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Pain on the spectrum

A multidisciplinary study conducted by researchers from the Technion, Tel Aviv University and Haifa University refuted the notion that people with autism spectrum disorder do not experience pain

"If you stab us - won't we bleed? If you tickle us - won't we laugh? If you poison us - won't we die? And if you mistreat us - will we not take revenge?", says the Jew Shylock in the famous monologue from Shakespeare's play, "The Merchant of Venice". If you open the manual of mental disorders that is currently used by psychiatrists around the world, you are likely to discover a surprising statement, according to which people with a disorder on the autistic spectrum are indifferent to pain. This statement was formulated on the basis of mainly observational studies, which evaluated the reactions of people with a disorder on the autistic spectrum to medical procedures involving pain, yet it sounds outrageous and almost incomprehensible.

A new study that is still in progress, and which is being carried out with the help of a research grant from the National Science Foundation, did recently refute this assertion. The research is led by a multidisciplinary team of researchers: Dr. Tami Bar-Shalita from the Department of Occupational Therapy at Tel Aviv University, Prof. Irit Weissman-Fogel from the Department of Physiotherapy at the University of Haifa, Dr. Yelena Granovsky from the Clinical Neurophysiology Laboratory of the Technion and the Rambam Medical Center , Prof. Einat Gal from the Department of Occupational Therapy at the University of Haifa, and doctoral students Tzala Hoffman and Mary Klingel Levy.

"This is a population that has difficulty with social understanding in communication and language," says Dr. Bar-Shalita, "We assumed that they may not report that they are in pain, or that they report in such a way that the environment does not understand them."

The consequences of the determination in the manual of mental disorders, the DSM, are far-reaching, naturally, and hence the urgency to investigate them. "I was an oncology nurse in a children's department and what brought me to this research is some children who missed their pain and suffering - children with autism who usually knew how to communicate and tell about experiences but simply did not tell about the pain they experienced," says Tzala Hoffman; "I have seen children who come to intensive care at a very late stage of an illness, or in an emergency situation. We did not understand how we did not recognize their distress in time. The first thing the parents told me was that the child has a very high pain threshold. But when we asked how the child still behaves when he is in pain, they described behaviors that are typical of children with autism: repetitive behaviors, self-harming behaviors, and more. That is, the behavior indicated pain even when the children did not report pain, but the environment did not understand and did not know how to recognize it in time."

The research of the research team started somewhere else altogether. Dr. Bar-Shalita, Dr. Granovsky and Prof. Weissman-Fogel have been researching for years the connection between pain and hyper-sensory reactivity: a situation where stimuli are not painful in our normal environment - the buzzing or flashing of neon lights and normal noises in the environment that most of us do not notice On them, an exaggerated response is brought about indicating that these sensory stimuli are very disturbing. "Some people are unable to function or participate in social events when they are exposed to the buzzing of neon lights, or to the clicks of cutlery during a meal," explains Dr. Bar-Shalita.

Many of the people with autism also suffer from a sensory regulation disorder, which can be expressed in both overreactivity to stimuli and underreactivity.

Following their research in the field of pain and sensory regulation, they came to autism because among people with a disorder on the autistic continuum it is common to discover a sensory regulation disorder. At least 70% of people with autism suffer from this disorder, which can be expressed in both overreactivity to stimuli and underreactivity.

Another finding of their research led to the current preoccupation with the question of pain among people with autism: they discovered that hyper-reactivity to non-painful stimuli is also related to hypersensitivity to pain. In the first article in the field published by the three researchers several years ago, they proposed that an imbalance in the neural activity in the brain, which usually leads to overstimulation of the central nervous system, is the basis of the disorder in sensory regulation.

In the current study, they examine the question of pain among volunteers with autism spectrum disorder. The researchers recruited 80 subjects diagnosed with high-functioning autism and 80 subjects without autism to the control group; All of these underwent interviews, quantitative tests to assess pain, recordings of brain activity at rest and during stimulation, and filled out questionnaires, among other things, for the purpose of examining the disorder in sensory regulation. "The first thing we saw in the study is that subjects with an autistic spectrum disorder experience high psychological stress," says Dr. Bar-Shalita. Another significant finding that the researchers identified is that the subjects with a disorder on the autistic continuum are actually more sensitive to pain stimuli and that they rate pain higher, compared to healthy people, without a diagnosis of autism. The differences in reporting the pain increase as the intensity of the pain stimulus increases. This means that the statement in the manual of mental disorders is incorrect: people with a disorder on the autistic continuum also suffer from pain, and even more so than people who are not diagnosed with autism. Dr. Irit Weissman Fogel

"We are waiting for all the results before developing a theory based on findings," says Dr. Bar-Shalita. If the researchers succeed in identifying results that distinguish between autistics and non-autistics through the tests they administer to people on the autistic continuum, this may advance the understanding of autism. Moreover, the researchers hope that these tests may help in the classification and diagnosis of autism subtypes according to sensitivity to pain and the degree of disturbance in sensory regulation, thus promoting personalized treatment.

Life itself:

Dr. Yelena Granovski loves animals and especially cats, Dr. Irit Weissman Vogel is a runner and loves nature walks, Dr. Tami Bar-Shalita loves to play the piano.

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