title: Preserved emotional awareness of pain in a patient with extensive bilateral damage to the insula, anterior cingulate, and amygdala.
abstract: Functional neuroimaging investigations of pain have discovered a reliable pattern of activation within limbic regions of a putative "pain matrix" that has been theorized to reflect the affective dimension of pain. To test this theory, we evaluated the experience of pain in a rare neurological patient with extensive bilateral lesions encompassing core limbic structures of the pain matrix, including the insula, anterior cingulate, and amygdala. Despite widespread damage to these regions, the patient's expression and experience of pain was intact, and at times excessive in nature. This finding was consistent across multiple pain measures including self-report, facial expression, vocalization, withdrawal reaction, and autonomic response. These results challenge the notion of a "pain matrix" and provide direct evidence that the insula, anterior cingulate, and amygdala are not necessary for feeling the suffering inherent to pain. The patient's heightened degree of pain affect further suggests that these regions may be more important for the regulation of pain rather than providing the decisive substrate for pain's conscious experience.
authors.affiliation: Department of Neurology, University of Iowa, Iowa City, IA, 52242, USA. jfeinstein@laureateinstitute.org.|Department of Psychology, University of Iowa, Iowa City, IA, 52242, USA. jfeinstein@laureateinstitute.org.|Department of Psychology and School of Community Medicine, University of Tulsa, Tulsa, OK, 74104, USA. jfeinstein@laureateinstitute.org.|Laureate Institute for Brain Research, 6655 S. Yale Avenue, Tulsa, OK, 74136-3326, USA. jfeinstein@laureateinstitute.org.
authors.forename: Justin S
authors.initials: JS
authors.lastname: Feinstein
authors.affiliation: Department of Neurology, University of Iowa, Iowa City, IA, 52242, USA.|Laureate Institute for Brain Research, 6655 S. Yale Avenue, Tulsa, OK, 74136-3326, USA.|Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, Los Angeles, CA, 90095, USA.
authors.forename: Sahib S
authors.initials: SS
authors.lastname: Khalsa
authors.affiliation: School of Psychology and Clinical Language Sciences, University of Reading, Reading, RG6 6AL, UK.
authors.forename: Tim V
authors.initials: TV
authors.lastname: Salomons
authors.affiliation: Department of Psychology, University of Northern British Columbia, Prince George, BC, V2N 4Z9, Canada.
authors.forename: Kenneth M
authors.initials: KM
authors.lastname: Prkachin
authors.affiliation: Department of Physical Therapy and Rehabilitation Science, University of Iowa, Iowa City, IA, 52242, USA.
authors.forename: Laura A
authors.initials: LA
authors.lastname: Frey-Law
authors.affiliation: Department of Physical Therapy and Rehabilitation Science, University of Iowa, Iowa City, IA, 52242, USA.
authors.forename: Jennifer E
authors.initials: JE
authors.lastname: Lee
authors.affiliation: Department of Neurology, University of Iowa, Iowa City, IA, 52242, USA.|Department of Psychology, University of Iowa, Iowa City, IA, 52242, USA.
authors.forename: Daniel
authors.initials: D
authors.lastname: Tranel
authors.affiliation: Department of Neurology, University of Iowa, Iowa City, IA, 52242, USA.|Laboratory of Functional Imaging, INSERM U678s/UPMC, 75013, Paris, France.
authors.forename: David
authors.initials: D
authors.lastname: Rudrauf
mesh_terms: D000679:Amygdala / Q000473:pathology* / Q000503:physiopathology; D002540:Cerebral Cortex / Q000473:pathology* / Q000503:physiopathology; D004644:Emotions / Q000502:physiology*; D005149:Facial Expression; D006179:Gyrus Cinguli / Q000473:pathology* / Q000503:physiopathology; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D009434:Neural Pathways / Q000473:pathology / Q000503:physiopathology; D010147:Pain Measurement; D058748:Pain Perception / Q000502:physiology*; D057566:Self Report
keywords: Brain lesion; Consciousness; Emotion; Feeling; Limbic system