Pain Classifications

Source:  Pain Classifications    Tag:  congenital insensitivity to pain


Nociceptive

Nociceptive pain is caused by stimulation of  peripheral nerve fibers that respond only to stimuli approaching or exceeding harmful intensity ( nociceptors), and may be classified according to the mode of noxious stimulation; the most common categories being "thermal" (heat or cold), "mechanical" (crushing, tearing, etc.) and "chemical" (iodine in a cut, chili powder in the eyes).
Nociceptive pain may also be divided into "visceral," "deep somatic" and "superficial somatic" pain.  Visceral structures are highly sensitive to stretch,  ischemia and  inflammation, but relatively insensitive to other stimuli that normally evoke pain in other structures, such as burning and cutting. Visceral pain is diffuse, difficult to locate and often  referred to a distent, usually superficial, structure. It may be accompanied by nausea and vomiting and may be described as sickening, deep, squeezing, and dull.    Deep somatic pain is initiated by stimulation of nociceptors in ligaments, tendons, bones, blood vessels,  fasciae and muscles, and is dull, aching, poorly-localized pain. Examples include sprains and broken bones.  Superficial pain is initiated by activation of nociceptors in the skin or other superficial tissue, and is sharp, well-defined and clearly located. Examples of injuries that produce superficial somatic pain include minor wounds and minor (first degree) burns.
Neuropathic pain is caused by damage or disease affecting any part of the nervous system involved in bodily feelings (the  somatosensory system). [15] Peripheral neuropathic pain is often described as “burning,” “tingling,” “electrical,” “stabbing,” or “pins and needles.” [16] Bumping the " funny bone" elicits acute peripheral neuropathic pain.

Phantom

Phantom pain is pain from a part of the body that has been lost or from which the brain no longer receives signals. It is a type of neuropathic pain.  Phantom limb pain is a common experience of  amputees.
The prevalence of phantom pain in upper limb amputees is nearly 82%, and in lower limb amputees is 54%.   One study found that eight days after amputation, 72 percent of patients had phantom limb pain, and six months later, 65 percent reported it.Some amputees experience continuous pain that varies in intensity or quality; others experience several bouts a day, or it may occur only once every week or two. It is often described as shooting, crushing, burning or cramping. If the pain is continuous for a long period, parts of the intact body may become sensitized, so that touching them evokes pain in the phantom limb, or phantom limb pain may accompany urination or defecation.
Local anesthetic injections into the nerves or sensitive areas of the stump may relieve pain for days, weeks or, sometimes permanently, despite the drug wearing off in a matter of hours; and small injections of  hypertonic saline into the soft tissue between vertebrae produces local pain that radiates into the phantom limb for ten minutes or so and may be followed by hours, weeks or even longer of partial or total relief from phantom pain. Vigorous vibration or electrical stimulation of the stump, or current from electrodes surgically implanted onto the spinal cord all produce relief in some patients.
Work by  Vilayanur S. Ramachandran using  mirror box therapy allows for illusions of movement and touch in a phantom limb which in turn cause a reduction in pain.
Paraplegia, the loss of sensation and voluntary motor control after serious spinal cord damage, may be accompanied by  girdle pain at the level of the spinal cord damage, visceral pain evoked by a filling bladder or bowel, or, in five to ten per cent of paraplegics, phantom body pain in areas of complete sensory loss. This phantom body pain is initially described as burning or tingling but may evolve into severe crushing or pinching pain, fire running down the legs, or a knife twisting in the flesh. Onset may be immediate or may not occur until years after the disabling injury. Surgical treatment rarely provides lasting relief.

Psychogenic

Psychogenic pain, also called  psychalgia or  somatoform pain, is pain caused, increased, or prolonged by mental, emotional, or behavioral factors. Headache, back pain, and stomach pain are sometimes diagnosed as psychogenic. Sufferers are often stigmatized, because both medical professionals and the general public tend to think that pain from a psychological source is not "real". However, specialists consider that it is no less actual or hurtful than pain from any other source.
People with long term pain frequently display psychological disturbance, with elevated scores on the  Minnesota Multiphasic Personality Inventory scales of  hysteriadepression and  hypochondriasis (the " neurotic triad"). Some investigators have argued that it is this neuroticism that causes acute injuries to turn chronic, but clinical evidence points the other way, to chronic pain causing  neuroticism. When long term pain is relieved by therapeutic intervention, scores on the neurotic triad and  anxiety fall, often to normal levels. Self-esteem, often low in chronic pain patients, also shows improvement once pain has resolved .
“The term 'psychogenic' assumes that medical diagnosis is so perfect that all organic causes of pain can be detected; regrettably, we are far from such infallibility... All too often, the diagnosis of neurosis as the cause of pain hides our ignorance of many aspects of pain medicine.”
—  Ronald Melzack, 1996.


Pain asymbolia and insensitivity

The ability to experience pain is essential for protection from injury, and recognition of the presence of injury. Episodic analgesia may occur under special circumstances, such as in the excitement of sport or war: a soldier on the battlefield may feel no pain for many hours from a traumatic amputation or other severe injury.
Although unpleasantness is an essential part of the  IASP definition of pain, it is possible to induce a state described as intense pain devoid of  unpleasantness in some patients, with morphine injection or psychosurgery. Such patients report that they have pain but are not bothered by it, they recognize the sensation of pain but suffer little, or not at all. Indifference to pain can also rarely be present from birth; these people have normal nerves on medical investigations, and find pain unpleasant, but do not avoid repetition of the pain stimulus.
Insensitivity to pain may also result from abnormalities in the nervous system. This is usually the result of  acquired damage to the nerves, such as  spinal cord injurydiabetes mellitus ( diabetic neuropathy), or  leprosy in countries where this is prevalent. These individuals are at risk of tissue damage due to undiscovered injury. People with diabetes-related nerve damage, for instance, sustain poorly healing foot ulcers as a result of decreased sensation.
A much smaller number of people are insensitive to pain due to an inborn abnormality of the nervous system, known as " congenital insensitivity to pain". Children with this condition incur carelessly repeated damage to their tongue, eyes, joints, skin, and muscles. They may attain adulthood, but have a reduced life expectancy. Most people with congenital insensitivity to pain have one of five  hereditary sensory and autonomic neuropathies (which includes  familial dysautonomia and  congenital insensitivity to pain with anhidrosis). These conditions feature decreased sensitivity to pain together with other neurological abnormalties, particularly of the  autonomic nervous system.A very rare syndrome with isolated congenital insensitivity to pain has been linked with mutations in the  SCN9A gene, which codes for a sodium channel (Na v1.7) necessary in conducting pain nerve stimuli.