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

Photo: Getty
Show Hide image

The UK press’s timid reaction to Brexit is in marked contrast to the satire unleashed on Trump

For the BBC, it seems, to question leaving the EU is to be unpatriotic.

Faced with arguably their biggest political-cum-constitutional ­crisis in half a century, the press on either side of the pond has reacted very differently. Confronting a president who, unlike many predecessors, does not merely covertly dislike the press but rages against its supposed mendacity as a purveyor of “fake news”, the fourth estate in the US has had a pretty successful first 150-odd days of the Trump era. The Washington Post has recovered its Watergate mojo – the bloodhound tenacity that brought down Richard Nixon. The Post’s investigations into links between the Kremlin and Donald Trump’s associates and appointees have yielded the scalp of the former security adviser Michael Flynn and led to Attorney General Jeff Sessions recusing himself from all inquiries into Trump-Russia contacts. Few imagine the story will end there.

Meanwhile, the New York Times has cast off its image as “the grey lady” and come out in sharper colours. Commenting on the James Comey memo in an editorial, the Times raised the possibility that Trump was trying to “obstruct justice”, and called on Washington lawmakers to “uphold the constitution”. Trump’s denunciations of the Times as “failing” have acted as commercial “rocket fuel” for the paper, according to its CEO, Mark Thompson: it gained an “astonishing” 308,000 net digital news subscriptions in the first quarter of 2017.

US-based broadcast organisations such as CNN and ABC, once considered slick or bland, have reacted to Trump’s bullying in forthright style. Political satire is thriving, led by Saturday Night Live, with its devastating impersonations of the president by Alec Baldwin and of his press secretary Sean Spicer by the brilliant Melissa McCarthy.

British press reaction to Brexit – an epic constitutional, political and economic mess-up that probably includes a mind-bogglingly destructive self-ejection from a single market and customs union that took decades to construct, a move pushed through by a far-right faction of the Tory party – has been much more muted. The situation is complicated by the cheerleading for Brexit by most of the British tabloids and the Daily Telegraph. There are stirrings of resistance, but even after an election in which Theresa May spectacularly failed to secure a mandate for her hard Brexit, there is a sense, though the criticism of her has been intense, of the media pussy-footing around a government in disarray – not properly interrogating those who still seem to promise that, in relation to Europe, we can have our cake and eat it.

This is especially the case with the BBC, a state broadcaster that proudly proclaims its independence from the government of the day, protected by the famous “arm’s-length” principle. In the case of Brexit, the BBC invoked its concept of “balance” to give equal airtime and weight to Leavers and Remainers. Fair enough, you might say, but according to the economist Simon Wren-Lewis, it ignored a “near-unanimous view among economists that Brexit would hurt the UK economy in the longer term”.

A similar view of “balance” in the past led the BBC to equate views of ­non-scientific climate contrarians, often linked to the fossil-fuel lobby, with those of leading climate scientists. Many BBC Remainer insiders still feel incensed by what they regard as BBC betrayal over Brexit. Although the referendum of 23 June 2016 said nothing about leaving the single market or the customs union, the Today presenter Justin Webb, in a recent interview with Stuart Rose, put it like this: “Staying in the single market, staying in the customs union – [Leave voters would say] you might as well not be leaving. That fundamental position is a matter of democracy.” For the BBC, it seems, to question Brexit is somehow to be unpatriotic.

You might think that an independent, pro-democratic press would question the attempted use of the arcane and archaic “royal prerogative” to enable the ­bypassing of parliament when it came to triggering Article 50, signalling the UK’s departure from the EU. But when the campaigner Gina Miller’s challenge to the government was upheld by the high court, the three ruling judges were attacked on the front page of the Daily Mail as “enemies of the people”. Thomas Jefferson wrote that he would rather have “newspapers without a government” than “a government without newspapers”. It’s a fair guess he wasn’t thinking of newspapers that would brand the judiciary as “enemies of the people”.

It does seem significant that the United States has a written constitution, encapsulating the separation and balance of powers, and explicitly designed by the Founding Fathers to protect the young republic against tyranny. When James Madison drafted the First Amendment he was clear that freedom of the press should be guaranteed to a much higher degree in the republic than it had been in the colonising power, where for centuries, after all, British monarchs and prime ministers have had no qualms about censoring an unruly media.

By contrast, the United Kingdom remains a hybrid of monarchy and democracy, with no explicit protection of press freedom other than the one provided by the common law. The national impulse to bend the knee before the sovereign, to obey and not question authority, remains strangely powerful in Britain, the land of Henry VIII as well as of George Orwell. That the United Kingdom has slipped 11 places in the World Press Freedom Index in the past four years, down to 40th, has rightly occasioned outrage. Yet, even more awkwardly, the United States is three places lower still, at 43rd. Freedom of the press may not be doing quite as well as we imagine in either country.

Harry Eyres is the author of Horace and Me: Life Lessons from an Ancient Poet (2013)

This article first appeared in the 20 July 2017 issue of the New Statesman, The new world disorder