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Paincognition and suffering

Paincognition and suffering. Aya Nakae Osaka University Graduate School of Medicine, Department of Anesthesiology. Outline. What is pain? My research What is “schizophrenia?” The correlation between schizophrenia and chronic pain Results Future plans.

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Paincognition and suffering

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  1. Paincognition and suffering Aya Nakae Osaka University Graduate School of Medicine, Department of Anesthesiology

  2. Outline • What is pain? • My research What is “schizophrenia?” The correlation between schizophrenia and chronic pain Results • Future plans

  3. 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.

  4. 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.

  5. 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.

  6. Components of pain • Nociception • Perception of Pain • Suffering • Pain behaviours Pain behaviours Suffering Perception of Pain Nociception

  7. Nociception Nociception

  8. 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

  9. Suffering Negative and emotional reactions caused by • pain • depression • fear • anxiety • stress • etc Suffering

  10. Pain behaviours • Saying” Ouch!!” • Grimacing • Limping • Lying down • Recourse to health care • Refusing work Pain behaviours

  11. The purpose of our research The clarification of the process from pain perception to suffering through researching patients with schizophrenia and chronic pain.

  12. Why patients with schizophrenia? They are less sensitive to pain • ruptured appendix • perforated bowels • peritonitis • painless myocardial infarction • Chronic pain is rare. ? ? ?

  13. Why are they less sensitive? • Cognitive impairment • Affective impairment • Attention deficiency

  14. Why patients with schizophrenia? Pain Pain Suffering Suffering Pain Behaviour Pain Behaviour Patients with chronic pain Patients with schizophrenia

  15. Degree of pain suffering Weak Strong Schizophrenia Normal Chronic pain Schizophrenia is a human model considered to be the opposite of that with chronic pain.

  16. Methods Chieko was an artist who created many works of art after suffering with schizophrenia. Chieko Takamura

  17. 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

  18. 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.

  19. 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

  20. Expression of pain • McGill Pain Questionnaire (short form) S-PRI: Subjective assessments A-PRI: Affective assessments T-PRI: Total assessments • Visual Analogue Scale (VAS)

  21. Results This picture by Norwegian artist Edvard Munch is said to show the hallucination of a patient with schizophrenia.

  22. Participants

  23. Discussion Self-portrait with bandaged ear. Vincent van Gogh, who was troubled By mental health, cut off his own ear.

  24. Causes of Schizophrenia • Genetic Intermediate phenotypes • Prenatal • Social • Others Eugen Bleuler (1857-1939) coined the term "Schizophrenia" in 1908.

  25. What is a phenotype? Gregor Johann Mendel

  26. The phenotype Control Patients The data showed potential phenotype groups in schizophrenia.

  27. Analgesic effect of antipsychotics? Dopamine D2 antagonist (traditional Antipsychotics) and opioids Neuroleptic analgesia Less sensitivity to pain due to antipsychotics’ analgesic effects? Not dosage dependent

  28. 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.

  29. HPT and pain suffering Degree of pain suffering Strong Weak Patients with normal heat pain thresholds have a normal degree of suffering? Normal Schizophrenia ? ? Chronic pain Heat pain threshold Low High Schizophrenia Normal

  30. Patient 1: Confident against pain!! Heat pain threshold • History of spinal contusion injury(SCI) • No pain • No analgesics High Low

  31. Patient 2: Always feels knee pain Heat pain threshold • Feels pain due to osteoarthritis in the knee. • Receives general therapy for knee pain High Low

  32. Patient 3: Feels pain but ・・・・・ Heat pain threshold • History of SCI with paralysis • She feel pain. • She looks free from pain High Low

  33. HPT and pain suffering Degree of pain suffering Strong Weak Normal Schizophrenia Chronic pain Heat pain threshold Low High Schizophrenia Normal

  34. 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.

  35. Schizophrenia less sensitive to pain ? 1. Sensory insensitivity 2. Less suffering due to the noxious stimuli ? ? ? ?

  36. 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.

  37. 1. Detailed evaluation of sensitivity

  38. 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

  39. 3. Other possible imaging studies • Dopamine • Glutamate

  40. Significance : Area detection Area detection Molecular mechanism Direct stimulation therapy Evaluation of degree and treatment

  41. Significance : Genes Target gene Molecular mechanism Progress in schizophrenia research New analgesic and anesthetic

  42. Acknowledgements Department of Psychiatry Ryota Hashimoto and his colleagues Nihon KodenCooporation Syogo Maeda & Tomoko Oku Department of Pain Medicine Masahiko Shibata Graduate School of Dentistry SyoichiIshigaki Department of Anesthesiology All my colleagues

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