m more inclined to see pain as a ‘conscious reaction blocker’ because, for want of a better way to explain it, that puts more meat in its ‘lingering’ purpose. But, sorry, that’s digressing from the query of your original post.
        I’ll be watching this post with real interest, mostly because you presented a framework for discussion of the issues, which seems to ask the right questions, before assuming any conclusions which might spin the query down the usual cul de sacs. You’ve given the issues their own momentum….should be interesting to see where it goes.

        Gerry

        Reply
  4. Efwef Gwerb

    I think I know where you’re heading with this Tim. The emboldened section from your post indicates we might be able to manipulate the dream state (a state of attenuated self-consciousness) to alter what happens when we’re awake. To do the experiment, we’d need to recruit a population who can do lucid dreaming.

    It gets to the question of what causes chronic pain…. damaged aspects of self image? I’d say absolutely “yes!” to this. I subscribe to the idea that all pain serves the function of drawing attention to the self in order to re-integrate shamed aspects of the self-image. This is old school psychoanalysis. http://www.ncbi.nlm.nih.gov/pubmed/18399746

    If you accept this as a premise, things start to become very interesting, and this whole idea of pain being ‘functional’ applies just as much to acute pain as it does chronic. When I used to work for a football club, I would hone my observation skills during the warm up period by trying to predict who would get injured during the match. I became very accurate. Players demonstrated certain repeating behaviours (non-physical) which often tipped me off that they were *unconsciously* considering whether they would get injured today, and what that might mean for them. Some psychiatrists will tell you “there are no accidents” and my experience supports that notion.

    Despite all the analysis that my mind engages in outside of clinic hours, the time spent in the rooms with a client is quite different. An analytical attitude is not at all healing – it’s almost the opposite in fact. The last thing a client wants is someone trying to figure out why he chose his left ankle injury as a way to resolve his personal dramas.

    EG

    Reply
    • timcocks0noi

      Hey EG, as always, an interesting angle. I’m uncomfortable with the word shame – that might just be my not understanding how you are using it in the psychoanalysis sense, but i think it might lead to notions of blame and fault which can be dangerous territory when dealing with people experiencing pain.
      I have met some people who respond very well to therapists that i know take a very analytical approach to therapy. I’ve seen these therapists undertake (what i think) is a way-over-the-top assessment – measuring every movement with an instrument to get a precise angle reading, measuring leg length with a tape measure, poring over scans and x-rays and so on, and can recall thinking that the client must be hating it, only to have the client report that they felt so much better even after the assessment because finally someone was “taking them seriously”. But this has got nothing to do with dream pain and i digress.
      Thanks for adding your thoughts and unique perspectives.
      Tim

      Reply
  5. Efwef Gwerb

    Tim I think the media (and certainly social media) often link the word ‘shame’ with guilt and wrong-doing. Actually they seem use it as a tool to manipulate anyone in the news spotlight with fear of mass disapproval! So I understand what you’re saying. However I don’t mean it in that way, but rather define it as “a feeling of being unworthy and unlovable”.

    I’ve also seen this situation you describe where the client feels validated by someone taking the time to do a 30 minute assessment with all the measurements and 100 questions, etc. For a client who has a fear of not being taken seriously, this could provide some good relief. But a quicker and perhaps more effective way (?) to address this fear might be to bring the issue to light by simply stating “You haven’t had your pain taken seriously. That’s not a nice feeling”.

    Regards,

    EG

    Reply
  6. Nena Serret

    Hello- I shared this with Lorimer when he came to speak in LA to group of PTs and he was quite shocked, along with everyone else, about my story. I have had very vivid dreams and nightmares since a young age, sometimes so real it is hard to believe it was a dream when I wake up. A few years ago, I dreamt I was shot in the chest, with a shotgun, looked down and blood was streaming out of my chest. I was thinking- ok this is a dream, I will wake up, but then I was in pain and bleeding, and I thought, ok I am not waking up so this is real! I fell forward in my dream, then woke up. I sat up in bed, with chest pain, pounding hard and then it slowly resolved in 1-2 minutes.
    So when question is asked, can pain be felt in dreams?, for me it happened once. I have never been shot so do not know what that feels like!
    Crazy- I know.
    -Maria in LA

    Reply
    • timcocks0noi

      Hi Maria
      Thanks for sharing your story. That must have been a truly horrible experience. In hindsight now, do you think it may have been possible that there was some nociception, perhaps associated with your chest area, that was incorporated into your vivid dream with a pain experience constructed, or do you think it was purely a dream construction?
      Also fascinating that you were able to construct an experience of “pain as a result of being shot” in your dream without ever having that experience in a waking state. Although thinking about this, I’m pretty sure that most people who experience flying in their dreams have never actually flown (unaided of course)!

      Thanks again Maria and thanks to all for some really interesting and provoking comments
      Tim

      Reply
      • Nena Serret

        Hi Tim- I feel it was the dream construction of a pain experience. It was cause and effect for me: I got shot, felt pain, was bleeding, then fell forward and woke up. The pain slowly dissipated as I explained, once awake. Interesting enough, I had another dream last night, where I had edema in my left arm and I was palpating and examining myself and could sense the pressure of a swollen arm and the pressure of my exam along my left arm. It was very real and I thought, crap, I have lymphedema ( I happen to treat patients with lymphedema and every now and then have dreams/ nightmares that I have developed it myself). I guess one could say my CNS is in a hypervigilant state.
        Maria

        Reply
  7. timcocks0noi

    Thanks Maria
    A truly remarkable experience. It does seem you that you have some pretty intense dreams!
    The lymphedema dream has some links perhaps with the theory that Eagleman mentioned about dreams being a way for us to test and practice our survival responses? A way for you to run the scenario of “I have lymphedema” and ask “what would I do, how would I cope?”
    Fascinating stuff
    Tim

    Reply

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