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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Why the Liberal Democrats by-election surge is not all it seems

The Lib Dems chalked up impressive results in Stoke and Copeland. But just how much of a fight back is it?

By the now conventional post-Brexit logic, Stoke and Copeland ought to have been uniquely inhospitable for the Lib Dems. 

The party lost its deposit in both seats in 2015, and has no representation on either council. So too were the referendum odds stacked against it: in Stoke, the so-called Brexit capital of Britain, 70 per cent of voters backed Leave last June, as did 62 per cent in Copeland. And, as Stephen has written before, the Lib Dems’ mini-revival has so far been most pronounced in affluent, Conservative-leaning areas which swung for remain. 

So what explains the modest – but impressive – surges in their vote share in yesterday’s contests? In Stoke, where they finished fifth in 2015, the party won 9.8 per cent of the vote, up 5.7 percentage points. They also more than doubled their vote share in Copeland, where they beat Ukip for third with 7.3 per cent share of the vote.

The Brexit explanation is a tempting and not entirely invalid one. Each seat’s not insignificant pro-EU minority was more or less ignored by most of the national media, for whom the existence of remainers in what we’re now obliged to call “left-behind Britain” is often a nuance too far. With the Prime Minister Theresa May pushing for a hard Brexit and Labour leader Jeremy Corbyn waving it through, Lib Dem leader Tim Farron has made the pro-EU narrative his own. As was the case for Charles Kennedy in the Iraq War years, this confers upon the Lib Dems a status and platform they were denied as the junior partners in coalition. 

While their stance on Europe is slowly but surely helping the Lib Dems rebuild their pre-2015 demographic core - students, graduates and middle-class professionals employed in the public sector – last night’s results, particularly in Stoke, also give them reason for mild disappointment. 

In Stoke, campaign staffers privately predicted they might manage to beat Ukip for second or third place. The party ran a full campaign for the first time in several years, and canvassing returns suggested significant numbers of Labour voters, mainly public sector workers disenchanted with Corbyn’s stance on Europe, were set to vote Lib Dem. Nor were they intimidated by the Brexit factor: recent council by-elections in Sunderland and Rotheram, which both voted decisively to leave, saw the Lib Dems win seats for the first time on massive swings. 

So it could well be argued that their candidate, local cardiologist Zulfiqar Ali, ought to have done better. Staffordshire University’s campus, which Tim Farron visited as part of a voter registration drive, falls within the seat’s boundaries. Ali, unlike his Labour competitor Gareth Snell and Ukip leader Paul Nuttall, didn’t have his campaign derailed or disrupted by negative media attention. Unlike the Tory candidate Jack Brereton, he had the benefit of being older than 25. And, like 15 per cent of the electorate, he is of Kashmiri origin.  

In public and in private, Lib Dems say the fact that Stoke was a two-horse race between Labour and Ukip ultimately worked to their disadvantage. The prospect of Nuttall as their MP may well have been enough to convince a good number of the Labour waverers mentioned earlier to back Snell. 

With his party hovering at around 10 per cent in national polls, last night’s results give Farron cause for optimism – especially after their near-wipeout in 2015. But it’s easy to forget the bigger picture in all of this. The party have chalked up a string of impressive parliamentary by-election results – second in Witney, a spectacular win in Richmond Park, third in Sleaford and Copeland, and a strong fourth in Stoke. 

However, most of these results represent a reversion to, or indeed an underperformance compared to, the party’s pre-2015 norm. With the notable exception of Richmond’s Sarah Olney, who only joined the Lib Dems after the last general election, these candidates haven’t - or the Lib Dem vote - come from nowhere. Zulfiqar Ali previously sat on the council in Stoke and had fought the seat before, and Witney’s Liz Leffman and Sleaford’s Ross Pepper are both popular local councillors. And for all the excited commentary about Richmond, it was, of course, held by the Lib Dems for 13 years before Zac Goldsmith won it for the Tories in 2010. 

The EU referendum may have given the Lib Dems a new lease of life, but, as their #LibDemFightback trope suggests, they’re best understood as a revanchist, and not insurgent, force. Much has been said about Brexit realigning our politics, but, for now at least, the party’s new normal is looking quite a lot like the old one.