Is Pain Real? The Peculiar, Perplexing and Paradoxical World of Pain
On 24 April 2021, I delivered a keynote lecture at the Torrance Festival of Ideas, Georgia, USA titled: ‘Is Pain Real?’.
The 3-day Festival brought together a diverse mix of thinkers from around the world to discuss ‘Big Ideas’ on an eclectic mix of topics including consciousness, creativity, imagination, identity empathy, humour, love and pain, to name but a few. My slot on the virtual stage was 7pm BST on a sunny spring Saturday evening, which coincided with a cacophony of noise emanating from my neighbours’ gardens as they hosted their first bbqs since the onset of lockdown – typical!
The title of my talk occurred by accident. In 2019, I was invited to talk at the Leeds International Festival about whether pain could be an illusion of tissue damage. In haste, I offered the snazzy title ‘Is Pain Real?’ without thinking about it too much. By the time I came to write the talk I realised that my ideas for content didn’t match my title. As a consequence, preparing and refining the talk has taken my thinking down some unexpected lines of enquiry as I would have to define pain, define ‘real’, and then assess whether the pain matched criteria for being ‘real’. This relatively simple question was going to push my powers of logic and reason to their limit.
The answer to the question ‘Is Pain Real?’ seems rather obvious – surely yes?
Pain is defined as an unpleasant bodily sensation associated with actual or potential tissue damage. ‘Real’ is defined as everything that exists, energy and matter and the ‘stuff’ that would be here if we humans were not – i.e. the electromagnetic spectrum, atoms and subatomic particles. Life-experience, society, education and health care practitioners tell us that pain signals tissue damage (‘real stuff’). So, surely pain must be real.
I challenged the audience: How do you as a person become aware of this tissue damage?
Chemicals released when cells get damaged (‘real stuff’) get converted into electrical signals (nerve impulses) by tissue damage detectors (‘nociceptors’) and the impulses are conducted to the brain by nerve fibres from body parts. This is how the brain finds out about what is happening to the ‘real stuff’ inside and outside of your body and gives you are awareness of these changes via sensations - you see, hear, smell, taste and feel touch and pain with your brain not with your sense organs. No brain, no pain. It is important to appreciate pain is not detected nor transmitted through ‘pain pathways’ but rather actual or potential tissue damage is converted into electrical signals (nerve impulses) that influence brain processes resulting in pain.
I challenged the audience: How sure are you that pain always signals tissue damage?
I provided a series of examples that broke this rule. I described the situation where soldiers do not feel pain immediately after having a limb blown off showing that you can have serious tissue damage but no pain. I also described a genetic abnormality called congenital insensitivity to pain where tissue damage detectors do not work properly, and the person has difficulty learning to avoid things that cause tissue damage because they do not experience pain. I also explained how the brain can create pain in a missing body part following an amputation and how pain may persist despite healing of an original injury. I argued that persistent pain can trick patients and practitioners into believing there must be tissue damage tissue (pathology) when in fact there is not - sometimes (but not always) pain may be an illusion of tissue damage.
I challenged the audience: How sure are you about the reality of your pain?
Pain must be real because you experience it as an unpleasant sensation happening within your body. But paradoxically, pain is subjective and invisible and cannot be directly measured by equipment. Pain is what the person says it is and this does not sit comfortably within the objective nature of medical practice. We can all recall instances where we do not believe our expression of pain has been taken seriously by someone else.
I challenged the audience: How sure are you about the reality of someone else’s pain?
Pain must be real because other people express that they experience pain using words like ‘Ouch, that hurts!’. I challenged the audience to recall instances when they have doubted whether a person’s pain was real believing instead that the person was using ‘pain’ as an excuse to get more attention. You are certain when you are in pain but doubtful when others say they are in pain. If you cannot experience another person’s pain and they cannot experience yours how do you know it is real?
I challenged the audience: How much can you trust your brain to report reality?
The brain prioritises efficiency over accuracy and this leads to perceptual experience riddled with misinterpretation of ‘real stuff’ (i.e. matter and energy). I explained that current thinking from the neurosciences suggests that conscious experience may be a controlled hallucination (simulation) rather than a replication of reality. This is nothing to worry about because this simulation of reality has successfully enabled humans to exist in the complex environment of the world for over 5 million years.
I argued Pain probably is Real
The experience of pain and the reality of being in pain are the same thing (subjective). There needs to be a ‘real person’ present to be the subject of the painful experience. So, if you are real and you report pain, then pain must be real – even when tissue has healed. This leaves one remaining assumption …
How real are you?
It is known that the majority of atoms in your body (i.e. the ‘real stuff’) are not the same ones that you were born with. If most of the ‘real stuff’ in that constitutes your cells, tissues and organs is regularly replaced, what gives you that sense of continuity in your identity of ‘self’ throughout your life? Are you really real?
I suggested that this may a good topic for next year’s Festival.
Mark is Director of the Centre for Pain Research and leads a vibrant team of researchers. He has published over 200 research articles and book chapters and supervises PhD students. Mark teaches across all levels of our taught course provision.