Reactions to Pain in Various Abnormal Mental States

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Abstract
The study on which we are going to report has its origin in a clinical observation made twenty-six years ago (Schilderand Stengel,1928).An elderly female patient whose main symptom was a receptive aphasia, showed a peculiar reaction to painful stimuli. She failed to withdraw from the source of those stimuli, or did so only to a very slight degree, irrespective of the part of the body surface affected. She never showed that tendency to total withdrawal which characterizes normal behaviour. Sometimes she exhibited paradoxical reactions in that she followed the stimuli with her hand as if to invite more pain. There was no indication of a disturbance of perception. That the patient perceived pain could be inferred from her utterances and from wincing, which she often showed very markedly, while at the same time failing to withdraw the afflicted part of her body. This was another argument against the presence of a disturbance of sensation which did not affect the whole body surface. Within a few weeks the aphasia subsided sufficiently to enable the patient to talk about her attitude to the painful stimuli. She definitely experienced them as such but did not seem to mind them. Reactions to certain other stimuli were found to be equally abnormal. Neither a match lit close to her eyes, nor a loud clap, would cause her to withdraw in a normal manner. It did not make any noticeable difference whether these stimuli were sprung on her unexpectedly or whether she could watch them being inflicted, nor did it matter who administered them. In marked contrast to the apparent indifference to external stimuli, the patient was sensitive to internal pains and used to complain in an almost hypochondriacal manner about stomach pain. The same discrepancy was noticed in other cases. The patient's peculiar behaviour in relation to painful or other noxious stimuli inflicted from outside which are usually experienced and reacted to as threats, was assumed to be due to a disorder on a higher level of integration. It was called, perhaps not very aptly,asymbolia for pain, the patient, while able to perceive pain, being unable to appreciate its significance as a signal of danger and to react accordingly. The term is obviously not comprehensive enough and does not take into account the patient's failure to respond normally to other external stimuli to which the usual reaction is withdrawal. This behaviour pattern was subsequently observed in a considerable number of cases. Clinical observations suggested that this symptom was related to parietal lobe lesions in the dominant hemisphere, and this was borne out by a series of post-mortem examinations. Asymbolia for pain has since been observed by others and is often referred to among the effects of parietal lobe lesions. However there is still much that is obscure about it. In psychiatric hospitals one can often observe it in cases of brain atrophy in which the parietal, or parieto-temporal area is more severely involved than other parts of the brain. The symptom fits well into the present-day concepts of parietal lobe syndromes (Critchley, 1951). It implies an inability to integrate external stimuli, or, as Schilder put it, to connect the experience of pain with the body image.