Chronic pain affects decision making...

CHRONIC BACK PAIN IMPAIRS DECISION MAKING

Scientific evidence supports the hypothesis that
chronic pain impairs an individual's decision-making capability

As part of one study, investigators compared 26
healthy people with 26 patients with chronic back
pain (CBP) and 12 patients with a condition called
chronic complex regional pain syndrome (CRPS).
CRPS is a chronic nerve disorder typically afflicting
the arms or legs, which usually onsets following an
injury.

The study participants were asked to perform a test researchers use to assess emotional decision-
making. The test, called the Iowa Gambling Task,
is a gambling card game.

Subjects with CBP performed 41% worse than did
pain-free individuals. Those with CRPS performed
even poorer.

The study's authors conclude that "our evidence indicates that chronic pain is associated with a specific cognitive deficit, which may impact every
day behavior especially in risky, emotionally laden, situations."

"Other cognitive abilities, such as attention, short-
term memory, and general intelligence tested
normal in the chronic pain patients."

Source:www.goykehealthcenter.com...

The full paper is at scincedirect.com, but I don't have a log in and I'm not paybing $30 for it.

Apparently atrophy, actual damage, has been found in the prefrontal cortex of chronic pain sufferers. This is worrying for me, as I have generalised CRPS, but is hardly a surprise. Hmmph. As if the drugs and pain didn't mess up my mind enough. I have been aware, particularly when re-reading my posts here at ATS, that I am slipping. My brain is not what it once was; I misunderstand things, miss whole chunks of what I'm reading and am now looking at having to give up skippering the boat I live on.

I simply can't put my family and friends in danger by being in charge at sea. Just one more thing to add to the list of pleasant memories, along with playing guitar, walking, painting, etc.

Does this affect anybody else here?

To conclude, I no longer have any confidence in my critical faculties, and will be far more cautious when posting here at ATS.

While I make no statement of opinion on your condition, because you would know yourself better than I ever could, I just want to caution you about one thing.

This is a study with a very small sample, and I wouldn't look at it as completely definitive until a larger study is done verifying the results.

Stress, depression, sleep deprivation and vitamin deficiency can also lead to cognitive "bumps."

Do you take a good multivitamin daily? People I know also swear by gingko biloba. I took it myself, but didn't notice any discernible difference in my thinking. But it could be that it didn't affect me. Worth trying, I reckon.

Frankly, I think that's a "well, DUH!" moment... but I'm glad to see a paper on this.

There's no doubt that chronic pain saps the spirit (and leads to depression), and I'm not surprised that it would eventually have an impact on the actual structure of the nervous system. I'd like to see more attention and research devoted to this topic.

I know that when I am experiencing back pain (I have lordosis) that I tend to be quicker to make decisions and less focused on issues. So the findings don't surprise me... but I'd like to see more done about this.

(edited to add that I just noticed it's a 2004 paper... so we see how much attention it got.)
Here's the article in its full version (my google-fu is at the max tonight) :
ifisc.uib.es...

[edit on 6-7-2007 by Byrd]

Thankyou, Major (salute!).

I should really take a supplement, as the drugs I'm on tend to interfere with the uptake of some vitamins.

It is a (very) small sample, but I found this article first on the RSD UK support forum, and lots of people there found it rang true for them, even if it is hard to admit. But, then, we are all on the same drug regime. The only variation really is the type of opiate.

there is a view that the pain messages themselves damage the area in the brain that receives them. I know for a fact that my spinal cord has changed, along with the dorsal horn at the base of the brain, the whole vascular and limbic systems and there has been quite a lot of bone thinning. Given these widely spread atrophic effects it isn't a big stretch to think that other areas of the brain may be affected.

Really, thanks for bringing up the vitamin subject. I was taking them up until about six months ago, and then fell out of the habit.

Edited to add: I'm sorry to hear about your back, Byrd. I saw a leaflet in a doc's waiting room a while back that said that 13% of people in th UK (11 or 12% in the US I think) have some kind of chronic pain. Its still treated with medicine's either developed a long time ago, or for different illnesses, such as epilepsy (Lyrica/Pregabalin). They bring out new opiates now and then, but I have a terrible reaction to any opiate, and I know a few other people that do as well.

As a society, we are not very well equipped for communicating about pain, and too many people (including doctors) don't really understand the mechanism behind it. In fact it is only because of the US's insurance framework that any research is done. The amount of money they would save by finding better treatments is the main impetus.

[edit on 6-7-2007 by Karilla]

Well, I hope the vitamins work for you. Glad I could suggest something that might be useful.

I also Googled up a search of information on diet and cognitive impairment. There is a lot of really good information there from the skimming I did, such as the apparent fact that the Atkins diet is harmful to cognition, the Mediterranean diet might improve it, and so on.

The right food can have a huge effect on your health, mentally and physically, in ways even a vitamin supplement can't.

I have had spinal fusion surgery on L4-L5 and I also test positive for HLAB27. I had some tests done a few years ago about the HLAB27 and the doctor said he thinks it is not affecting me. It is a gene thing that causes severe arthritis of the spine and joints so I hope it never kicks in cuz just from the surgery it is impossible to explain how horrible it is. The only people that truly understand are others in the same boat.

Severe pain RULES EVERY THING YOU DO!!! I am going to overcome it though per I am a musician and I will never give up the fight. I totally agree that it makes you not as fast and alert etc...

It is a miracle that some people with severe pain even do anything. The thing that I have found is that you get judged by others per they think you are just a whiner, or lazy. When I say that I mean when you go to work. Pain decides what kind of job you do as well, unless you are lucky enough to have a skill that does not require phsyical stuff and you have good benefits. Pain decides everything.

There are people that have overcome it and that is my plan. These are my goals---Positive Mental Thoughts, Diet, Exercise, and Faith In Myself. I am lucky in many ways and I even think sometimes this experience has made me very strong mentally and has in many ways pushed me harder to achieve my dreams.

Anyways thanks for the words of encouragement for those who don't have pain and A Calling Of Arms to those who do. May we never walk alone. I could go on forever about this but I have rambled enough. Peace!

I can beleive this, as an avid roller blader for many years and after many falls, i live in chronic pain affecting my legs and knees and sciatica nerves.
Sometimes i'm too disturbed to make desicions- but we can take this further and say that anything that bothers us would be an impediment to make rational desicions. I wouldnt think its just confined to back pain!

My .02

Apparently there is research being conducted in America that seems to show an actual reduction in mass of the prefrontal cortex, which is the decision making part of the brain, so the theory goes that either the constant pain messages or the mechanism that is causing the physical changes in the sympathetic and central nervous systems is affecting brain tissue aswell. So the difficulty in "staying focussed" that all of us in pain seem to suffer from may actually be from brain damage!

What quantative difference this makes (we're still going to be a bit dopey, whether it's brain damage or distraction) but the more research into the pain the better as far as I am concerned!

I have given up on the idea of the Ketamine induce coma in Germany. The risk of pneumonia is at 33%, only 50% will get any benefit, it costs £30k, there is also a risk of permanent vegetative state, death and severe brain damage. I simply couldn't put my family through that.

DGTempe: Sciatica affects the whole sciatic nerve doesn't it? Do they have you on the old tri-cyclic anti-depressants, amitryptamine or nortryptamine? I have found that Duloxetine, a new non try-cyclic (I think it's SSRI) is specifically indicated for neuropathic pain - it might be worth having a word with your doc.

Before anyone asks, these have been shown to help with chronic pain, and aren't necessarily for depression. I have been diagnosed with depression aswell, but it kind stands to reason. A psychiatrist I saw said: "Don't worry, you're not actually mentally ill. If I was in agony all the time I'd want to top myself too." Doctors, eh?

Here's an article on the scientific paper I mentioned above. Its from the RSD-UK forum, and I have no link, I'm afraid.

Aching atophy: more than unpleasant, chronic pain shrinks the brain

An occasional headache is a nuisance, but severe, unrelenting pain can blight your existence. Often leading to anxiety and depression, chronic pain, scientists have learned, can shrink the brain and may impair one of the most valuable mental functions: the ability to make good decisions.

Pain is a defense system that indicates when something is wrong, explains Marshall Devor (Hebrew University of Jerusalem). "When there is a persistent tissue disorder or there has been injury to the nerves, it's like an alarm that is broken. Pain becomes a disease in its own right," Devor points out.

Pain signals originate at the site of injury but soon lay siege to the entire nervous system. When pain is unremitting, dramatic changes follow: spinal cord neurons become hypersensitive and start firing in response to weak stimuli. This hyperexcitability ratchets up all pain responses, which explains why people with diseases such as arthritis, cancer and diabetes, or with nerve trauma caused by surgery, sometimes experience widespread pain from even the lightest touch.

"Pain always travels to the brain," insists Vania Apkarian (Northwestern University) a bioelectrical engineer and physiologist, "and could cause damage". To test his hypothesis, Apkarian resorted to magnetic imaging. Zooming in on the brain chemical N-acetyl aspartate (the amount of which correlates with the density of neurons) he identified a striking difference in the prefrontal cortex. Pain was triggering brain atrophy there, apparently.

Apkarian compared the overall volume and regional grey matter density in patients who had chronic back pain with controls. The preliminary results were revealing: the average atrophy was greater in people with lower back pain than normal. "The difference is highly significant," he comments.

Because the prefrontal cortex is crucial for emotional decision-making, Apkarian wondered if constant pain might be clouding people's judgment. He asked 26 people who had suffered lower back pain for more than one year and 29 normal volunteers to play a gambling card game called the Iowa Gambling Task. The test was originally developed by neuroscientist Antonio R. Damasio (University of Iowa) and his colleagues to study decision-making in risky, emotionally laden situations. It involves selecting cards from decks with different potential cash payouts and penalties. Normal subjects learned to optimize their choices, but participants with a pain history made bad decisions, averaging 40 percent fewer good choices compared with normals. What's more, the amount of suffering correlated with how badly they played. "Chronic pain is driving these people to make poor judgments," concludes Apkarian.

Yet other cognitive abilities remained intact. "None of these patients are dramatically impaired," says Apkarian, who excluded from the study people with high depression or anxiety to avoid confounding factors. "This study raises the question of whether these people are making appropriate decisions in every day life," speculates. Apkarian, who found similar results with sufferers of chronic complex regional pain syndrome, a nerve disorder that may follow injury to the arms or legs.

"These are very interesting results, but we need to know more about what these changes really mean. Are they reflecting changes in brain metabolism or true nerve cell loss?" opines Anthony Jones (University of Manchester, UK), Director of the human pain research group. "It seems unlikely that a strong sensory input would cause brain damage since we know the brain is so good at protecting itself," he adds. If the loss is real, then the next step would be to determine if the damage can be reversed-and compensate for painful choices.

Dr Lisa Melton—Science Writer, Novartis Foundation, London

WOW! My husband suffers from severe causalgia due to a motorcycle accident 6 years ago. The doctors are unfortunately pretty much as clueless as we are as to how best to help him. He is on a whole concoction of medication (including anti-convulsants, anti-psychotics, anti-depressants, alpha blockers and beta blockers) and we have always just put down his memory loss, etc to the drugs he has to take. It would be really fantastic if somebody could come up with something that will help with the pain without destroying the rest of his body. The doc said we have to make a decision as to whether we want "quantity (of life) or quality (of life)" when we initially went to see someone about his pain. In other words, the drugs will kill you but you will be relatively comfortable while they're doing it but if you don't take the drugs your life will be a living hell but you'll live longer!
In my opinion, I quite believe that the research conducted is accurate as I have seen the evidence in my own home.

Hi, LovingSoul. Causalgia is what I have, also. Its mostly referred to as CRPS (complex regional pain syndrome) type II. What used to be called RSD (reflex sympathetic dystrophy) is now more commonly called CRPS type I. Basically, type II is when there is an identifiable nerve injury, whilst type I is when there is no nerve injury. Otherwise the conditions are the same.

Just for context, here is the McGill pain scale, which shows the severity of the experienced pain.



Apart from Paula Abdul and House, there are few prominent sufferers, but hopefully with more awareness people will be diagnosed earlier, one of the major factors in remission. Apparently the figures for children being diagnosed with CRPS/RSD are 30% lower than those for adults, with the assumption being that there are many children who are suffering undiagnosed, rather than it a being a condition that affects adults more than children.

Editted to change image to a clearer one.

[edit on 12-7-2007 by Karilla]

[edit on 12-7-2007 by Karilla]

That sound's horrid, I feel extemely bad for you.

I can, as a suffer of chronic acute pain attest to the fact that I find it much harder to do things than I used to, even spell properly (and I have my fair share of degrees, including several above masters level). When I'm completely on form and feel like actually doing something, I'm so drugged up with painkiller, that its almost as hard to think as it is when its just the pain 'talking'.

I've read that study before somewhere and passed it onto a few people who found it interesting. It's actually good to get info like this out there I think, because sometimes, people only see the tablets, they then think "oh, wannabe junkie" and don't take you as a REAL person.

I remember having the 'lightbulb' test, where a machine heats up a special, well, lightbulb, that they put against your skin and you give them an idea of when its too painful, and they measure you on a scale from 1-10. My nerves were so numptied from the years of pain they actually had to stop the test because I couldn't feel the bulb for several minutes. Originally, they had concluded (without any tests) that my threshold was abnomally low because I said regardless of what I took, my pain never really went under a 7 on a 10/score chart.

The worst part of all of this is that those tablets you take to stop the pain are making your body's temple a doss house. I now have an abnormal liver and my blood practically can't clot because of the amount of paracetamol (Acetominophen to those in the US) I've taken (over 6 years I think it is, it affects your blood clotting factor, and over 3 it starts to degrade your liver). Combined with my other tablets, they're making me a wreck!

Aye, the Iowa Gambling Task. Sorry to hear about your condition, Karilla.

I wouldn't worry too much. The IGT measures a specific form of decision-making, that is, affective/emotion-based decisions. Thus, people can be cognitively normal in almost every way but show some impairment in making decsions under situations of complexity and ambiguity. These are the sort of situations in which emotions can guide adaptive decisions.

This impairment generally shows as a tendency to make impulsive and risky decisions, or what the Iowa group call 'myopia for the future' - i.e. favouring short term gain at the risk of long term pain.

If you think you do show a degree of impulsivity in your judgements, try to run important decisions past those you trust.

I would also note that something like 20-30% of the 'normal' population show poor decision-making on the IGT.

[edit on 27-7-2007 by melatonin]

reply to post by Byrd


There is no doubt that chronic pain saps life and mental energy of the person. There is hope out there though. See this article by Dr. William von Peters - www.ethericwarriors.com...

i have CRPS as well and i suffer. it manifested after i was in an accident at work and lost a finger and tore up a couple others.
i have been dealing with it for 19 months and workers comp has finally allowed crps into my claim. it took 2 court hearings and appeals.
i have been on lyrica and some serious painkillers this entire time. i am finally able to take steps towards maybe getting a spinal chord stimulator.

all that said... i am super foggy all the time. if the pain is not affecting my brain then the meds are. sometimes i am talking and i just lose it. i know what i want to say but i cant get the words out. i forget things all the time. i am agitated all the time.

it sucks