![\"protectometer-introduction\"](\"http:\/\/pesquisaemdor.com.br\/wp-content\/uploads\/2017\/08\/protectometer-introduction.jpg\")
<\/a><\/p>\nFigura 1. Protet\u00f4metro<\/p>\n
Como nota final – precisamos ter uma perspectiva de sistemas que inclua conhecimento sobre neurofilosofia, o sistema nervoso, o sistema imunol\u00f3gico, o sistema end\u00f3crino e assim por diante. Estas s\u00e3o as “grandes rochas” que precisam ser exploradas antes de come\u00e7ar a focar nos pequenos gr\u00e3os. O novo livro Explain Pain Supercharged gerencia eficazmente os pacientes em uma perspectiva de sistemas e, mais importante, em uma perspectiva biopsicossocial, e nos ensina a impulsionar nossas habilidades de comunica\u00e7\u00e3o e educa\u00e7\u00e3o. Al\u00e9m disso, nos ensina a conceituar a dor persistente para os pacientes. Talvez a narrativa do paciente possa nos ajudar a entender como um indiv\u00edduo d\u00e1 sentido ao mundo, e talvez mais pesquisas neste campo possam melhorar nossa compreens\u00e3o entre a\u00e7\u00e3o e predi\u00e7\u00e3o. No fim, a Revolu\u00e7\u00e3o da dor \u00e9 definitivamente necess\u00e1ria para mudar as cren\u00e7as, o caminho no n\u00edvel social e cultural, e as previs\u00f5es individuais sobre nosso corpo e sobre o movimento.<\/p>\n
ENGLISH VERSION<\/h2>\nHow precise are your predictions? A blog post about predictive processing and interoceptive accuracy.<\/strong><\/h2>\nIn the last couple of weeks, I have been inspired to delve into some of the mechanisms related to \u201cneurotag\u201d activity \u2013 i.e. activity in functional networks that are involved in producing pain as an output. Both the light of Prof. Moseley\u2019s brilliant Explain Pain Supercharged-course in Copenhagen, and the fascinating TED-talk \u201cYour brain hallucinates your conscious reality\u201d by neuroscientist Anil Seth, I\u2019ve tried to get a grasp on two topics in particular: predictive processing and interoceptive accuracy. I am by no means an expert in the field, and these thoughts are work in progress so please proceed with a kind mind.<\/p>\n
In short, predictive processing is the brain\u2019s best attempt of making sense of the world, and results from attempts to accommodate information that has deviated from our predictions (Clark, 2016). We now know that our experiences are inferred (Heidegger, 1962; Sullivan, 1995); we fill in the gaps (Gregory, 1980), selectively attend (Allport, 1993; Dayan et al, 2000), unconsciously prime (Beierholm et al, 2009; Howhy, 2012), and in essence prioritize efficiency over accuracy (Humphrey, 2005; Trimmer et al, 2013a). In order to survive, we must perceive our environment effectively, identify threats, and act to avoid damage to our body – or, if damage occurs, we must act rapidly to promote recovery (Tabor et al, 2017). Butler & Moseley (2013), and Trimmer et al (2013b) argue that pain, whether acute or chronic, is always rational, according to the suite of information available to the person, and as part of a protective strategy; one attempts to defend one\u2019s self <\/em>in the presence of inferred threat (Wall, 1979). This perspective is congruent with the Bayesian inference framework (Edwards, 2012; Friston, 2011; Yuille et al, 2005) which emphasizes the importance of understanding how information about the world, both internal and external, is integrated in the formation of perceptual experience (Anchisi & Zanon, 2015; Yoshida et al, 2013). A precise and accurate analysis is crucial because a poor understanding of sensations like pain may result in erroneous decisions about the cause of pain and, therefore, about the best course of action (Tabor et al, 2017). Interestingly, it may seem that experiences that violate our predictions, i.e. unexpected ones, create predictive errors that lead to a greater protective response \u2013 an embodied response that occurs outside our awareness. Whether this is merely related to perceptions of reality, or includes persistent pain \u2013 remains to be validated (as far as I know).<\/p>\nSo why do I think that interoceptive accuracy (or precision) may be important for pain? Information about the bodily state is pertinent to make predictions, and according to Clark et al (2015), interoception is a predictive process that involves \u201cthe use of acquired knowledge to predict the incoming sensory barrage\u201d. More importantly, the interoceptive matrix collects physiological information from all tissues of the body and concerns optimal homeostasis and wellbeing of the organism (J\u00e4nig, 2006). I am not convinced that interoception has a superior role compared to proprioception or exteroception \u2013 but the literature is quite interesting. Di Lernia (2016) suggest that there is a missing link between the sense of the physiological condition of the entire body and the perceptions of pain in persistent conditions, and that predictive coding theories may explain an underlying principle of importance for persistent pain. Di Lernia further suggest the existence of an \u201canticipatory\/interceptive buffer\u201d \u2013 a buffer that loses its salience (sensitivity) in persistent pain, which represents an interesting hypothesis. If this line of reasoning is probable, it may imply that we are less responsive to what is occurring \u201chere and now\u201d. If we look at modern pain science theories such as Melzack\u2019s \u201cPain Neuromatrix Model\u201d (Melzack, 2005) or Gifford\u2019s \u201cMature Organism Model\u201d (Gifford, 1998) we know that pain as an output is dependent on a type of self-referential mechanism that samples itself in a circular manner. The Mature Organism Model suggests that pain can be considered an integrative experience forged upon sampling, appraisal, scrutinizing, and response processes from a top-down perspective. Empirical evidence also suggests that there is a precision-weighting, which is a generic computational process happening throughout the brain (Iglesias et al, 2013), and this may be instantiated through neuromodulatory mechanisms of gain control at a synaptic level (Moran et al, 2013; Seth & Friston, 2016). Importantly, the balance between homoeostatic reflexes and more goal-directed allostatic behaviour rests upon the confidence (i.e. precision) placed in deeper expectations about how we will behave (Seth & Friston, 2016). Again, whether this applies to persistent pain still has to be investigated rigorously. But what if our ability to feel our own bodily state, and to process that information is distorted and no longer as precise as it once were? Wouldn\u2019t all prior experiences and beliefs about our own bodily state influence our predictions about the future? Thus, what if our predictions cause more harm than good?<\/p>\n
Therefore, I wonder whether the therapeutic interventions that help our patients are the ones that successfully update our internal model for making precise predictions? Perhaps the top-down expectancy violation that occurs with belief reconceptualization reduces prediction errors, which then minimizes an existential need for biological or psychosocial protection (from an embodied first-person perspective)? When we explain pain and increase awareness of DIMs (Danger in Me) and SIMs (Safety in Me), we provide knowledge, resources and empower patients \u2013 which gives the patient less \u201cstuff\u201d to worry, catastrophize, and ruminate about. If we limit the number of predictions available to make, we may limit the amount of prediction errors, and thus, the need for protection on multiple levels throughout the hierarchy. What if we simultaneously update interoceptive accuracy or improve the \u201canticipatory\/interoceptive buffer\u201d (create body ownership, mindfulness\/acceptance, improve sensory discrimination) \u2013 is it possible that we update the \u201csample and scrutinize\u201d-model by reducing top-down and bottom-up prediction errors? In broader terms, does this mean that we are we targeting \u201cneurotag\u201d activity, shifting the indicator downwards on the \u201cprotectometer\u201d? (Fig.1).<\/p>\n
In the last couple of weeks, I have been inspired to delve into some of the mechanisms related to \u201cneurotag\u201d activity \u2013 i.e. activity in functional networks that are involved in producing pain as an output. Both the light of Prof. Moseley\u2019s brilliant Explain Pain Supercharged-course in Copenhagen, and the fascinating TED-talk \u201cYour brain hallucinates your conscious reality\u201d by neuroscientist Anil Seth, I\u2019ve tried to get a grasp on two topics in particular: predictive processing and interoceptive accuracy. I am by no means an expert in the field, and these thoughts are work in progress so please proceed with a kind mind.<\/p>\n
In short, predictive processing is the brain\u2019s best attempt of making sense of the world, and results from attempts to accommodate information that has deviated from our predictions (Clark, 2016). We now know that our experiences are inferred (Heidegger, 1962; Sullivan, 1995); we fill in the gaps (Gregory, 1980), selectively attend (Allport, 1993; Dayan et al, 2000), unconsciously prime (Beierholm et al, 2009; Howhy, 2012), and in essence prioritize efficiency over accuracy (Humphrey, 2005; Trimmer et al, 2013a). In order to survive, we must perceive our environment effectively, identify threats, and act to avoid damage to our body – or, if damage occurs, we must act rapidly to promote recovery (Tabor et al, 2017). Butler & Moseley (2013), and Trimmer et al (2013b) argue that pain, whether acute or chronic, is always rational, according to the suite of information available to the person, and as part of a protective strategy; one attempts to defend one\u2019s self <\/em>in the presence of inferred threat (Wall, 1979). This perspective is congruent with the Bayesian inference framework (Edwards, 2012; Friston, 2011; Yuille et al, 2005) which emphasizes the importance of understanding how information about the world, both internal and external, is integrated in the formation of perceptual experience (Anchisi & Zanon, 2015; Yoshida et al, 2013). A precise and accurate analysis is crucial because a poor understanding of sensations like pain may result in erroneous decisions about the cause of pain and, therefore, about the best course of action (Tabor et al, 2017). Interestingly, it may seem that experiences that violate our predictions, i.e. unexpected ones, create predictive errors that lead to a greater protective response \u2013 an embodied response that occurs outside our awareness. Whether this is merely related to perceptions of reality, or includes persistent pain \u2013 remains to be validated (as far as I know).<\/p>\n So why do I think that interoceptive accuracy (or precision) may be important for pain? Information about the bodily state is pertinent to make predictions, and according to Clark et al (2015), interoception is a predictive process that involves \u201cthe use of acquired knowledge to predict the incoming sensory barrage\u201d. More importantly, the interoceptive matrix collects physiological information from all tissues of the body and concerns optimal homeostasis and wellbeing of the organism (J\u00e4nig, 2006). I am not convinced that interoception has a superior role compared to proprioception or exteroception \u2013 but the literature is quite interesting. Di Lernia (2016) suggest that there is a missing link between the sense of the physiological condition of the entire body and the perceptions of pain in persistent conditions, and that predictive coding theories may explain an underlying principle of importance for persistent pain. Di Lernia further suggest the existence of an \u201canticipatory\/interceptive buffer\u201d \u2013 a buffer that loses its salience (sensitivity) in persistent pain, which represents an interesting hypothesis. If this line of reasoning is probable, it may imply that we are less responsive to what is occurring \u201chere and now\u201d. If we look at modern pain science theories such as Melzack\u2019s \u201cPain Neuromatrix Model\u201d (Melzack, 2005) or Gifford\u2019s \u201cMature Organism Model\u201d (Gifford, 1998) we know that pain as an output is dependent on a type of self-referential mechanism that samples itself in a circular manner. The Mature Organism Model suggests that pain can be considered an integrative experience forged upon sampling, appraisal, scrutinizing, and response processes from a top-down perspective. Empirical evidence also suggests that there is a precision-weighting, which is a generic computational process happening throughout the brain (Iglesias et al, 2013), and this may be instantiated through neuromodulatory mechanisms of gain control at a synaptic level (Moran et al, 2013; Seth & Friston, 2016). Importantly, the balance between homoeostatic reflexes and more goal-directed allostatic behaviour rests upon the confidence (i.e. precision) placed in deeper expectations about how we will behave (Seth & Friston, 2016). Again, whether this applies to persistent pain still has to be investigated rigorously. But what if our ability to feel our own bodily state, and to process that information is distorted and no longer as precise as it once were? Wouldn\u2019t all prior experiences and beliefs about our own bodily state influence our predictions about the future? Thus, what if our predictions cause more harm than good?<\/p>\n Therefore, I wonder whether the therapeutic interventions that help our patients are the ones that successfully update our internal model for making precise predictions? Perhaps the top-down expectancy violation that occurs with belief reconceptualization reduces prediction errors, which then minimizes an existential need for biological or psychosocial protection (from an embodied first-person perspective)? When we explain pain and increase awareness of DIMs (Danger in Me) and SIMs (Safety in Me), we provide knowledge, resources and empower patients \u2013 which gives the patient less \u201cstuff\u201d to worry, catastrophize, and ruminate about. If we limit the number of predictions available to make, we may limit the amount of prediction errors, and thus, the need for protection on multiple levels throughout the hierarchy. What if we simultaneously update interoceptive accuracy or improve the \u201canticipatory\/interoceptive buffer\u201d (create body ownership, mindfulness\/acceptance, improve sensory discrimination) \u2013 is it possible that we update the \u201csample and scrutinize\u201d-model by reducing top-down and bottom-up prediction errors? In broader terms, does this mean that we are we targeting \u201cneurotag\u201d activity, shifting the indicator downwards on the \u201cprotectometer\u201d? (Fig.1).<\/p>\n