At the intersection of anger, chronic pain, and the brain: A mini-review, 2022, Yarns et al

Highlights

• Brain plasticity and emotions affect nociplastic pain conditions like fibromyalgia.
• Anger and its regulation have particularly strong effects on nociplastic pain.
• Nociplastic pain and anger may have opposite neural correlates.
• Improving anger regulation could normalize brain activity in nociplastic pain.
• The Anger-Brain-Nociplastic Pain (ABPN) Model can be tested in future research.

Abstract

Chronic pain remains one of the most persistent healthcare challenges in the world. To advance pain treatment, experts have recently introduced research-driven subtypes of chronic pain based on proposed underlying mechanisms. Nociplastic pain (e.g., nonspecific chronic low back or fibromyalgia) is one such subtype which may involve a greater etiologic role for brain plasticity, painful emotions induced by life stress and trauma, and unhealthy emotion regulation. In particular, correlational and behavioral data link anger and the ways anger is regulated with the presence and severity of nociplastic pain. Functional neuroimaging studies also suggest nociplastic pain and healthy anger regulation demonstrate inverse patterns of activity in the medial prefrontal cortex and amygdala; thus, improving anger regulation could normalize activity in these regions. In this Mini-Review, we summarize these findings and propose a unified, biobehavioral model called the Anger, Brain, and Nociplastic Pain (AB-NP) Model, which can be tested in future research and may advance pain care by informing new treatments that address anger, anger regulation, and brain plasticity for nociplastic pain.

Paywall, https://www.sciencedirect.com/science/article/abs/pii/S0149763422000471

 

I can only assume a 'believer' had 10 minutes spare and was bored so came up with this.

In my experience anger has the opposite effect on pain to that suggested.

Maybe they have only seen those in pain who come to them for help and get angry when they get no help and hear irrelevant and meaningless rubbish, and have come to the erroneous conclusion that anger increases pain, rather than that people spouting claptrap around those in pain may get a an increasingly irritated response when assistance is not forthcoming?

Of course if you start with the assumption that chronic pain is a character/behavioural issue defect......

 

If someone has been in pain for many years, that has been ignored, disbelieved and dismissed, of course they are likely to be angry! But anger is an emotion that is "disapproved of" particularly in women, which is why so many of them are fobbed off with pills to flatten emotions.

 

Biases are towards the underestimation of pain in female patients, which is related to gender stereotypes, and gender biases in pain estimation may be an obstacle to effective pain care.

I have also read horror stories on how women of colour in pain are mistreated, mocked and dismissed.

 

So literally nothing was learned from the awful experiment in the 70's of telling people dying of cancer they were dying because they were angry? It has to continue happening again and again to millions more people? Just because medicine can't let go of 19th century fairytales? There are loads of nasty articles talking about those horrible RA patients, who were also "angry" because of pain, if that's how someone wants to interpret this.

There are few things genuinely more infuriating than having pain or illness dismissed, in this scenario medicine is responsible for most of that "anger", exactly like it was before, and before, and before and always damnit. It's frankly basically provocation here, taunting to get a response.

 

Nociplastic pain: towards an understanding of prevalent pain conditions
https://pubmed.ncbi.nlm.nih.gov/34062144/

Abstract
Nociplastic pain is the semantic term suggested by the international community of pain researchers to describe a third category of pain that is mechanistically distinct from nociceptive pain, which is caused by ongoing inflammation and damage of tissues, and neuropathic pain, which is caused by nerve damage.

The mechanisms that underlie this type of pain are not entirely understood, but it is thought that augmented CNS pain and sensory processing and altered pain modulation play prominent roles. The symptoms observed in nociplastic pain include multifocal pain that is more widespread or intense, or both, than would be expected given the amount of identifiable tissue or nerve damage, as well as other CNS-derived symptoms, such as fatigue, sleep, memory, and mood problems.

This type of pain can occur in isolation, as often occurs in conditions such as fibromyalgia or tension-type headache, or as part of a mixed-pain state in combination with ongoing nociceptive or neuropathic pain, as might occur in chronic low back pain. It is important to recognise this type of pain, since it will respond to different therapies than nociceptive pain, with a decreased responsiveness to peripherally directed therapies such as anti-inflammatory drugs and opioids, surgery, or injections.

.....................................................................ends

There is a challenge for neurology in matching reported pain to organic evidence. Having a "semantic term" for pain that is not well matched to "identifiable tissue or nerve damage" is inevitable, and this does seem a much stronger approach than the 'central sensitisation' rabbit hole .

If neuroimaging studies do have validity, and as there is evidence for Nociplastic pain to respond less well to "anti-inflammatory drugs and opioids, surgery, or injections" then it is reasonable for neurology to explore other treatment models, even if that might make uncomfortable reading for those of who might fit the Nociplastic category.

The key thing seems to be that validity testing is via neuroimaging, so there is the potential for some empirical data although sceptism is warranted given the propensity for some pretty crass interpretation of neuroimaging data: Is Neuroimaging Just Modern Phrenology?

https://knowingneurons.com/2017/11/29/phrenology/

 

Yes anger is a sure fire analgesic for me, if i get really angry i feel what i can only describe -in comparison to how i normally feel- as fabulous! - Much more energy, strength & vigour, and my pain levels go right down. The problem is if i *use* that energy, i then pay for it as i normally would... but it feels physically lovely while it lasts.


Also... who decides what 'healthy' anger regulation is. There is some difference of opinion on that even within psychology.

"Do it my way dear & you'll feel much better"

 

When they write "nociplastic pain and healthy anger regulation demonstrate inverse patterns of activity in the medial prefrontal cortex and amygdala" I don't think the researchers are claiming a causal link between anger and pain, the way I read it is: they are saying that the flow of activity as imaged from the brain in the experience of 'healthy anger regulation' is the reverse of the flow of activity in response to experience of 'nociplastic pain', and that therefore by emulating anger regulation as attested by neuro-imaging (i.e whatever behaviour reproduces the imaging) axiomatically, conditions in the brain should become more amenable to the experience of reduction of nociplastic pain.

There may be all sorts of failings to this model but it doesn't seem to be inherently non scientific. The use of the term 'healthy anger regulation' is a bit naff but from a 'brain' perspective regulation is about neural states, healthy and non healthy in that context just means achieving regulation without negative impacts.

The article specifies fibromyalgia but pain in ME/CFS is likely to be seen by neurologists as nociplastic, if we see ME/CFS as (at least in part) a neurological condition we have to take on board the propositions made by neurologists. It's not like arguments with the psychs where the patient position was justifiably: "this is not your territory, you are offering no help or insight, get off our lawn". Pragmatically, patient advocacy is going to have to seek to engage with neurology in a more nuanced way than was needed with Psychiatry/Psychology.

 

I dont see any lack of willingness to engage with the propositions of anyone, but to take them on board they have to be credible. To my mind it would be wrong to take, or not take, on board, something based on the speciality of whomever was doing the proposing. That seems highly unscientific to me.

Ah, interesting...
So you're saying that they're saying whatever behaviour regulates the experience of anger, should also regulate (& relieve) this type of pain?

I havent the strength to read it in sufficient detail. I hope you're right.

 

How things should be isn't a useful place to start unless one has the power to make the 'should' into reality. That's not our position, so pragmatically PwME advocacy is going to have to make the running on engagement if PwME want neurologists to change their approach, and given the belief that most of us have that ME/CFS is wholly or at least in large part 'neurological', wanting that engagement seems to be a given - FND not withstanding.

Neurology is a smaller number discipline than psychiatry and the neurologists are not exactly having to search for work - demand likely outstrips resources by orders of magnitude so neurologists are not going to be knocking at our door, at least not without new data and a positive response from the patient population.

Some comparative numbers from the NHS on psychiatry and neurology


https://digital.nhs.uk/data-and-inf...istical/nhs-workforce-statistics/october-2021

Figures are for full time equivalents of medics only from all grades by specialism. Figures for Psychologists are not available, though some will be included in these figures:

General psychiatry 6,676.007

Old age psychiatry 1,049.257

Psychiatry of learning disability 427.211

Psychotherapy 84.87

Total Psychiatry Drs FTE 8152.475


Neurology 1614.165

Neurosurgery 952.9316

Total Neuro Drs FTE 2567.097

apprx ratio of Psych to Neuro = 3/1

 

I'm having difficulty understanding how one would measure anger levels in anyone.

I mean, from experience when fatigued or stressed -- people who normally would not get angry do. This happens with being ill. Are they more angry?

The question is then -- were they angry in the first place when not tired but just used their energy to 'suck it up' and to not display anger because inappropriate? And is that what their healthy counter-parts are doing?

So that could mean that both the healthy and ill could have comparable levels of anger they experience but one can deal effectively with suppression and one cannot. And what of those health people who suppress anger -- is anger suppression bad? What if the ill person normally coped rather well and did not easily anger as much as their healthy counter-part?

Or is it just that those who don't show anger clear don't get angry? Obviously there are some variables in all this. I'm unclear about how these are taken into account.

 

Maybe that Scientology Thetan-detecting machine? It's about as scientific so might as well. Anger or trauma causing illness? The ghosts of aliens who were thrown into volcanos and inhabit bodies causing illness? Same difference, really.

 

Wouldn’t that be really embarrassing to publish a paper on type A personality being related to stomach ulcers just at the same time other scientists prove that stomach ulcers are due to a bacterial infection, and then go on to earn a Nobel prize for that?

To actually advance that people with fibromyalgia have an anger problem and best treated with anger management program further stigmatize women and FM sufferers. I would hate being asked by a doctor whether i have an anger problem just as i hate being asked whether i have been abused as a child.

 

Being angry is not the point - the authors (as far as I can tell) are not making a causal link between anger and illness. The hypothesis seems to be that there are different responses to a given experience, and those responses differentially alter (for want of a better phrase) the neurological environment in ways that make the experience of nociplastic pain stronger or weaker. The further proposition then is that by seeking a preferred response rather than a learned/instinctual/automatic response the experience of pain can be reduced. I guess some sort of 'brain training is envisaged'.

Anger is specified because the authors are saying that the act of seeking a preferred response to anger (their "healthy anger regulation") has the effect of changing the neurological environment in ways that are conducive to reducing the experience of nociplastic pain.

The hypothesis may of course be wrong but neuralplasticity seems a sound approach - Mechanisms and Genetics of Neurodevelopmental Cognitive Disorders, 2021

 

Thanks for that response @CRG it does clarify for me what was being said. I'll give this some further thought.

 

Are the researchers merely using anger scans because they have them in their possession and found an inverse link?

After all, they are affliated with the Veteran's Hospital in LA, where plenty of veterans have PTSD from various wars the US prosecuted. Typically PTSD in veterans is associated with angry outbursts. Gulf War veterans have been studied as to their high incidence of FM.

There is so much more to trying to adapt to the vagaries of life with chronic pain and all its attendant miseries, than a narrow focus on the best way to handle anger.

As a person with severe (disabled status) FM, the only times I might become angry are when I am emotionally overwhelmed (usually by senseless remarks by a family member or friend). Take times to process, takes extra rest and TLC. Or if my rights are violated, someone trying to take something away from me that I feel belongs to me.

What improves things drastically for me is starting out the day with little to no pain (although it builds up and by 2pm day over). What makes one wake up in a low-pain state? And self-esteem is higher, better self-care, etc. ensues.


I would like them to explore the neural network for living in a parallel universe, a parallel life. Pain is noxious.

I want research to be promising. If not that, then relevant.


Edited to add: If research can find the areas of the brain that are hyped up into overdrive and cause sensory issues and a generalized super-pain/anxious state, well that would be good. A pharma or transcranial agent.

 

What's the term for the kind of pain caused by spiciness? It doesn't cause any tissue or nerve damage. Still pain. Same with some toxic compounds like some plants and some animals, like bullet ants, produce. Doesn't cause any damage, the pain is still overwhelming, probably works by stimulating pain receptors without causing them damage. In some cases it can last for years, probably compounds, enzymes, that the immune system can't clear and it just has to be fully expanded.

I'm not sure why I'm even expecting a coherent explanation for this, though. Pain is as much a complete mess as, well, everything, frankly. The algorithm of medicine is patient either dies or doesn't come back, they really don't have much to go with when outside of the common scenarios. It didn't work well for centuries but they never had to face it, now they do and it's basically paper tiger meets threat and it just crumples like a wet... paper tiger.