Neurophysiologic and pathologic aspects of acute and chronic pain

Acute pain produced by disease or injury is the net effect of highly complex interactions of various neural systems and psychological factors. Through the interaction of the afferent systems and neocortical processes, the individual is provided perceptual information regarding location, magnitude, and spatial and temporal properties of the noxious stimulus that activates motivational tendencies toward escape or attack and permits analysis of multimodal information, past experience, and probability of outcome of different response strategies. In contrast, chronic pain is a malefic force that taxes the physical, emotional, and economic resources of the patient, his famiily, and society. Moreover, chronic pain is characterized by physiological affective and behavioral responses that are quite different than those of acute pain. The clinician must keep these differences in mind in order to provide patients with optimal relief of their pain.

[Variations of intraocular pressure induced by psychological stress (author's transl)]

Peculiar psychic reactivity of glaucomatous patients detected clinically and widely treated in the literature, has led us to study the behaviour of intraocular pressure in normal and glaucomatous subjects when submitted to various stresses. The data obtained show that prolonged stress increases intraocular pressure in normal subjects, unlike shorter stress which only causes an increase of intraocular pressure in glaucomatous patients. The possible genesis of the phenomenon is discussed.

Mild high-renin essential hypertension. Neurogenic human hypertension?

To determine whether the elevated plasma renin activity in some cases of mild essential hypertension expresses sympathetic-nervous-system over-activity, we compared indexes of sympathetic activity in 16 patients with mild high-renin essential hypertension, 15 hypertensive patients with normal plasma renin activity and 20 normal subjects. Patients with elevated activity exhibited a raised plasma norepinephrine concentration (P less than 0.05), a greater fall in cardiac output with cardiac beta-adrenergic blockade by intravenous propranolol (P less than 0.01), reduction in total peripheral vascular resistance with alpha-adrenergic blockade produced by intravenous phentolamine (P less than 0.01), and reduction to normal of blood pressure by "total" autonomic blockade (atropine, propranolol and phentolamine). On psychometric testing, patients with high-renin hypertension, but not those with normal plasma renin activity, exhibited suppressed hostility (P less than 0.01), a behavioral pattern linked to increased sympathetic activity. The hypertension in these patients with high renin activity is neurogenic and possibly psychosomatic in origin.

Life-threatening "vagal reaction" to emotional stimuli

"Vagal reactions" may follow sudden emotional or physical strain in "vagotonic individuals" and are usually benign. In the case described, emotional stimuli caused life-threatening vagal reactions in a "healthy individual." Implantation of an artifical pacemaker was necessary to control the attacks.

[Acupuncture and relaxation]

Relaxation and tranquility are commonly induced by acupuncture. Techniques are presented and neurophysiological theories underlying the therapeutic effect are discussed. Emphasis is laid on the importance of this effect in psychiatric management.

[The mechanism of releasing and bio-behavioral significance of the hypothalamo-hypophyso-adrenal gland reaction to the environment (alarm reaction)]

Laboratory experimentation has demonstrated the large increase in the rate of circulating norepinephrin (N.E.), in a parallel with an improvement in cardiovascular dynamism of suprarenalectomized rabbits under the action of injection IV of hydrocortisone. As from this ascertainment, the author attempts to make a synthesis of known experimental facts demonstrating that next to a regulation in constancy (with negative retroaction) of the C.R.F. leads to A.C.T.H. leads to cortisol system, there exists a servomechanism (control external to the system) as from the activity of the nervous systems as compared with environment. Hydrocortisone favouring passive avoidance, and extinction facilitating the activity of the cholinergic inhibiting system of action (I.S.A.). A.C.T.H. facilitates active avoidance and the catecholaminergic activating system of action (A.S.A.). Now, it has already been demonstrated in the same laboratory that stimulation of I.S.A. or inhibition of the A.S.A. freed N.E. from the peripherous nerves of a adrenalectomized animal. It, therefore, seems that the early freeing of A.C.T.H. following aggression is capable of favouring locomotive activity (flight or fight). Should the latter be efficient, there is a return to the prior behavioural and endocrinal balance. On the other hand, should they be inefficient, there arises a vicious circle (regulation with tendency, positive retroaction) because secondary secretion of glucocorticoids will maintain inhibition of action and the secondary freing of the mineralocorticoids are discussed as well as the central mechanism of illness so called "psychosomatic".

An integrative model for the treatment of psychosomatic disorders. The place of sleep and dreams revisited

The functions and dysfunctions of slow wave sleep and of REM sleep and its associated dreams have a tremendous significance in understanding the psychosomatic model of illness and in establishing preventive strategies. Ten patients suffering from a variety of psychosomatic illnessess spent 3-4 nights sleeping at the Dream Laboratory. A psychiatric evaluation was carried out and those suffering from schizophrenia, severe depression, acute stage of physical illness and organic deficits were not accepted for the study. It was postulated that increased psychosomatic 'penetrance' as measured by poverty of fantasy life, feelings of helplessness, absence of dream reports, vacant and contrived emotional expression and poor psychological mindedness would be correlated with psychological test results (IPAT anxiety Scale and Zung Depression Rating Scale), manifest dream content analysis and particular REM and stage 4 deficit. The higher psychosomatic 'penetrance' in our study was not found in all patients with a psychosomatic diagnosis but rather in those patients suffering from ulcerative colitis. The degree of 'penetrance' was related to specific physiological, psychological and interpersonal parameters. Based on these findings a spectrum of clinical and physiological criteria of selection for particular therapeutic intervention was presented.

The pathophysiology of sleep disorders in pediatrics. Part II. Sleep disorders in children

In this part of the chapter we have used new terminology and developed a new system for classification of sleep disorders in children. We suggest that excessive daytime sleepiness should be investigated by clinicians before troubles at school necessitate referral. The narcolepsy-hypersomnia syndrome generally has not been recognized in the pediatric age group. Symptoms of excessive fear of falling asleep need to be viewed in this context. Sleep apnea-hypersomnia has received insufficient attention in the American literature. It is a syndrome that affects both adults and children with potentially disastrous cardiovascular and pulmonary complications. The relationship of the sleep apnea-hypersomnia syndrome to the sudded infant death syndrome remains speculative, although preliminary results from our longitudinal study have indicated a possible link. Both the narcolepsy-hypersomnia and the sleep apnea-hypersomnia syndromes are reviewed in detail. In contrast, we review briefly the NREM dyssomnias, including night terrors, sleepwalking, sleep talking and enuresis. All are well known to clinicians dealing with children, and we have related them to findings emanating from the sleep laboratory. We suggest that they are physiologically rather than psychogenically based and frequently represent immaturities of the central nervous system. Finally, the insomnias of childhood are presented. We emphasize that they are rare, and after ruling out organic conditions and drug-dependency syndromes, cultural styles or family stresses generally account for the majority of complaints.

Prediction of psychotropic properties of lisuride hydrogen maleate by quantitative pharmaco-electroencephalogram

Based on "quantitative pharmaco-EEG" using computer-analyzed EEG (CEEG) measurements, unknown CNS effects of lisuride hydrogen maleate (LHM) were established. CEEG profiles of LHM in low dosages (less than or equal to 10 mcg) are similar to CNS "inhibitory" compounds, while in higher dosages (25 mcg to 100 mcg) they resemble "psychostimulant" compounds. By measuring the brain function using computer period analysis of cerebral biopotentials, dose-efficacy relations were found (in the range of 25-75 mcg) which suggest the bioavailability of LHM at the CNS level. By comparing the CEEG profiles of LHM with the previously studied compounds, five different clinical uses of LHM were predicted. The pilot trials suggest that LHM may have therapeutic potentials in patients with "aging" and/or organic brain syndromes, and in children with behavioral disturbances.

[Introduction to psychosomatic medicine (author's transl)]

Psychosomatic medicine is a "holistic" conception of pluricausal medicine which has as an objective to study not the isolated disease, but the sick man, that is the humanised patient in his most complete nosological and ecological perspective. Numerous arguments seem to indicate the reality of clinical and experimental links between emotional life, psychic troubles and the dysfunctioning of organs or the apparition of visceral lesions. Anatomical and physiological studies play a capital role at the level of the hypothalamus, limbic system and at different neuroendocrinological systems (pituitary, corticoadrenal and medulloadrenal). On the experimental level, beside confining ulcers obtained by different technics on the laboratory rat, one must insist on the experiments of Weiss who showed that the peptic ulcers of the rat, under certain conditions, depend on two variables: the number of stimuli which the animal must face and the informative feedbacks more or less useful, which it receives in return. The investigations undertaken on the sick man show the importance of functional troubles with respect to anomalies of the autonomic nervous system or anomalies of intramural ganglions, which explain perhaps the notion of target organs for the troubles. Considering the most recent concepts which valorise the role of genetic factors in the determination of psychosomatic diseases, one can conceive that psychological determinants, affective or environmental, are cofactors which integrate themselves with somatic, genetic, constitutional and nutritional factors to produce the final morbid picture.

[Stress sensitivity and adaptation]

On the basis of theoretical, clinical and experimental analyses the influence of different stress categories, especially of psycho-emotional and socio-emotional stress, upon cerebro-visceral regulation processes is investigated. Central-nervous information processing in various brain areas (neocortex, limbic system, hypothalamus, formatio reticularis mesencephali etc.) and learning processes are equally affected by stress factors as are haemodynamic and biochemical parameters. Changes of the carbohydrate and lipid metabolism, of plasma renin activity, catechol amine release and the counter-regulatory insulin enhancement are especially pronounced in "stress-sensitive risk persons", e.g. in the hypertensive as a maladaptive dysregulation-as opposed to the adaptive regulation capacity of healthy individuals. The investigated functional patterns of different systems of the organism allow the distinction of hyper- and hyporeactive forms of maladaptation. The pathogenetic efficiency of stress is determined not only by the quantity, quality, duration of exposure and basic processes of the central nervous system, but also by man's personality structure and his sensitivity to stress (genetic predisposition and/or acquired maladaptation). More insight into the neuro-biological processes underlying the motivational and psycho-emotional performance of the brain and its connection withe humoral-hormonal and cardiovascular systems is necessary to treat and to control cerebrovisceral dysregulations such as arterial essential hypertension. It will be a task of psychotherapy to help improve man's adaptive capacity and to desensibilize stress-sensitive risk persons.

Emotions and skin (II)-the conditioning of scratch responses in cases of lichen simplex

Lichen simplex is generally regarded as a condition initiated and perpetuated by scratching and emotional tension. It was felt that the scratching might partly be a conditional response to itching and other signals, and that feelings of guilt, anxiety and hostility would be prominent features in these patients. Conditioning experiments designed to establish scratch responses to an itch stimulus (UCS) and a tone (CS) showed that lichen simplex patients conditioned more readily and extinguished more slowly than controls. These finding were more marked when the itch stimulus was applied to affected as compared with normal skin. It was not possible to distinguish differences in the psychological tests between patients and controls. The possible significance of these findings is discussed.

Denial revisited: reflections on psychosomatic theory

Certain clinical observations cast doubt on the validity of the traditional psychological explanation of psychosomatic disorders, which invokes the concept of a psychodynamic conflict derived from psychoanalytic theory. Psychosomatic patients appear to be unable to describe feelings in words, show a marked paucity of fantasy, and do not make significant internal psychological changes in these areas in the course of psychodynamically oriented psychotherapy. It is suggested that neurophysiological hypotheses may be more useful for understanding psychosomatic processes and specifically that disturbances in the function of the palleostriatral dopamine tract are related to psychosomatic disorders. Testable inferences from this hypothesis are proposed, including the suggestion that clinically and neurophysiologically, schizophrenia and psychosomatic disorders are the obverse of one another.