CP 12.05_Neuro.
final 11/15/05 3:17 PM Page 97
NEUROSCIENCE NEWS
Studies of interest to practicing psychiatrists
Does chronic pain shrink the brain?
Edmund S. Higgins, MD
C hronic pain—particularly lower back
pain—is frustrating to both patient and
clinician. Because most cases lack an obvious
physical explanation, the doctor may wonder if
the patient is faking or exaggerating—that the
pain is “in the patient’s head.” Studies suggest
this cerebral component may exist—but not in
ways you might expect.
HOW THE BRAIN PROCESSES PAIN
According to traditional belief, the brain passively
receives noxious signals from injured tissue
(nociceptive) or damaged nerve (neuropathic).
Extensive—some would say excessive—tests are
often conducted in search of a bone or muscle
injury that might explain the pain.
Functional imaging studies across 15 years
have shown activity in various brain regions
when subjects feel pain. In addition to the
somatosensory cortex, pain also activates brain
areas involved with mood, attention, and anxiety.
More important, the brain does not passively
receive signals from the periphery but can inhib-
it ascending signals with endogenous opioids,
such as endorphins and enkephalins.
Apkarian et al1 found that CNS changes may
Current p S Y C H I AT R Y
explain persistence of pain and lack of peripheral
findings. The researchers compared gray matter
density in 26 patients with chronic back pain and
26 pain-free controls. Patients in the pain group
met International Association for the Study of
Pain criteria for chronic back pain and had unre-
lenting pain for >1 year, primarily in the lumbo-
sacral region.
Structural brain MRIs showed patients with
chronic back pain had 5% to 11% less cortical
gray matter volume than did pain-free controls
(Figures 1 and 2, page 98). The authors noted that
it would take an average pain-free person 10 to 20
years to lose this much gray matter as a function
of aging. Further computer analysis of the images
by brain region showed reduced bilateral dorso-
lateral prefrontal cortex density. Together, these
results show significant brain atrophy associated
with chronic back pain.
These findings document for the first time
that a heterogeneous group of patients with unre-
Dr. Higgins is clinical associate professor of family
medicine and psychiatry, Medical University of South
Carolina, Charleston (higginse@musc.edu).
VOL. 4, NO. 12 / DECEMBER 2005 97
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NEUROSCIENCE NEWS
Studies of interest to practicing psychiatrists

lenting back pain had changes in the cerebral

Figure 1
cortex—particularly the prefrontal cortex.
These changes may help perpetuate chronic How pain, aging diminish gray matter
pain because the dorsolateral prefrontal cortex 6.5

Total cortical gray matter volume

is believed to control pain perception from the Chronic back pain
top down.2 In other words, diminished cortical Control
6.0
control reduces the “brakes” on pain signals

(cc x 100)
ascending from the periphery. 5.5

5.0
POSSIBLE CAUSES
But what reduces gray matter? Several causes 4.5
have been proposed.
Genetics. Some persons who were born with 4.0
20 30 40 50 60 70 80
less gray matter than normal may be predis- Age (years)
posed to chronic back pain. Researchers also Persons with chronic back pain generally have less
suggest that a decreased hippocampus may be gray matter than pain-free controls across the lifespan.
an independent risk factor for posttraumatic Source: Reference 1. Copyright 2004, the Society for Neuroscience.
Reprinted with permission.
stress disorder. (See “Posttraumatic stress
disorder: Nature and nurture?” CURRENT
PSYCHIATRY, May 2004, at www.currentpsy-
chiatry.com.) Figure 2

Drugs. Medications and other substances taken Group-averaged gray matter volumes
to alleviate pain might also reduce gray matter.
Total cortical gray matter volume

Excessive alcohol and opioid use have long- 6.5

term adverse effects on the CNS.3 Is treatment 6.0
or self-medication mildly toxic to the brain?
(cc x 100)

Overuse atrophy. Apkarian et al1 propose that 5.5

cortical loss may be secondary to overuse.
They suggest that persistent pain percep- 5.0
tion—and the resultant negative affect and
4.5
stress—causes an excitotoxic and inflammato-
ry state that wears out portions of the brain cir- 4.0
cuitry. If this is true, then chronic pain itself Control Chronic back
causes cerebral atrophy. group pain group
Source: Reference 1. Copyright 2004, the Society for Neuroscience.
Whatever the explanation, this study indi- Reprinted with permission.
cates that chronic lower back pain pathology
extends beyond the lower back.
References
1. Apkarian AV, Sosa Y, Sonty S, et al. Chronic back pain is associated
with decreased prefrontal and thalamic gray matter density. J
Related resources Neurosci 2004;24:10410-5.

Deyo RA, Weinstein JN. Low back pain. N Engl J Med 2. Lorenz J, Minoshima S, Casey KL. Keeping pain out of mind: the
2001;344:363-70. role of the dorsolateral prefrontal cortex in pain modulation. Brain
2003;126:1079-91.

International Association for the Study of Pain. www.iasp-pain.org.
3. Goldman D, Barr CS. Restoring the addicted brain. N Engl J Med
2002;347:843-5.

98 Current
pSYCHIATRY
VOL. 4, NO. 12 / DECEMBER 2005