Pain helps us to survive - but it can also turn our own body into an enemy

When a patient is diagnosed with fibromyalgia, all too often symptoms are dismissed as "all in the mind".

Rare individuals born without pain perception (congenital insensitivity to pain, CIP) rapidly accumulate disabilities and tend to die young. Pain makes us withdraw from and subsequently avoid injurious situations, it prompts us to protect damaged structures such as eyes or joints, and it alerts us to diseases such as appendicitis that may prove fatal without treatment. And what is true of physical pain also applies to its emotional counterpart. Pain is good for us. It helps us to survive.

But what if pain perception goes haywire? Like all UK general practitioners, I have several patients with a frustrating if fascinating condition called fibromyalgia. Jane (as I’ll call her) is typical of the severe end of the spectrum: she’s a woman in her 40s (early middle-aged women are most frequently affected), her life is blighted by unremitting pain in muscles throughout her body and no painkiller gives her any relief (she has tried them all, even morphine).

Over the years she’s become progressively disabled, finding it harder to do even simple things such as help her young children dress, and she’s able to work fewer and fewer hours. Around 18 months ago she went long-term sick and earlier this year her employer terminated her contract. She’s now struggling to adjust to a life on benefits. Apart from the constant pain, one of the things she worries about most is other people’s disbelief. To casual observation, Jane appears in the pink of health.

People with fibromyalgia have precious little to show for their suffering. They have no swelling, inflammation, limp or deformity. Blood tests, X-rays, scans and biopsies are normal. Theirs is a subjective illness. They find that family and friends eventually tire of hearing about their intractable pain and its impacts. Little wonder that depression and anxiety are common complications.

To cap it all, their doctors frequently grow frustrated as they return, time and again, to report a distinct lack of improvement with each and every treatment they try. Over the years, many physicians have questioned fibromyalgia’s validity as a disease; physical symptoms are dismissed as “all in the mind”, the implication being that, in an unconscious way, these patients “need” their illness as a passport to duck out from the stresses, strains and dissatisfactions of everyday life.

Advances in imaging the functioning nervous system are beginning to shed light on what’s really going on. To experience pain, you have to have the requisite sensory apparatus: receptors (nociceptors) that detect harmful changes within the body’s tissues and organs; and nerve cells (neurons) that relay this information to the brain.

This sensory apparatus is missing in those rare individuals with CIP. But sensing alone is not enough. Once pain nerve signals reach the brain they are subject to what is termed central processing, involving a number of the brain’s most evolutionarily primitive regions, regions that are involved with raw emotional response – with fight, flight and survival. It’s this central processing that transforms nociceptor sensory input into our subjective experience of pain.

There’s a heck of a lot of other nerve traffic passing from body to brain that’s got nothing to do with pain. For example, our muscles are constantly generating information about their position, stretch and contraction, all of which ensures the apparently effortless coordination of our movements and balance.

In fibromyalgia, some of this non-pain information seems to become capable of triggering the brain’s central pain processing regions. The very fact of having normally functioning muscles begins to be experienced as chronic, widespread pain.

It’s not fully clear what causes this malfunction, but a process called central sensitisation is at its heart. We know that 30 per cent of patients with uncontrolled rheumatoid arthritis –where diseased joints constantly bombard the brain with nociceptive input – will eventually develop superimposed fibromyalgia. Sheer volume of pain traffic in the nervous system may be one factor in central sensitisation.

However, many fibromyalgia sufferers don’t have painful arthritis. Their fibromyalgia may be linked to genetically disposed abnormalities in brain chemistry. The chemicals (neurotransmitters) involved in central pain processing have different functions elsewhere in the nervous system, which may account for the additional symptoms many fibromyalgia patients experience – sleep disturbance, profound fatigue, and impaired concentration and thinking (“fibrofog”).

It’s as yet unclear what causes these neurotransmitter abnormalities to be “unmasked” at a certain time but intriguing studies into “pain memory” suggest that stresses in adult life may reignite central sensitisation originally developed in the context of severe emotional or physical pain when young, something that may explain the association between fibromyalgia and childhood abuse or trauma.

We’re still a long way from understanding fibromyalgia, but we are at least now aware that, as an illness, it’s all in the brain, if not the mind.

Pain tells us when an activity is damaging our body too much to go on. Image: Getty

This article first appeared in the 13 November 2013 issue of the New Statesman, The New Exodus

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Will Euroscepticism prove an unbeatable advantage in the Conservative leadership race?

Conservative members who are eager for Brexit are still searching for a heavyweight champion - and they could yet inherit the earth.

Put your money on Liam Fox? The former Defence Secretary has been given a boost by the news that ConservativeHome’s rolling survey of party members preferences for the next Conservative leader. Jeremy Wilson at BusinessInsider and James Millar at the Sunday Post have both tipped Fox for the top job.

Are they right? The expectation among Conservative MPs is that there will be several candidates from the Tory right: Dominic Raab, Priti Patel and potentially Owen Paterson could all be candidates, while Boris Johnson, in the words of one: “rides both horses – is he the candidate of the left, of the right, or both?”

MPs will whittle down the field of candidates to a top two, who will then be voted on by the membership.  (As Graham Brady, chair of the 1922 Committee, notes in his interview with my colleague George Eaton, Conservative MPs could choose to offer a wider field if they so desired, but would be unlikely to surrender more power to party activists.)

The extreme likelihood is that that contest will be between two candidates: George Osborne and not-George Osborne.  “We know that the Chancellor has a bye to the final,” one minister observes, “But once you’re in the final – well, then it’s anyone’s game.”

Could “not-George Osborne” be Liam Fox? Well, the difficulty, as one MP observes, is we don’t really know what the Conservative leadership election is about:

“We don’t even know what the questions are to which the candidates will attempt to present themselves as the answer. Usually, that question would be: who can win us the election? But now that Labour have Corbyn, that question is taken care of.”

So what’s the question that MPs will be asking? We simply don’t know – and it may be that they come to a very different conclusion to their members, just as in 2001, when Ken Clarke won among MPs – before being defeated in a landslide by Conservative activists.

Much depends not only on the outcome of the European referendum, but also on its conduct. If the contest is particularly bruising, it may be that MPs are looking for a candidate who will “heal and settle”, in the words of one. That would disadvantage Fox, who will likely be a combative presence in the European referendum, and could benefit Boris Johnson, who, as one MP put it, “rides both horses” and will be less intimately linked with the referendum and its outcome than Osborne.

But equally, it could be that Euroscepticism proves to be a less powerful card than we currently expect. Ignoring the not inconsiderable organisational hurdles that have to be cleared to beat Theresa May, Boris Johnson, and potentially any or all of the “next generation” of Sajid Javid, Nicky Morgan or Stephen Crabb, we simply don’t know what the reaction of Conservative members to the In-Out referendum will be.

Firstly, there’s a non-trivial possibility that Leave could still win, despite its difficulties at centre-forward. The incentive to “reward” an Outer will be smaller. But if Britain votes to Remain – and if that vote is seen by Conservative members as the result of “dirty tricks” by the Conservative leadership – it could be that many members, far from sticking around for another three to four years to vote in the election, simply decide to leave. The last time that Cameron went against the dearest instincts of many of his party grassroots, the result was victory for the Prime Minister – and an activist base that, as the result of defections to Ukip and cancelled membership fees, is more socially liberal and more sympathetic to Cameron than it was before. Don’t forget that, for all the worry about “entryism” in the Labour leadership, it was “exitism” – of Labour members who supported David Miliband and liked the New Labour years  - that shifted that party towards Jeremy Corbyn.

It could be that if – as Brady predicts in this week’s New Statesman – the final two is an Inner and an Outer, the Eurosceptic candidate finds that the members who might have backed them are simply no longer around.

It comes back to the biggest known unknown in the race to succeed Cameron: Conservative members. For the first time in British political history, a Prime Minister will be chosen, not by MPs with an electoral mandate of their own or by voters at a general election but by an entirelyself-selecting group: party members. And we simply don't know enough about what they feel - yet. 

Stephen Bush is editor of the Staggers, the New Statesman’s political blog. He usually writes about politics.