The Two Aspects of Pain

Carl Hendel, MD. 2002


Pain, as defined by the International Association for the Study of Pain is " unpleasant sensory and emotional experience......". There are really two components to all pain, the cerebral and the limbic component. In other words, there is pain intensity and pain unpleasantness. These can be independently considered. It seems that pain unpleasantness (limbic or emotional pain) can be very debilitating. However, it can be modified, and that is important in effective pain management.

If a person experiences his/her pain through the filters of emotional history, old issues, such as fear, hopelessness, helplessness, abandonment, anger, frustration, failure, and more, can escalate the pain unpleasantness to unbearable levels. This can be a major obstacle to being able to function.

A central role of the pain professional is to empower the patient. Victim experiences disempower the patient. Often, therapy for the pain requires examining the person's beliefs. If the belief structure does not support the patient, these may need to change. There are approaches in psychotherapy which can facilitate this. With re-education and openness to new learnings, more supportive and accurate beliefs can develop. This may be relatively brief therapy for some, and may be quite prolonged in others, depending some on life experiences, age, origins of the dysfunctional beliefs and more. Updating the databases, so-to-speak, between the intellectual and emotional aspects of our consciousness can relieve the pressure of fear, helplessness, hopelessness, and the rest of the "negative emotional experiences."

We can teach the patient to experience the two aspects of pain by asking:

On a scale of 0-10, how unpleasant is your pain?

(zero = no unpleasantness, 10 is maximal unpleasantness)

This is the limbic experience, the emotional brain.

On a scale of 0-10, how intense is your pain?

(zero = no pain, 10 is maximal intensity)

This is the cerebral (sensory) experience of pain.

It is not uncommon for pain patients to report, especially with opioid medication, that the intensity is unchanged, but it "doesn't bother me so much." If we can help the patient resolve, reduce, and manage his/her limbic pain, we might accomplish the same goal. Some imagery approaches can be valuable, such as getting to know images for the pain intensity and for the pain unpleasantness. A skilled professional may be able to harvest wisdom and guidance from these images and be able to facilitate changes in the images which can result in changes on the experiential level as well.

The integrative approach for pain management may include effective pain intensity medication, and there are wonderful new breakthroughs in pain pharmacology. Effective limbic pain management is also part of the healing formula. Through counseling, imagery, other talking therapies, and when necessary, appropriate doses of psychotherapeutic medications, a person can change. I believe that the antidepressants, anxiolytics, etc. should preferably be used in conjunction with counseling, not as the sole approach to emotional pain. The process of neurogenesis has shown that new experiences, such as novel new learnings, can cause new brain tissue growth in the limbic brain. Maybe we really can grow emotionally, and that is very hopeful for the future of many pain patients.