Hard as nails

Tom alerted me to this fantastic brief case published in the British Medical Journal where a builder is admitted to hospital in great pain after a nail penetrated all the way through his boot. But it turned out that the pain was entirely psychological, as the nail had missed his foot by sliding between his toes.

A builder aged 29 came to the accident and emergency department having jumped down on to a 15 cm nail. As the smallest movement of the nail was painful he was sedated with fentanyl and midazolam. The nail was then pulled out from below. When his boot was removed a miraculous cure appeared to have taken place. Despite entering proximal to the steel toecap the nail had penetrated between the toes: the foot was entirely uninjured.

As Tom mentioned “One of the things I love about it is that the builder had no incentive to ‘fake’. He knew he should have acted tough so we know that the pain he felt wasn’t over-acting. It was imaginary pain, but it was real imaginary pain!”

This isn’t really the nocebo effect, where ‘side-effects’ appear after having taken nothing but a placebo, but more similar to what doctors might describe in its persistent form as somatisation disorder where physical symptoms appear that aren’t explained by tissue damage.

However, both are similar in that real pain arises from beliefs, expectations and perceptions. We now know that all pain has a significant mental component and, consequently, psychological therapy is an effective treatment for chronic pain.

It’s no coincidence that Tom picked up this snippet in a talk by psychologist Stuart Derbyshire who has done some fantastic studies on the neural basis of psychologically controlled and induced pain by using hypnosis in fMRI scanners.

Link to brief piece in the BMJ.

6 thoughts on “Hard as nails”

  1. Thats a crazy story. Placebo, Nocebo and the Somatisation disorders may all result from a common expectation effect – which is something I think the hyponosis people are better at using than us psychologists.
    I just wrote a presentation on the placebo effect and its role in psychological therapies. It boils down to the fact that even if a therapy is evidence based and of proven efficacy, the placebo effect plays a role, and conversely, even if a “therapy” is entirely placebo, it can still be effective!
    I think once we psychologists get a proper grip on Placebo/Nocebo/psychsomatic effects we’ll understand human nature a lot better…
    PS: I’ve found it impossible to sign in to typepad to comment on your blog using either facebook or google account – Not sure the OpenID thing is working properly with the people that host your blog – you might want to investigate.

  2. Sounds like a great case. Agree completely that placebo/nocebo is expectation dependent and a window on human nature. The Moerman book on the “meaning response” is particularly good on this point.
    Can’t read the article directly because of the paywall. Could you link to the free abstract/extract, or give the title of the article? BMJ paywall gives no clues to when this was published, so I can’t find it on Ovid via my university login.

  3. I agree with this article that in treating chronic pain psychological therapy is an effective treatment. And also, There are actually two types of pain, one is acute pain and the other is chronic pain. Surgery, broken bones, toothache, burns etc. are the usual cause of acute pain, while cancer pain, arthritis pain, neurogenic pain (pain resulting from damaged nerves) and so forth causes chronic pain. However, acute pain may eventually lead to chronic pain. a natural anti-inflammatory and analgesic, perhaps the most powerful health product in the world today. What are the benefits of the incredible mangosteen fruit particularly in managing pain and inflammation? Xanthones, which are very unique to the mangosteen appears to possess numerous potential beneficial properties such as, “antiallergic, anti-inflammatory, antituberculotic, antitumor, antiplatelet, Beta-adrenergic blocking and anticonvulsant” properties.

    Kind Regards,

  4. Fisher et al. Minerva. British Medical Journal. 1995.
    Is as good as I can find. This is a useful clinical example of pain in the absence of damage. The output of the threat detection system responding to defend the organism based on the input it has available and not taking any chances. Great for use in chronic pain education.
    Kind thoughts,

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