paincognition and suffering aya nakae osaka university graduate school of medicine, department of...
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Paincognition and suffering
Aya NakaeOsaka University Graduate School of Medicine, Department of Anesthesiology
Outline
What is pain? My researchWhat is “schizophrenia?” The correlation between schizophrenia and chronic pain Results Future plans
The definition of pain
Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.
What is pain? (Simple cases)
1. Tissue damage occurs.2. Inflammation change occurs.3. As a result, patients feel pain.4. Pain disappears with the scar.
What is pain? (Difficult cases)
Some patients feel pain for a long time.
Many such patients feel more pain than predicted by tests.
Patients are unable to work.
Components of pain
Pain behaviours
Suffering
Perception of Pain
Nociception
1.Nociception2.Perception of Pain3.Suffering4.Pain behaviours
Nociception
Nociception
Perception of pain
The message is received by the brain and pain is perceived because of the way, the brain works in individuals.
Perception of Pain
Suffering
Negative andemotional reactionscaused by pain depression fear anxiety stress etc
Suffering
Pain behaviours
Saying” Ouch!!” Grimacing Limping Lying down Recourse to health
care Refusing work
Pain behaviours
The purpose of our research
The clarification of the process from pain perception to suffering through researching patients with schizophrenia and chronic pain.
Why patients with schizophrenia?
They are less sensitive to painruptured appendix perforated bowels peritonitis painless myocardial infarctionChronic pain is rare.
??
?
Why are they less sensitive?
Cognitive impairment Affective impairment Attention deficiency
Why patients with schizophrenia?
Pain Pain
Suffering Suffering
Pain Behaviour Pain Behaviour
Patients with chronic pain Patients with schizophrenia
Degree of pain suffering
StrongWeak
Schizophrenia Normal Chronic painSchizophrenia is a human model considered to be the opposite of
that with chronic pain.
Methods
Chieko TakamuraChieko was an artist who created many works of art after suffering with schizophrenia.
Participants
Patients with schizophrenia: - Diagnosed using DSM-IV criteria - Exclusion criteria 1) cannot understand the test 2) cannot answer the questionnaire
accurately Healthy control: - Not diagnosed with any psychiatric illnesses
Clinical assessments of patients
Symptoms of schizophrenia - Positive and Negative Syndrome Scale (PANSS) Medication - Chlorpromazine equivalents History
patient’s age on diagnosis diabetes self injury etc.
Pain assessments
Electrical stimulation - minimum detection threshold - pain detection threshold - pain tolerance Thermal stimulation - warm/cold detection threshold - heat/cold pain threshold - heat/cold tolerance
Expression of pain
McGill Pain Questionnaire (short form)
S-PRI: Subjective assessments A-PRI: Affective assessments T-PRI: Total assessments Visual Analogue Scale (VAS)
Results
This picture by Norwegian artist Edvard Munch is said to show the hallucination of a patient with schizophrenia.
Participants
Patients Controls
Total 39 32
Male 15 15Female 24 17
Age Patients (MeanSEM)
Controls (MeanSEM)
Total 37.2 (±12.9) 35.7 (±9.8)
Male 37.3 (±14.9) 36.3 (±9.1)
Female 37.2 (±12.2) 35.1 (±10.7)
Discussion
Self-portrait with bandaged ear.Vincent van Gogh, who was troubledBy mental health, cut off his own ear.
Causes of Schizophrenia
Genetic Intermediate phenotypes Prenatal Social Others
Eugen Bleuler (1857-1939) coined the term "Schizophrenia" in 1908.
What is a phenotype?
Gregor Johann Mendel
The phenotype
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HPT
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Patients Control
The data showed potential phenotype groups in schizophrenia.
Analgesic effect of antipsychotics?
Dopamine D2 antagonist (traditionalAntipsychotics) and opioids Neuroleptic analgesia
Less sensitivity to pain due toantipsychotics’ analgesic effects?
Not dosage dependent
Severe schizophrenia?
Less sensitivity to pain due to the symptoms of schizophrenia?
No correlation between symptoms and pain sensitivity shown in PANSS (schizophrenia syndrome scale) data.
Schizophrenia
Normal
HPT and pain suffering
StrongWeak
SchizophreniaNormal
Chronic pain
Degree of pain suffering
Heat pain threshold
High Low
Patients with normal heat pain thresholds
have a normal degree of suffering?
? ?
Patient 1: Confident against pain!!
History of spinal contusion injury(SCI)
No pain No analgesics
High Low
Heat pain threshold
Patient 2: Always feels knee pain
Feels pain due to osteoarthritis in the knee.
Receives general therapy for knee pain
High Low
Heat pain threshold
Patient 3: Feels pain but ・・・・・
History of SCI with paralysis She feel pain. She looks free from pain
High Low
Heat pain threshold
Schizophrenia
Normal
HPT and pain suffering
StrongWeak
SchizophreniaNormal
Chronic pain
Degree of pain suffering
Heat pain threshold
High Low
Why don’t need analgesics?
The last patient felt pain. She didn’t want her pain treated.
Pain is an unpleasant sensory and emotional experience
Her pain probably was not so unpleasant to require treatment.
Schizophrenia less sensitive to pain
1. Sensory insensitivity2. Less suffering due to
the noxious stimuli
? ???
?
Future plans (1, 2, 3 ・・・・ )
John Forbes Nash, Jr. is an American mathematician who received a Novel Prize for his works in game theory.Nash is the subject of the Hollywood movie “A Beautiful Mind”. The film focuses on Nash's mathematical genius and his struggle with schizophrenia.
1. Detailed evaluation of sensitivity
2. fMRI study
Participants Patients with schizophrenia not suffering
from pain and Controls Pain task 15˚C, 45˚C , 50˚C stimulation lasting 20s Analyzing the areas which
contribute to suffering
3. Other possible imaging studies
Dopamine Glutamate
Significance : Area detection
Area detection
Evaluation of degree and treatment
Molecular mechanism
Direct stimulation
therapy
Significance : Genes
Target gene
Molecular mechanism
New analgesic and anesthetic
Progress in schizophrenia
research
Acknowledgements
Department of PsychiatryRyota Hashimoto and his colleaguesNihon Koden CooporationSyogo Maeda & Tomoko OkuDepartment of Pain MedicineMasahiko ShibataGraduate School of DentistrySyoichi IshigakiDepartment of AnesthesiologyAll my colleagues