A young woman goes away to college. It is an experience of delight and discovery for her, but also one of stress. Academic and social pressures overwhelm, and a mind, formerly resourceful and elastic, is bent. She enters a depressive interlude. She may experience tearful despondency, or perhaps a syndrome of fatigue, apathy, and disinterest. Regardless, she will likely recover spontaneously. First depressions usually do. Later in her young life she encounters another stressor, a parental divorce. Depression comes quicker and deeper this time. Spontaneous recovery is less certain, but even so, with time and perhaps drug therapy, her depression abates, and she enters an interval of wellness. Her disease, however, is now ingrained and subject to recrudescence. Throughout the remainder of her life this woman will experience interludes of depression, sometimes in response to a stressful provocation, but often in the absence of any identifiable stressor. An alternate behavior is established, and recurrent depression appears randomly through her life.

Many diseases exhibit this natural history. They appear initially under provocation. At their onset they are stimulus-dependent. Epilepsy in the child, for instance, may be precipitated by flickering
lights, and migraine by a host of stressors which we identify as triggers. Migraine, epilepsy, and depression are all recurrent diseases. They reappear under provocation. With each recurrence, the neural systems subserving them become more integrated and fixed. They become, if you will, more confident and sure of themselves. Ultimately they acquire a life of their own. They begin to appear even in the absence of provocation. They become stimulus-independent. This is the phenomenon of kindling. Neural systems, by dint of repetition, incite alternate behaviors which recur throughout life.

The kindling theory is a widely accepted and convenient explanation for the recurrent nature of many neuropsychiatric illnesses. Aggressive treatment of epilepsy, migraine, and depression is warranted, not only for the sake of patient comfort, but to prevent kindling, that is to prevent the later recurrence of the disorder. Painfulness, certainly as much a cerebral experience as epilepsy and
depression, may also be kindled.

Lumbar disc disease is often a recurrent and progressive disorder. One disc after another ruptures and one operation after another is performed. In the process, vertebral alignment is disordered. Spinal instability ensues, and as the disease advances, arthritis and the constriction of nerves by scar tissue gradually develops. Pain evolves from a relatively simple mechanical disorder, an extruded disc impinging on a nerve, to a much more complex and confusing illness. It is hard to make generalizations about a disease as complicated as the failed back, but there is one that I believe will stand even the most critical analysis. That is, as the disease progresses, the precise pain generator becomes less easy to identify. The longer the disease lasts, the less certain we are of its true nature. This is, I suspect, because of kindling.

The kindling theory is a simple conceptual and organizational idea. It makes common sense, and it can be transcribed into many illness behaviors. Substance abuse begins as stimulus-dependent behavior-alcohol for the relief of anxiety or insomnia, opiates for the relief of pain. Both later become stimulus-independent. Post traumatic stress disorder begins as stimulus dependent, but the behaviors continue after the stimulus has been removed. Epilepsy, migraine, depression, substance abuse, post traumatic stress disorder, and painfulness all obey the same natural history.

We really should recognize that the phenomenon of kindling is operative in chronic pain as it is in so many other illnesses. There is a barrier, however, and that is the mind-body dichotomy. "This pain can't be in my mind. This pain is real!" These two declamations are, of course, not mutually exclusive. The pain is real, and it is in the mind. A state of pain is a cerebral as well as corporal experience, and these two cannot be separated. That which happens to the body happens without exception also to the mind.

Dr. Cochran uniquely incorporates the fields of neurology, internal medicine, and psychiatry in deriving insightful - sometimes, disturbing - yet hopeful conclusions for the chronic pain sufferer. He brings to light intriguing new treatment strategies that should be of interest to the medical community and chronic pain sufferers alike. http://www.understandingpain.com

Autor: martinvnostrand

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