Meanings of Pain, Volume 3: Vulnerable or Special Groups of People (2022, Springer)

• First book to describe what pain means in vulnerable or special groups of people
• Clinical applications described in each chapter
• Provides insight into the nature of pain experience across the lifespan

This book, the third and final volume in the Meaning of Pain series, describes what pain means to people with pain in “vulnerable” groups, and how meaning changes pain – and them – over time.

Immediate pain warns of harm or injury to the person with pain. If pain persists over time, more complex meanings can become interwoven with this primitive meaning of threat. These cognitive meanings include thoughts and anxiety about the adverse consequences of pain. Such meanings can nourish existential sufferings, which are more about the person than the pain, such as loss, loneliness, or despair.

Although chronic pain can affect anyone, there are some groups of people for whom particular clinical support and understanding is urgently needed. This applies to “vulnerable” or “special” groups of people, and to the question of what pain means to them. These groups include children, women, older adults, veterans, addicts, people with mental health problems, homeless people, or people in rural or indigenous communities. Several chapters in the book focus on the lived experience of pain in vulnerable adults, including black older adults in the US, rural Nigerians, US veterans, and adults with acquired brain injury. The question of what pain experience could mean in the defenceless fetus, neonate, pre-term baby, and child, is examined in depth across three contributions.

This book series aspires to create a vocabulary on the “meanings of pain” and a clinical framework with which to use it. It is hoped that the series stimulates self-reflection about the role of meaning in optimal pain management.

Meanings of Pain is intended for people with pain, family members or caregivers of people with pain, clinicians, researchers, advocates, and policy makers. Volume I was published in 2016; Volume II in 2019.

Request a sample by emailing me: simon.vanrysewyk@utas.edu.au, or vanrysewyk@hotmail.com

Buy the complete book on Springer’s website, here.

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Learning the concept of pain – first literature review towards a paper

How do children learn the concept of pain? What is the ‘concept of pain’?

Children’s pain language

“Children rapidly develop an extensive vocabulary to describe pain between 12 and 30 months of age, with words for pain from injury emerging first and reflecting the development of normal speech acquisition. The differences in verbal expressions in the context of minor illnesses and injuries suggest that children make a cognitive distinction between the origins and sensory aspects of pain.

“Children’s expressive pain vocabulary appears to serve multiple purposes beyond simple description.We found that very young children have awareness of objects and actions that can alleviate pain and use language to seek parents’ attention and to engage parents in pain relief activities. In keeping with general language development, the youngest children used individual pain words or exclamations to convey more complex concepts (known as holographic or telegraphic speech) whereas older children demonstrated greater linguistic competence, including use of metaphor, simile and analogy (Karmiloff & Karmiloff-Smith 2001; Meadows 2006). Interestingly, the basic exclamatory vocalizations are retained throughout childhood and may reflect familial or cultural context that persist into adulthood (Craig et al. 2006).We found that parents’ communicative intent was primarily to gain further information from children about the source and nature of pain and to direct children’s behaviour.”

Franck L, Noble G, Liossi C. From tears to words: the development of language to express pain in young children with everyday minor illnesses and injuries. Child: care, health and development. 2010;36(4):524-33.

“Children’s use of the different pain descriptors changes as they grow older. Younger children (≤3;11), for example, mainly use interjections, such as “ouch” or “ow,” and words like “ache” to describe their pain. Literature indicates that children start to use the word “pain” for the first time at the age of 3;0 to 3;11 (Craig et al., 2006) and continue to use interjections and descriptors to describe their pain as they grow older (Craig et al., 2006; Ely, 1992; Wennström & Bergh, 2008).

When younger children do not yet have the cognitive and language skills to explain the bodily sensations that they experience during pain (Dubois et al., 2008), they try to explain pain with concrete phrases like “I lose my smile and feel bad” (Jerrett & Evans, 1986) or “I’m not feeling well” (Kortesluoma & Nikkonen, 2006). Some use comparisons such as “I had a real bad – kinda like a scar” (Ely, 1992) or “Feels like someone hit it with a sledge hammer” (Abu-Saad, 1984a). Other children explain what caused the accident that resulted in the pain experience, such as “I was playing too rough…” (Harbeck & Peterson, 1992) or “I touched the warm pot” (Johnson et al., 2016).

As children’s thinking develops on a more symbolic level, they start to describe their pain by using more graphic descriptors, such as “terrible, disgusting,” “aching and hurting” (Kortesluoma & Nikkonen, 2006), and “beating or pounding in my head” (Harbeck & Peterson, 1992). Older children tend to include intensifiers when using descriptor words: “really bad;” “pain was radiating…;” “pounding, stabbing, throbbing” (Kortesluoma & Nikkonen, 2006); “horrible; annoying; pin-like; sharp; shooting” (Abu-Saad, 1984a; Harbeck & Peterson, 1992; Savedra, Gibbons, Tesler, Ward, & Wegner, 1982; Wilkie et al., 1990); or “aching; stinging; itching” (Abu-Saad, 1984b; Johnson et al., 2016; Kortesluoma & Nikkonen, 2006; Pölkki, Pietilä, & Rissanen, 1999).

From approximately 8 years of age, children start to think in a more abstract way to describe pain: “Sometimes it is worse and sometimes more like stabbing” (Savedra et al., 1982). Building on these skills, older children (> 10;0) use comparisons (“Like there was a fire inside my head;” “Feels like someone hit it with a sledge hammer”) and define pain as a psychological state based on emotions (“Pain is really upsetting no matter where the pain is;” Kortesluoma & Nikkonen, 2006).

Johnson E, Boshoff K, Bornman J. Scoping review of children’s pain vocabulary: implications for augmentative and alternative communication. Canadian Journal of Speech-Language Pathology and Audiology. 2018;42(1):55-68.

Children’s pain behaviour

“A considerable diversity of actions has been identified as signifying pain in children, including behaviors that could be characterized as verbal (e.g., “asking for help,” “complaining of pain,” and “cursing”), facial activity (e.g., “wincing,” “furrowed brow,” and “widening eyes”), nonverbal vocalizations (e.g., “whimpering,” “crying,” and “moaning”), limb action (e.g., “flailing arms and legs,” “rubbing,” and “protecting/favoring/guarding part of body that hurts”), body action (e.g., “tensing up” and “restless”), physiological manifestations (e.g., “looking pale,” “irregular breathing,” and “shivering torso”), and social behaviors (e.g., “withdrawn,” “hard to console,” and “angry verbalizations”).

Factor analyses yielded three major factors: the “Automatic” factor included items related to facial expression, paralinguistics, and consolability; the “Controlled” factor included items related to intentional movements, verbalizations, and social actions; and the “Ambiguous” factor included items related to voluntary facial expressions.”

Sekhon KK, Fashler SR, Versloot J, Lee S, Craig KD. Children’s behavioral pain cues: Implicit automaticity and control dimensions in observational measures. Pain Research and Management. 2017.

Parents/caregivers

“Parents have well developed, although personal, ways of recognizing and responding to their children’s communication of pain, but also experience uncertainty in their judgments. Parents would benefit from information about the developmental aspects of pain and should be included as active partners in their children’s pain assessment and management.”

Liossi C, Noble G, Franck LS. How parents make sense of their young children’s expressions of everyday pain: a qualitative analysis. European Journal of Pain. 2012;16(8):1166-75.

“Overall, 101 pain incidents were observed, the majority of which evoked low levels of pain and distress, which resolved after 1 min. Pain incidents occurred at a rate of 1.02 incidents/child/hour, with 81% of children experiencing at least one incident, which is higher than previous research with preschoolers and daycare staff. Common parent responses included a range of verbal (reassurance) and nonverbal (staying closer, hugging/kissing child) behaviors. Boys were more likely to not exhibit any protective behaviors. Parents were more likely to pick up older toddlers”.

Noel M, Chambers CT, Parker JA, Aubrey K, Tutelman PR, Morrongiello B, Moore C, McGrath PJ, Yanchar NL, Von Baeyer CL. Boo-boos as the building blocks of pain expression: an observational examination of parental responses to everyday pain in toddlers. Canadian Journal of Pain. 2018;2(1):74-86.

“During the preschool developmental period, parents are instrumental in modelling appropriate pain responding through social learning and modulating their child’s response to pain. Although the literature on parental influences during clinical pain experiences has greatly improved our understanding of social factors in paediatric pain, several avenues of research remain largely unexplored. Specifically, the small number of studies which explored everyday pains spanned a wide time-period, with almost 2 decades between the most recent studies. In this same time period, our understanding of parental influences during clinical pain experiences has advanced significantly, but this evidence does not readily apply to everyday pain experiences. An increased focus should be placed on understanding where children learn about pain and how caregivers respond to common pain incidents in their natural environment.”

O’Sullivan G, McGuire BE, Roche M, Caes L. Where do children learn about pain? The role of caregiver responses to preschoolers’ pain experience within natural settings. Pain. 2021;162(5):1289-94.

“Me seeing you seeing my pain”

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Sculpture by Fabio Viale

Meanings of Pain (Springer International Publishing, 2016) was created to advance understanding of pain experience as a bearer of meaning. Progress in modern biomedicine is necessary to explain pain and to aid in its treatment; yet, preference for biomedical explanation of pain in the field has meant that research and clinical attention to the experience of pain and to common factors of pain, such as meaning, as both a clinical topic and a research method, mostly remains a blind spot in knowledge.

Meaningful changes that we notice in others are often subtle and small changes in facial expression, and are similar to features of clinicians that patients find meaningful, such as aspects of clinician demeanour (enthusiasm, positive personality, attentiveness), which are often embodied in subtle facial expressions, gestures, or particular tones of voice (e.g., Gracely et al. 1985). Pain is a personal experience, not an action; yet it displays itself in those actions in which a human person in pain is revealed to observation (Craig et al. 2010). Body-parts are subject to involuntary changes during pain, such as reflexive withdrawal, but in the social transaction of pain, the involuntary changes revealed in the face are more meaningful than in other body-parts (Prkachin et al. 1983; Craig, 2009). This is because body-parts do not have the individuating meaning of the face: the meaning of revealing me, here, now. The expression on a human person’s face is largely determined by involuntary facial actions; yet, it is the living picture of the person that “peers” from it, and hence a concentrated symbol of the “self”. In facial expressions of pain, the face is not a mere bodily part, but the whole person: the self is spread across its surface, and there displayed.

Intentional control of pain through facial actions is normally judged by observers to be an insincere expression of pain, and open to doubt (Hill & Craig, 2002). The controlled pain face is perceived as a mask, which conceals the person lying “behind” it. The expressions on the human face are not always transparent effects of the personal experiences that elicit them, as perhaps they are in nonhuman mammals. Human beings can deceive through their faces, and children and adults can use the face to fake, as well as exaggerate, or suppress, pain (Williams, 2002). It is possible that deception is possible because we do not distinguish a human person from his or her face. Protective acts such as withdrawal reflexes, guarded postures, and disabled behaviour, can communicate pain to sensitive observers (Sullivan, 2008). But when I observe another’s pain face, I am not meeting a physical part of him, as I am when I notice his injured arm or leg. I am meeting him, a real person, who reveals himself in the face as one like me. There are deceiving faces, but not deceiving arms or legs.

Facial expressions of pain call on you to respond to me. As soon as I notice pain in another person, my responsibilities are engaged. I am held to account for it. The face has this meaning for us because it is the boundary at which the other in pain appears, offering “this person” as one in need of help. This feature is perhaps at the heart of what it means to treat pain. Care of persons in pain would be impossible without the assumption that we can commit ourselves through promises, take responsibility now for some event in the future or the past, and enter into obligations that we hold as not transferable to other persons—all of which are perceived in the face.

We may separate pain from its social meaning, and assign to it an impersonal, “bodily” meaning. However, an observation of pain which, whether or not intentionally, focuses exclusively upon the body-parts of another, but which neglects the preliminary changes in the face, as well as in the voice, hands and posture, perhaps is unethical. The failure to recognise the personal existence of the other in pain is therefore an affront, both to him and to oneself. In separating pain from its social meaning, we remove it from the interpersonal world of social relations, which compels us to recognise human beings as persons and sometimes to compromise or risk ourselves for them.

The most meaningful feature in displays of pain is the eyes, followed by brows, eyelids, mouth, head, forehead, and then other body-parts (Prkachin et al. 1983). Although glances are normally voluntary, they participate in the pattern of involuntary social communication where one person in painful distress is “revealed” in his body to the one who observes him. To turn my eyes to you is a voluntary act; but what I receive from you is not anything I voluntarily do. The eye enables the human person in pain to be displayed to another in his body, and in the act of display to call on the observer to intervene on their behalf. The complex transaction of pain involves the voluntary and the involuntary to co-mingle on the surface of the human body. The joining of minds that begins when an expression of pain is answered with a reciprocated response is partly fulfilled in “me seeing you seeing my pain”, which is not the reciprocity of normal cooperation, but of meaning. I believe many patients with pain desire to experience first-hand this more concentrated form of social recognition.

References

Craig KD. A social communications model of pain. Canadian Psychology/Psychologie Canadienne 2009; 50:22-32.

Craig KD et al. Perceiving pain in others: automatic and controlled mechanisms. J Pain 2010; 11(2):101-8.

Gracely RH et al. Clinicians’ Expectations Influence Placebo Analgesia. Lancet 1985; 1(8419):43.

Hill ML, Craig KD. Detecting deception in pain expressions: The structure of genuine and deceptive facial displays. Pain 2002; 98:135-144.

Prkachin KM et al. Judging nonverbal expressions of pain. Canadian Journal of Behavioural Science/Revue canadienne des sciences du comportement. 1983; 15(4):409.

Sullivan MJL. Toward a biopsychomotor conceptualization of pain. Clin J Pain 2008; 24:281-290.

van Rysewyk S (ed). Meanings of Pain. Springer International Publishing: Switzerland, 2016.

Williams AC. Facial expression of pain: An evolutionary account. Behav Brain Scien 2002; 25:439-488.

Thoughts on “Reconsidering fetal pain” – by Stuart WG Derbyshire & John C Bockmann

Sculpture by Fabio Viale

“…we propose that the fetus experiences a pain that just is and it is because it is, there is no further comprehension of the experience, only an immediate apprehension.” – Reconsidering Fetal Pain (2019), by Stuart WG Derbyshire, John C Bockmann

I agree with this proposal.

Experiencing pain is being in an animal-like state. But, experiencing pain is not knowing that this is pain. I think experiencing pain becomes a state of knowing only if a person is a competent language user. 

A consequence of this idea is that pain experience is not always immediately transparent or lucid to the person experiencing it. Odd as it sounds, to be in pain is not to know pain. This challenges the Cartesian philosophy of mind.

Following Derbyshire and Brockman, the fetus or neonate experiences pain, but without understanding or recognition.

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Emre Ihan asked me: “Do you think learning is a form of recognition? A lot of neonates pull their legs away when nurses and their parents touch their heels, after weeks of heel lancing (heel pricks for blood tests). Could this be an anticipation of pain, and thus recognition that pain is imminent…”

Compare the neonate’s behaviour with a dog walking beside a road with the flow of traffic. The behaviour of the dog conforms to our left-hand drive convention, but it does not do so because it understands that convention.

In the same way, a chicken that stretches its neck and wings as in the mating ritual of the wandering albatross is not stretching its neck because it understands, or has a conception of, this mating pattern.

Point 1. There is behaviour that conforms to a complex pattern.

Point 2. This behaviour is not explained through a conception or understanding of that pattern. The behaviour just accidentally realises part of a complex pattern. 

Point 3. The explanation for the behaviour is explained by its relation to the complex patterned whole.

A plausible explanation of the neonate’s behaviour is in terms of the survival value to groups of humans of this form of behavior. These behaviours are performed because they form part of a hard-wired evolutionary pattern, not because the neonate recognises or follows a set of cognitive rules that are an abstract description of the pattern.

Thus, the neonate, like the dog or chicken, does not engage in their patterned behaviour “on purpose.” The neonate does not intend to follow rules or apply social norms.

Developmentally, that skill emerges later when the neonate is a child and learns, if it is fortunate enough, the concept of pain.

Call for Abstracts: Meanings of Pain, Volume III

Sculpture by Fabio Viale

Volume III Topic: Meanings of pain in vulnerable or special patient groups

Series Editor: Dr Simon van Rysewyk
Publisher: Springer

The Meanings of Pain book series describes how the meaning of pain changes pain experience – and people – over time.

Pain in the moment is experienced as immediately distressing or unpleasant. If pain persists over time, more complex meanings about the long-term consequences, or burden of pain, can develop. These meanings can include existential meanings such as despair or loneliness that focus on the person with pain, rather than pain itself.

Meanings of Pain offers a vocabulary of language about pain and meaning. An objective of the series is to stimulate self-reflection on how to use information about meaning in clinical and non-clinical pain settings. The book series is intended for people with pain, family members or caregivers of people with pain, clinicians, researchers, advocates, and policy makers.

Although chronic pain can affect anyone, there are some groups of people for whom particular clinical support and understanding is urgently needed. This applies to “vulnerable” or “special” groups of people and to the question of what pain means to them.

Volume III focuses on describing the meanings of pain in groups of “vulnerable” or “special” people, such as:

• Infants or children
• Women
• Older adults
• People with a physical or intellectual disability
• People with a brain injury
• People diagnosed with a disease
• Veterans
• Athletes
• Workers
• Addicts
• People with mental illness or mental disorders
• Homeless people
• People in rural or remote communities
• People in multicultural communities
• Indigenous peoples

Invited chapter types
The editor Dr Simon van Rysewyk invites contributions for Volume III on the meanings of pain in vulnerable or special patient groups. The following manuscript types will be considered:

• Original Research (e.g., original clinical, translational, or theoretical research)
• Reviews (e.g., Systematic Reviews, Meta-analytic reviews, Cochrane type reviews, Pragmatic Reviews)

Authors interested in submitting a chapter for publication in Volume III are invited to submit a 350-word Abstract, which includes the name and contact information of the corresponding author, to:

Dr Simon van Rysewyk
simon.vanrysewyk@utas.edu.au

Abstract Deadline: closed

“It is my opinion that this … work will stand as the definitive reference work in this field. I believe it will enrich the professional and personal lives of health care providers, researchers and people who have persistent pain and their family members. The combination of framework chapters with chapters devoted to analysing the lived experience of pain conditions gives the requisite breadth and depth to the subject.” – Dr Marc A. Russo, MBBS DA(UK) FANZCA FFPMANZCA, Newcastle, Australia, from the Foreword in Volume II

“Meanings of Cancer-Related Pain”

Sculpture by Fabio Viale

Australian Pain Society Annual Scientific Meeting 2020
Hobart Tasmania

Topical Session
Tuesday, April 7, 2020, 3.30-5.00pm

Session Description: Cognitive factors are important determinants of cancer-related pain experience. Simon van Rysewyk describes some common meanings and beliefs that people have about cancer, illness, and pain, and the consequences these meanings have in relation to common help-seeking behaviours or coping strategies people choose to adopt. Suffering is a cognitive and emotional response to recurrent perceived losses experienced in some people with cancer. Megan Best presents on the challenges in assessing people with cancer-related suffering and the relationship of suffering to cancer-related pain. Melanie Lovell compares levels of suffering in people with cancer-related pain versus non-cancer chronic pain, highlighting differential meanings of existential or spiritual distress and mood dysfunction. Best and Lovell outline management approaches to cancer pain and suffering that are not responsive to analgesia, such as meaning- or peace-centred therapies.

Session Objectives
At the end of the session, attendees will know:
– Common meanings of cancer-related pain and how people apply these meanings to cope with their pain
– Common meanings of suffering in cancer-related pain and the relationship between these meanings and non-cancer chronic pain experience and mood dysfunction
– Effective approaches to diagnosis and management of cancer-related pain symptoms, including interventions based on meaning

Presenter Duties
Chair: Professor Jane Phillips, University of Technology, Sydney
Organiser/Presenter 1: Dr Simon van Rysewyk, University of Tasmania
Presenter 2: Dr Megan Best, University of Sydney
Presenter 3: Associate Professor Melanie Lovell, University of Sydney

Humans beings are persons and organisms

Sculpture by Fabio Viale

As organisms, human beings interact with the world and each other through causal mechanisms that control us and every other physical thing. As persons, we act in the world through our thoughts, emotions, attitudes, or desires.

Accordingly, human beings are describable in two distinct, but complementary ways: in terms of the way the world is, through scientific descriptions of the causal mechanisms and laws that explain physical things, or, in terms of the way the world seems, through descriptions of personal experiences and meanings.

One or the other way of describing human beings comes into focus depending on the questions we ask about ourselves or the world. The features of personal experience—thought, feeling, speech and action—are amenable to standard scientific explanation as specific changes in the body. Traditionally, scientific research has had much to say about the physical nature of pain, but much less about the personal experience or meaning of pain. Indeed, the meaning of pain remains a blind spot in knowledge.

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A description of a human being as a person means that there is a way of understanding of human beings in which personal experience and meaning, rather than physical causation alone, is needed to answer the question, “What is happening?”

Human persons can distinguish between how things are in the world and how things seem to me. I can recognise within myself a perspective or point of view on the world and identify it as belonging to me. Every person has such a unique perspective; this is partly what it means to be a person rather than a physical thing. In contrast, a scientific description of the world does not presuppose any personal point of view. Physical science does not use words like “I”, “here,” or “now”. Does this mean that “persons” are unobservable to standard quantitative science?

Possibly. Imagine a complete explanation of pain according to the final neurophysiology of pain—whatever it turns out to be. Such an explanation of pain would, to put it very crudely, accurately map specific neurophysiological changes in physical parts in the living human organism and all their true causal interactions across time. However invaluable such an explanation would be to pain medicine, it could not describe the way pain seems to the person who experiences it, for which of the physical objects described in this explanation is me with pain, here, now? Immediate pain always seems a certain way to persons, and this “seeming” determines the experience of the person with pain. In describing personal pain, human beings use language with other meanings than the language used in neurophysiology. The final neurophysiological explanation of pain therefore could explain only one dimension of pain in human beings—the physical dimension—in language that could not capture the personal experience, burden, or meaning of pain.

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A philosophical assumption of neurophysiology is that a person is identical with his or her body. Person and body are one and the same thing. In terms of personal experience, however, the identity between person and body escapes personal understanding. For example, when I feel a pain, there is no information or evidence, or nothing that I could discover about my body subsequent to the experience of pain, that could demonstrate it to be false. When I feel a pain, I simply know that I am in pain.

In person to person interactions, we commonly respond to each other as though we are not identical with the human body, but in a compelling sense operating “through” the body, which seems to be a vehicle of thought, emotion, pain or suffering. We feel that each person we encounter in the world is a unique perspective that is not the body, but the “self”, which peers out through the face. The human face is the social instrument of persons. In seeking to understand you, or adjust how the world or your experience seems to you, I interact with you through your embodied perspective.

In pain experience, it is my loss of personal control over my body, and its dominion over me, that create the compelling sense, for me and for others, of an “incarnate” person. Pain imposes a significant vulnerability on persons: the vulnerability of a free person who is overwhelmed in his or her body by the presence of pain. This can make the person, and the person’s significant others, feel answerable for what he or she experiences.

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“Pain Takes Over Everything”: The Experience of Pain and Strategies for Management

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Sculpture by Fabio Viale

Marie Crowe, Deb Gillon, Cate McCall, and Jennifer Jordan

Abstract This chapter explores the personal experience of pain from its biological underpinnings to strategies people identified for managing this experience. The somatic experience of chronic pain describes the biological processes involved in pain and how this can become a chronic experience with psychological and social implications. The personal experience of pain is explored through a systematic review of research of qualitative experiences. We found that the experience of pain was similar despite its etiological underpinnings—whatever the biological cause there were similarities in the personal experience. Participants in the studies identified five themes that described these personal experiences: (1) body as obstacle; (2) disrupted sense of self; (3) invisible but real; (4) unpredictability; and (5) keeping going.

This section of the chapter is followed by the findings of a systematic review of how older people learn to manage their pain experiences:

– “adjusting to the inevitable”
– “doing it my way without medication”
– “the importance of support in managing the struggle”

The chapter concludes by discussing some of the strategies that can be used to manage the self in pain: support for self-management, medication, exercise and psychological interventions (mindfulness and cognitive behavioural therapy).

Clinical Implications: Many people manage their chronic pain by actively balancing the competing forces of hope and despair. There are similarities in this experience of chronic pain across a range of conditions which has implications for the development of pain management strategies and interventions that address the pain experience and not just the biological condition. Learning to manage the self in pain involves acceptance of pain as on-going and a part of who they are; keeping connected with others; keeping occupied through meaningful activities; getting meaningful support; and developing new meaning in life. Clinical interventions need to a focus on the person’s sense of self, strategies for maintaining hope, strategies that provide relief for the distress associated with pain; and providing people with a sense of control over their experiences both with the pain itself and in their encounters with the medical profession and the use of medication.

Meanings of Pain, Volume II, on Springer.

External Links
Painaustralia
Pain Health
Chronic Pain Australia

Pain Fact Sheets
The Nature and Science of Pain (Painaustralia)
Prevalence and the Human and Social Cost of Pain (Painaustralia)
Clinical Assessment of Pain (Painaustralia)
Multidisciplinary Pain Management  (Painaustralia)
Chronic Pain – A Major Issue in Rural Australia (National Rural Health Alliance)
Chronic Physical Illness, Anxiety and Depression (Beyond Blue)
Neuropathic (Nerve) Pain (Painaustralia)
Self-Managing Chronic Pain (Painaustralia)
The Pain Toolkit Australia (www.paintoolkit.org)
Chronic Pain Management Strategies (NSW ACI)
Communicating and building a pain treatment team (NSW ACI)
Pain and Physical Activity (NSW ACI)

Brisbane Pain Research Symposium 2019

This free whole-day symposium at UQ is open to all members of the community with an interest in advancing pain research and treatments.

About this Event

Hosted by the IMB Centre for Pain Research, we invite you to a whole-day multidisciplinary pain research symposium on Friday 29 November 2019 at the Queensland Bioscience Precinct Auditorium.

Building on the outstanding success of last year’s symposium which attracted over 250 registrants from right across the community, this upcoming student-led event brings together pain research groups from different disciplines across Brisbane and provides a platform for researchers at all career stages to showcase their work alongside leading national and international speakers in the field.

Our aim is to stimulate scientific discussion, collaboration and ongoing engagement to advance pain research and treatments with all sectors of the community, i.e. basic & clinical pain researchers, people living with pain-related conditions, medical practitioners & allied health professionals, academics and hospital administrators, industry representatives, government health agencies & regulatory bodies, people caring for those living with pain-related conditions and community support groups.

Instructions for submitting an abstract for a poster presentation or short talk are further below (FAQs). Postgraduate research candidates (Hons, Masters, PhD), early career researchers (ECRs) and clinicians are particularly encouraged to submit an abstract for the symposium.

Generous prizes for the Best Posters and Best Punchy Poster Talks will be available!

Abstract submissions are also welcome from hospital administrators, industry representatives, government health agencies & regulatory bodies, and community support groups.

Learn more about this event here.

Call for Papers: Pain Medicine Special Issue, “Meaning in the Context of Pain”

Sculpture by Fabio Viale

Dear reader,

Pain Medicine is planning an interdisciplinary Special Issue, “Meaning in the Context of Pain.” I am the lead guest editor; Dr John Quintner and Prof Milton Cohen are guest editors.

Meaning is an essential dimension of the experience of pain. Empirical evidence from qualitative and mixed method studies suggests that pain is not only associated with a common meaning of “threat” or “danger,” but also is experienced as immediately distressing or unpleasant. If this combined meaning persists over time, people’s concerns may shift from the experience of pain onto themselves as persons. As a result of this shift, powerful existential meanings such as hopelessness or loneliness may develop. Such experiential meanings interact with desires to reduce or eliminate pain, and with expectations about the perceived efficacy of a particular treatment for pain. These meanings may in turn result in a spectrum of negative moods, such as depression or despair, and negative beliefs such as fatalism. Such negative components of the emotional dimension are often at the core of the lived experience of pain.

Despite this evidence, the preference for and consequent overwhelming dominance of biomedical explanations in pain clinical practice and research has meant that this other dimension of the experience of pain has been overlooked.

Special Issue Themes and Sub-Themes

Themes of the “Meaning in the Context of Pain” Special Issue include, but are not restricted to, the following:

• Common experiential meanings of pain in different contexts
  • Chronic non-cancer pain or cancer-related pain
  • Pain in special or vulnerable groups
  • Pain and mental illness
  • Pain and substance abuse
  • Pain and fatigue

• How meaning modifies the experience of pain
  • Pain and personal identity over time, including stigmatisation
  • Family meanings and the experience of pain (e.g., “psychosomatic families”)
  • Perceived meaningfulness of life, including suicidality
  • How symbolic manipulation of meaning (e.g., verbal instruction) can change pain experience
  • Perceived meaning of different types of medical treatment
  • “Catastrophising” and “fear-avoidance” as expressions of meaning
  • The limits of meaning: when no meaning can be given to an experience of pain (e.g., “medically unexplained pain”)
  • Coming to terms with “pain acceptance”

• Therapeutic implications of meaning
  • Similarities and differences in meanings of pain between the person in pain versus observers
  • The influence of meaning on pain scale ratings
  • Implications of meaning-making for self-control or self-management of pain
  • How patients’ meanings of pain can inform treatment planning
  • Strategies patients use to find meaning in their pain
  • Work rehabilitation and returning to work
    
    
• Experiential research methods to study meanings of pain
  • Ethnography, narrative, phenomenology, grounded theory, and single-case study methods
  • Other research methods: Neurophenomenology, The Descriptive Experience Sampling Method, The Experiential-Phenomenological Method, The Elicitation Interview Method, quantitative designs, quantitative-qualitative designs

The meaning of “meaning” and clinical applications or implications of meaning in the context of pain must be addressed in detail in all contributions.

Keywords: pain, meaning, patient experience, pain management

Invited article types

Within the scope of the themes and sub-themes described above, the guest editors invite contributions considered in the form of the following manuscript types, in order of importance:

• Reviews (e.g., Systematic Reviews, Meta-analytic reviews, Cochrane type reviews, Pragmatic Reviews)
• Original Research (e.g., original clinical, translational, theoretical or philosophical research)

See Instructions to Authors in Pain Medicine.

If you wish to submit an article for consideration in this Special Issue, please let me know at: simon.vanrysewyk@utas.edu.au. Then, email me a 400-word description/summary/abstract by November 1, 2019.

Thank you for your time.

Does “pain” need redefining?

By Simon van Rysewyk,¹ John Quintner,² Milton Cohen^3
1School of Humanities, University of Tasmania, Australia; ²Arthritis & Osteoporosis Western Australia; ³St Vincent’s Clinic and Clinical School, University of New South Wales, Australia

Presented at the 2019 Patient Experience Symposium, April 29-30, 2019, Sydney, Australia.

Introduction: The widely accepted definition of pain promulgated by the International Association for the Study of Pain (IASP), although useful in a clinical context, is written mainly from the perspective of the “observer”.  As such it fails sufficiently to capture the perspective of the “experiencer” of pain.
Methods: This presentation briefly analyses the historical development of the IASP definition, and some of the commentaries and suggested modifications to it over almost 40 years. Common factors of pain that patients experience are described, together with theoretical insights from philosophy and biology.
Results: Major problems with the IASP definition of pain include: (i) the stance of the observer is privileged over that of the experiencer of pain; (ii) the obligatory linking with “tissue damage” focuses attention on the body as distinct from the person; and (iii) the validity of the experience when there is no obvious “cause” is questioned. A revised definition of pain is offered: Pain is a mutually recognisable somatic experience that reflects a person’s apprehension of threat to their bodily or existential integrity.
Conclusion: This definition integrates the subjectivity or “first-person” level of experience of pain, and the challenge for the “second-person” of clinical evaluation (if not also intervention) towards objective “third-person” goals. This redefinition of pain is compatible with that of the IASP but more philosophically sound, biologically relevant, clinically applicable, and meaningful for people experiencing pain and for health care professionals who engage with them.

Download here.

Meanings of Pain, Volume II: Common Forms of Pain and Language (2019, Springer)

• Provides a study of pain in which meaning is essential to the way pain is felt
• Describes meanings of pain in patients with common forms of chronic pain
• Discusses the importance of meaning in pain assessment, diagnosis, clinical language and medical stigmatisation

Experiential evidence shows that pain is associated with common meanings. These include a meaning of threat or danger, which is experienced as immediately distressing or unpleasant; cognitive meanings, which are focused on the long-term consequences of having chronic pain; and existential meanings such as hopelessness, which are more about the person with chronic pain than the pain itself.

This interdisciplinary book – the second in the three-volume Meanings of Pain series edited by Dr Simon van Rysewyk – aims to better understand pain by describing experiences of pain and the meanings these experiences hold for the people living through them. The lived experiences of pain described here involve various types of chronic pain, including spinal pain, labour pain, rheumatic pain, diabetic peripheral neuropathic pain, fibromyalgia, complex regional pain syndrome, endometriosis-associated pain, and cancer-related pain. Two chapters provide narrative descriptions of pain, recounted and interpreted by people with pain.

Language is important to understanding the meaning of pain since it is the primary tool human beings use to manipulate meaning. As discussed in the book, linguistic meaning may hold clues to understanding some pain-related experiences, including the stigmatisation of people with pain, the dynamics of patient-clinician communication, and other issues, such as relationships between pain, public policy and the law, and attempts to develop a taxonomy of pain that is meaningful for patients. Clinical implications are described in each chapter.

This book is intended for people with pain, their family members or caregivers, clinicians, researchers, advocates, and policy makers.

“It is my opinion that this … work will stand as the definitive reference work in this field. I believe it will enrich the professional and personal lives of health care providers, researchers and people who have persistent pain and their family members. The combination of framework chapters with chapters devoted to analysing the lived experience of pain conditions gives the requisite breadth and depth to the subject.” – Dr Marc A. Russo, MBBS DA(UK) FANZCA FFPMANZCA, Newcastle, Australia, from the Foreword

Review the Table of Contents and buy now on Springer.

Meanings of Pain, Volume II, follows on from Meanings of Pain, Volume I, published in 2016 by Springer.

Reasons for Investigator-Participation and Introspection in Pain Research

Reason 1: Historical Cases of Investigator-Participation in Pain Research

In the early twentieth century, scientists commonly viewed self-experimentation an essential part of medical research. Self-exposure to untested interventions was believed the most ethical way to assess human responses to those interventions, and to catalyse further research (Dresser 2013). Some of this research helped to found new scientific fields. Respiratory physiology was one such field, formed in the 1920s through self-experiments conducted by scientist John Haldane and colleagues. In 1984, physician Barry Marshall ingested Helicobacter pylori, which helped to establish the link between H. pylori and gastric pathology, and in 1992, self-experiments conducted by Mike Stroud and Ranulph Fiennes in Antarctica advanced understanding of nutrition in extreme conditions.

Self-experiments to study pain experience have been published by Sir Head (1920), Woollard and Carmichael (1933), Landau and Bishop (1953), Price (1972), Price et al. (1977), and Staud et al. (2001, 2008), to name only a few significant investigator-participants who studied pain. William Landau and George H. Bishop conducted standard psychophysical research on themselves to study the qualitative differences between “first pain” and “second pain” (i.e. “double pain”; later termed epicritic and protopathic pain) (Landau and Bishop 1953). Initially, Landau and Bishop identified through introspection the differential experiential qualities between first and second pain, followed by scientifically informed speculation about the mechanistic difference between the two types of pain. They discovered that first pain was sharp or stinging, well localized, and brief, whereas second pain was dull, aching, throbbing, or burning, and poorly localized, and longer lasting. The qualities of second pain were felt when skin C-nociceptors were stimulated.

These findings were subsequently confirmed by Price (1972) based on researcher and naïve participant introspective reports. Temporal differences between first and second pain were introspected on and mechanistically explained in terms of central temporal summation in studies by Price et al. (1977), and Staud et al. (2001, 2008), using investigator- and naïve-participants.

Conducting self-experiments to study referred pain, collaborators Herbert Woollard and Edward Carmichael observed that 300 g of weight placed on the right testicle produced slight discomfort in the right groin, while 650 g on the right testicle caused severe pain on the right side of the body. They confirmed that injury to the testicles caused pain to be referred throughout the body. For instance, as the weight on the testicle increased to over 900 g, they reported pain “of a sickening character” not only in the groin but also spreading across the back (Woollard and Carmichael 1933).

Self-experimentation on pain has on occasion led to surprising results. The psychologist B. Berthold Wolff self-experimented in his pain psychophysics laboratory, varying thermal pain which was produced at that time by briefly shining a strong light on a spot on the forearm blackened with candle black for a calibrated time and intensity of exposure (Hardy et al. 1940). On one occasion, Wolff pushed the button to deliver the noxious stimulus, but then something unexpected happened: he screamed with pain, which was brief but intense and filled his whole body. He described it as the most intense whole-body pain he had ever experienced. Wolff later discovered that the light stimulus had been knocked off its correct aim, and had missed his forearm altogether and instead diffused onto the opposite wall where it created a very strong flash of light throughout the normally dark room. Wolff speculated that, as he was expecting to feel pain, the unexpected flash of strong light had the same effect, producing an experience of pain.

It is unclear if investigators today independently conduct self-experiments or co-participate in their own pain studies. The convenience of recruiting participants from university classes and the internet may have made self-experimentation or co-participation of pain seem somewhat redundant to researchers. The Declaration of Helsinki advises on conducting ethical research using patients and healthy volunteers, although it is unclear if this is reason enough for challenging independent self-experimentation or investigator co-participation. In self-experiments, the researcher is both investigator and single participant, so the requirement for informed consent could be waived. Still, there is clear historical precedent for scientific investigators successfully observing and analyzing their own experiences of pain. The results of such published self-experiments have been integrated into the body of knowledge of pain, and replicated in numerous studies using naïve participant introspective reports and standard scientific methods.

References

Dresser R (2013) Personal knowledge and study participation. J Med Ethics. doi:10.1136/medethics-2013-101390.

Hardy JD, Wolff HG, Goodell H (1940) Studies on pain: a new method for measuring pain threshold: observations on spatial summation of pain. J Clin Investig 19(4):649–657.

Head H (1920) Studies in neurology. Oxford University Press, London.

Landau W, Bishop GH (1953) Pain from dermal, periosteal, and fascial endings and from inflammation: electrophysiological study employing differential nerve blocks. AMA Arch Neurol Psychiatry 69(4):490–504.

Price DD (1972) Characteristics of second pain and flexion reflexes indicative of prolonged central summation. Exp Neurol 37(2):371–387.

Price DD, Hu JW, Dubner R, Gracely RH (1977) Peripheral suppression of first pain and central summation of second pain evoked by noxious heat pulses. Pain 3(1):57–68.

Staud R, Vierck CJ, Cannon RL, Mauderli AP, Price DD (2001) Abnormal sensitization and temporal summation of second pain (wind-up) in patients with fibromyalgia syndrome. Pain 91 (1):165–175.

Staud R, Craggs JG, Perlstein WM, Robinson ME, Price DD (2008) Brain activity associated with slow temporal summation of C-fiber evoked pain in fibromyalgia patients and healthy controls. Eur J Pain 12(8):1078–1089.

Woollard HH, Carmichael EA (1933) The testis and referred pain. Brain 56(3):293–303.

Should investigators introspect on their own pain experiences as study co-participants? – Simon van Rysewyk and Carl L. von Baeyer

van Rysewyk S, von Baeyer CL. Should investigators introspect on their own pain experiences as study co-participants? In: van Rysewyk S (2016). Meanings of Pain. Springer International Publishing AG: Switzerland.

Abstract

The question of investigators introspecting on their own personal pain experiences in pain studies has received little attention in the literature. Study of this question may reflect ethical reservations about the many points at which self-interest may lead us to introspect on personal experiences through personal biases that in turn impair professional decision-making and perception. Despite this valid concern about research co-participation, we offer three reasons why investigators can introspect on personal pain as co-participants in their own pain studies. First, there is historical precedent for investigator participation and co-participation in scientific pain research using introspection as a study method. Second, general concerns about variability in self-report based on introspection on pain experience partly derive from true fluctuations in personal pain experience and perceived interests in self-reporting pain, not simply error in its scientific measurement. Third, the availability of the Experiential-Phenomenological Method, a mixed research method for the study of human experiences, allows investigators to co-participate with naïve participants in their own studies by encouraging passive introspection on personal pain experiences.

Download a copy of the chapter here.

 

Reconsidering the International Association for the Study of Pain definition of pain

Cohen M, Quintner J, van Rysewyk S (2018). Reconsidering the IASP Definition of Pain. Pain Reports, 3(2).

Abstract

Introduction: The definition of pain promulgated by the International Association for the Study of Pain (IASP) is widely accepted as a pragmatic characterisation of that human experience. Although the Notes that accompany it characterise pain as “always subjective,” the IASP definition itself fails to sufficiently integrate phenomenological aspects of pain.

Methods: This essay reviews the historical development of the IASP definition, and the commentaries and suggested modificationsto it over almost 40 years. Common factors of pain experience identified in phenomenological studies are described, together with theoretical insights from philosophy and biology.

Results: A fuller understanding of the pain experience and of the clinical care of those experiencing pain is achievable through greater attention to the phenomenology of pain, the social “intersubjective space” in which pain occurs, and the limitations of language.

Conclusion: Based on these results, a revised definition of pain is offered: Pain is a mutually recognizable somatic experience that reflects a person’s apprehension of threat to their bodily or existential integrity.

Associated Commentaries:

Osborn M. Situating pain in a more helpful place. PAIN Reports 2018:e642.

Treede RD. The IASP definition of pain: as valid in 2018 as in 1979, but in need of regularly updated footnotes. PAIN Reports 2018:e643.

Download a copy of the paper here.

‘Meanings of Pain in Patients with Cancer’ – Cancer Pain Symposium 2017

Cancer Pain Symposium, 9 December, 2017

Sydney Vital

Abstract

Pain due to cancer, a common effect of the disease and its treatment, makes the experience of cancer more distressing for patients and their families. The meaning of cancer-related pain has been referred to as the “feared consequence of cancer”, and associated with pathology and death. However, if cancer-related pain is related to (non-cancer) pain and its common factors, of which the meaningfulness of pain is one, and not the cancer disease, then the meaning of cancer-related pain is clinically relevant. The meanings of personal experiences are important to human beings, and influence how we respond to life’s changing circumstances. A neglected aspect of the clinical management of cancer is the patient’s ability to make the experience of cancer meaningful, despite the presence of disabling pain. This presentation provides an overview of the meanings of pain, and some pilot data based on Lipowski’s meanings of chronic illness, which suggests that cancer-related pain is qualitatively closer to chronic non-cancer pain than to cancer. Ideas are provided for health care professionals to make cancer and cancer-related pain more meaningful to patients and their families.

Meanings of Pain, Volume I (2016, Springer)

van Rysewyk S (2016). Meanings of Pain. Springer International Publishing AG: Switzerland.

• First book devoted to study of the meanings of pain
• Explains why meaning is important in the way that pain is felt
• Promotes integration of qualitative and quantitative research methods to study meanings of pain
• Includes insights that can aid in the clinical management of patients with pain

About Meanings of Pain, Volume I

Although pain is widely recognized by clinicians and researchers as an experience, pain is always felt in a patient-specific way rather than experienced for what it objectively is. This fact makes perceived meaning important in the study of pain. The book contributors explain why meaning is important in the way that pain is felt and promote the integration of quantitative and qualitative methods to study meanings of pain. For the first time in a book, the study of the meanings of pain is given the attention it deserves.

All pain research and medicine inevitably have to negotiate how pain is perceived, how meanings of pain can be described within the fabric of a person’s life and neurophysiology, what factors mediate them, how they interact and change over time, and how the relationship between patient, researcher, and clinician might be understood in terms of meaning.

Though meanings of pain are not intensively studied in contemporary pain research or thoroughly described as part of clinical assessment, no pain researcher or clinician can avoid asking questions about how pain is perceived or the types of data and scientific methods relevant in discovering the answers.

Reviews of Meanings of Pain

“Meanings of Pain offers an intriguing investigation into the implications of the psychological, sociological, and personal lived meanings of pain for the overall management of patients struggling with this chronic condition. … it may prove invaluable to the physician struggling to understand the intricacies of the patient pain experience, facilitating improved comprehensive pain therapy.” (Emily E. Smith-Straesser and Amanda M. Kleiman, Anestesia & Analgesia, Vol. 125 (5), November, 2017)

Pain Science and Sensibility Episode 29: Discussion of the book “Meanings of Pain”

Meanings of Pain – Book Review by Josie Billington (University of Liverpool), Andrew Jones, and James Ledson (The Royal Liverpool and Broadgreen University Hospitals NHS Trust)

Meanings of Pain – Book Review by Christin Bird

The Science and Philosophy of the Meaning of Pain – Review of Chapter 7, “A Scientific and Philosophical Analysis of Meanings of Pain in Studies of Pain and Suffering” in Meanings of Pain by Smadar Bustan – by Tim Cocks

Meanings of Pain – Book Review by Asaf Weisman

N=1 as a reference for general concepts of experiencing pain by Morten Høgh

New Developments

Springer is considering publishing Meanings of Pain in a multiple volume series. Watch this space for an update on this development.

Towards raising awareness of qualitative pain research

While awareness of qualitative research of lived pain is slowly increasing in the field of pain, it is far from established and needs cultivating from within the field by pain researchers (Mitchell & MacDonald, 2009; Osborn & Rodham, 2010; Price & Barrell, 2012). Pain research has traditionally been dominated by quantitative research methods, which have their roots in physiology, physics, biology, and psychophysics, arising from mathematics, statistics, and psychometrics (Price et al. 2002; Price & Aydede, 2005; Price & Barrell, 2012). This trend continues unabated today, and perhaps explains why Osborn and Rodham (2010) found that many individual pain researchers have not yet accumulated a significant body of qualitative pain research. A body of qualitative pain research would enable researchers to develop their arguments in more depth concerning the nature and types of personal meanings apparent in pain experience, especially clinical pain experiences across the lifespan. The rationale for conducting qualitative pain research is likely not clear to many in the field of pain, and researchers are probably unaware of the potential richness of qualitative pain data to uniquely describe lived pain or the diverse tools available for analyzing qualitative data. In line with this, Osborn & Rodham (2010) found that many of the qualitative pain studies they reviewed used only one type of analysis (i.e., data analysis was not triangulated), description rather than interpretation prevailed in discussion of data meaning, and research methods were not thoroughly described.

A powerful reason to conduct more qualitative pain research is the common complaint from clinical pain patients that they feel they have never had an opportunity to fully explore their lived pain experiences with health care professionals, that no one has ever fully understood what is wrong with them and, most importantly, that no one appears to be listening (e.g., Melzack, 1990; Hoffmann & Tarzian, 2001; Hansson et al. 2011; McGee et al. 2011; Thacker & Moseley, 2012; De Ruddere et al. 2014). Clinical failure to sufficiently appreciate patient pain and its felt meanings can result in profound patient dissatisfaction, exacerbation of feelings of isolation and confusion, among other negative existential appreciations, and cause up-regulation of nociception (Butler et al. 2003). Despite this significant problem in the treatment and management of clinical pain, some pain researchers (e.g., Apkarian et al. 2011; Wortolowska, 2011) and government agencies (e.g., National Research Council of the National Academies, 2008; National Institutes of Health, 2011) have argued for replacing first-person patient experiential pain data with brain-imaging data.

Although qualitative research alone cannot solve these challenges, because of its exploratory nature, it can complement quantitative clinical pain research to describe lived pain and the psychosocial factors that improve or worsen the efficacy of pain interventions, as well as core intervention components that are associated with desired or undesired patient outcomes (Price et al. 2002; Price & Aydede, 2005; Price & Barrell, 2012; Thacker & Moseley, 2012).

References

Apkarian, A. V., Hashmi, J. A., & Baliki, M. N. (2011). Pain and the brain: specificity and plasticity of the brain in clinical chronic pain. Pain, 152(3 Suppl), S49–64.

De Ruddere, L., Goubert, L., Stevens, M. A. L., Deveugele, M., Craig, K. D., & Crombez, G. (2014). Health Care Professionals” Reactions to Patient Pain: Impact of Knowledge About Medical Evidence and Psychosocial Influences. The Journal of Pain, 15(3), 262–270.

Hoffmann, D. E., & Tarzian, A. J. (2001). The girl who cried pain: a bias against women in the treatment of pain. The Journal of Law, Medicine & Ethics, 28(s4), 13–27.

McGee, S. J., Kaylor, B. D., Emmott H., & Christopher, M. J. (2011). Defining chronic pain ethics. Pain Medicine, 12, 1376–1384.

Melzack, R. (1990). The tragedy of needless pain. Scientific American, 262(2), 27–33.

National Institutes of Health. (2011). Biomarkers for chronic pain using functional brain connectivity. Common Fund NIH Government.

National Research Council of the National Academies. Emerging cognitive neuroscience and related technologies. (2008). Washington, DC: National Academies Press.

Price, D. D., & Aydede, M. (2005). The experimental use of introspection in the scientific study of pain and its integration with third-person methodologies: The experiential-phenomenological approach. In M. Aydede (Ed.), Pain: New Essays on its Nature and the Methodology of its Study (pp. 243–273). Cambridge, Mass.: MIT Press.

Price, D. D., & Barrell, J. J. (2012). Inner Experiences and Neuroscience. Merging the two perspectives. Cambridge, Mass.: MIT Press.

Price, D. D., Barrell, J. J., & Rainville, P. (2002). Integrating experiential-phenomenological methods and neuroscience to study neural mechanisms of pain and consciousness.

Thacker, M. A., & Moseley, G. L. (2012). First-person neuroscience and the understanding of pain. The Medical Journal of Australia, 196(6), 410–411.

Wortolowska, K. (2011). How neuroimaging can help us to visualise and quantify pain? European Journal of Pain, 5, 323–327.

A neurobehavioral-polyvagal theory of pain facial expression

The personal experience of pain produces a reliable effect on facial behavior in humans and in nonhuman mammals. Why should pain have a face? What is it for? I will attempt to head towards answering this question by invoking a theoretical framework: polyvagal theory (Porges, 2001, 2006).

1 Polyvagal Theory

According to polyvagal theory (Porges, 2001, 2006), evolution of neural control within the autonomic nervous system (ANS) has tracked three stages, each revealing a specific behavior, and a specific function:

In the first stage, the ancient unmyelinated visceral vagus nerve that enables digestion could respond to danger and pain only by reducing metabolic output and producing immobilization behaviors.

In the second stage, the sympathetic nervous system (SNS) made it possible to increase metabolic activity and inhibit the visceral vagus nerve, thus allowing fight/flight behaviors following perceived threat or pain.

The third stage, which is uniquely mammalian, involves a myelinated vagus that can rapidly control cardiac and bronchi output to enable spontaneous interaction (i.e., engagement or disengagement) with the environment. The interaction of the autonomic nervous system (ANS) with the hypothalamo-pituitary-adrenal (HPA) axis, nervous and immune systems change to maximize response to stressors such as nociception. During nociception, the ANS operates together with nervous, endocrine and immune systems to produce stress (Chapman et al. 2008; Porges, 2001, 2006). In terms of polyvagal theory, pain facial expression is a dynamic autonomic response caused by noxious signaling. In terms of polyvagal-type identity mechanistic theory pain facial expression is a type of behavior that is identical to a type of neurophysiological mechanism; namely, the phylogenetically recent brain-heart-face mechanism.

The expansion of cortex in the third stage increased innervation and neural control of the mammalian face: upper face innervation is bilateral and arises from the supplementary motor area (M2) and the rostral cingulate motor area (M3). Lower face innervation is contralateral and arises from primary motor cortex (M1), ventral lateral premotor cortex, and the caudal cingulate motor cortex (M4) (Morecraft et al. 2004). Human pain facial movements of the eyebrows and upper lip are type identical with negative emotional aspects of pain and activation of M1, M2, M3, whereas facial movements around the eyes are type identical with somatosensory aspects of pain, and activation of M2 and M3 (Kunz et al. 2011). Thus, evolution of cranial anatomy enabled a highly integrated facial representation of the multidimensional experience of pain.

2 Why Pain Should Have a Face

In clinical and experimental settings, the pain face is observed to rapidly appear following noxious stimulation, and diminish concurrent with cessation of the noxious stimulus, or when analgesics are administered (e.g., Craig & Patrick, 1985). The brain-heart-face mechanism is an integrated system with both a somatomotor part controlling the striated facial muscles and a visceromotor part controlling the heart through a myelinated vagus nerve (Porges, 2001, 2006). When the vagal tone to the cardiac pacemaker is high, the myelinated vagus acts as a brake or restraint limiting heart rate. Rapid inhibition and disinhibition of vagal tone to the heart supports the rapid mobilization of facial muscles and formation of the pain face concurrent with pain onset. In humans and nonhuman mammals, the main vagal inhibitory pathways in the myelinated vagus originate in the nucleus ambiguus.

The vagal brake supports the low-metabolic requirements involved in the rapidly appearing and disappearing pain face. Withdrawal of the vagal brake is strongly correlated with the rapid appearance of the pain face; reinstatement of the vagal brake is strongly correlated with the rapid diminishing of the pain face. These correlations are not unique to pain facial expression; similar relationships hold with regard to the vagal brake and the timing and duration of aversive, but non-noxious emotional facial expressions (e.g., Pu et al. 2010), and positive emotional facial expressions (e.g., Kok & Fredrickson, 2010).

In terms of the function of rapid pain face onset and offset, the vagal brake makes it possible for the individual in pain to quickly disengage from source of wounding and pain, concurrent with the rapid appearance or diminishing of pain facial expression, which may offer temporary access to additional metabolic resources to aid healing, recovery and self-soothing behaviors, with likely involvement from care givers.

Concerning aid from others, the vagal brake reliably maps onto specific interaction types observed in mammalian pain events. In pain events comprising the individual in pain and care givers, mammalian behavior is typed according to interpersonal communication through facial expressions, vocalizations, head and hand gestures (Hadjistavropoulos et al. 2011; Porges, 2001, 2006; Williams, 2002). A relevant feature is the rapid ‘switching’ of temporary engagement to temporary disengagement behaviors between the individual in pain and care givers. This interaction type may involve care givers speaking to the one in pain, and then quickly switching to listening; for the one in pain, looking into the face of the care giver, and then quickly switching to vocalizing (Craig et al. 2011; Hadjistavropoulos et al. 2011; Porges, 2001, 2006; Williams, 2002). The brain-heart-face mechanism thus allows the one in pain and the care giver to get the timing right. Some philosophers and neuroscientists claim that evolutionary neurobehavioral solutions to timing problems such as these are implicated in the origin of empathy and ultimately consciousness itself (Churchland, 2002; Cole, 1998; Engen & Singer, 2012; van Rysewyk, 2011).

However, if pain is severe or chronic and the vagal brake is withdrawn (or dysfunctional), the concurrency of increased pain facial expression, cardiac output, and other mobilization behaviors (i.e., increased SNS and HPA output), means that, if care giving is to succeed in promoting healing and recovery, the care giver’s vagal brake must be dynamically reinstated. By applying their own vagal brake, care givers may regulate their own visceral distress and thereby succeed in allocating valuable metabolic resources to communicate safety to the one in pain (and themselves) through calming facial and head behaviors, eye gaze, and prosodic vocalizations (i.e., increasing the vagal brake decreases SNS and HPA output). Since the vagal brake of the person in pain has been provisionally withdrawn, the care giver is effectively an integrated external brain-heart-face mechanism (cf. Tantam, 2009, the ‘interbrain’).

Thus, the pain facial muscles function as neural timekeepers detecting and expressing features of safety and danger that cue the one in pain to quickly disengage from the source of wounding and pain, simultaneous with the rapid appearance or attenuation of pain facial activity, and also cue others who can help.

References

Chapman, C. R., Tuckett, R. P., & Song, C. W. (2008). Pain and stress in a systems perspective: reciprocal neural, endocrine, and immune interactions. Journal of Pain, 9(2), 122-145.

Churchland, P. S. (1989). Neurophilosophy: Toward a Unified Science of the Mind-Brain. Cambridge, Mass.: MIT Press.

Cole, J. (1998) About face. Cambridge, Mass.: The MIT Press.

Craig, K. D., & Patrick, C. J. (1985). Facial expression during induced pain. Journal of Personality and Social Psychology, 48(4), 1080-1091.

Craig, K. D., Prkachin, K. M., & Grunau, R. E. (2011). .The facial expression of pain. In D. C. Turk, & R. Melzack, Handbook of Pain Assessment, 2^nd Edition (pp. 117-133). New York: The Guilford Press.

Engen, H. G., & Singer, T. (2012). Empathy circuits. Current Opinion in Neurobiology, 23, 1-8.

Hadjistavropoulos, T., Craig, K. D., Duck, S., Cano, A., Goubert, L., Jackson, P. L., Mogil, J. S., Rainville, P., Sullivan, M. J. L., de C. Williams, Amanda C., Vervoort, T., & Fitzgerald, T. D. (2011). A biopsychosocial formulation of pain communication. Psychological Bulletin, 137(6), 910-939.

Kok, B. E., & Fredrickson, B. L. (2010). Upward spirals of the heart: Autonomic flexibility, as indexed by vagal tone, reciprocally and prospectively predicts positive emotions and social connectedness. Biological Psychology, 85(3), 432-436.

Kunz, M., Lautenbacher, S., LeBlanc, N., & Rainville, P. (2011). Are both the sensory and the affective dimensions of pain encoded in the face? Pain, 153(2), 350-358.

Morecraft, R. J., Stilwell-Morecraft, K. S., & Rossing, W. R. (2004). The Motor Cortex and Facial Expression: New Insights From Neuroscience. The Neurologist, 10(5), 235-249.

Porges, S. W. (2001). The polyvagal theory: phylogenetic substrates of a social nervous system. International Journal of Psychophysiology, 42(2), 123-146.

Porges, S. W. (2006). Emotion: An Evolutionary By‐Product of the Neural Regulation of the Autonomic Nervous System. Annals of the New York Academy of Sciences, 807(1), 62-77.

Pu, J., Schmeichel, B. J., & Demaree, H. A. (2010). Cardiac vagal control predicts spontaneous regulation of negative emotional expression and subsequent cognitive performance. Biological Psychology, 84(3), 531-540.

van Rysewyk, S. (2011). Beyond faces: The relevance of Moebius Syndrome to emotion recognition and empathy. In: A. Freitas-Magalhães (Ed.), ‘Emotional Expression: The Brain and the Face’ (V. III, Second Series), University of Fernando Pessoa Press, Oporto: pp. 75-97.

Williams, A. C. D. C. (2002). Facial expression of pain: an evolutionary account. Behavioral and Brain Sciences, 25(4), 439-455.

First-Person Neuroscience of Pain: Puzzles, Methods and Data

First-Person Neuroscience of Pain: Puzzles, Methods and Data from simonvanrysewyk

Challenges facing pain reductionism

The official scientific definition of pain was initially formulated in the 1980s by a committee organized by the International Association for the Study of Pain (IASP). This definition and accompanying Note was updated in the 1990s by the IASP to reflect advancements in pain science and has since been widely accepted by the scientific community:

Pain: An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.

Note: The inability to communicate verbally does not negate the possibility that an individual is experiencing pain and is in need of appropriate pain-relieving treatment. Pain is always subjective. Each individual learns the application of the word through experiences related to injury in early life. Biologists recognize that those stimuli which cause pain are liable to damage tissue. Accordingly, pain is that experience we associate with actual or potential tissue damage. It is unquestionably a sensation in a part or parts of the body, but it is also always unpleasant and therefore also an emotional experience. Experiences which resemble pain but are not unpleasant, e.g., pricking, should not be called pain. Unpleasant abnormal experiences (dysesthesias) may also be pain but are not necessarily so because, subjectively, they may not have the usual sensory qualities of pain. Many people report pain in the absence of tissue damage or any likely pathophysiological cause; usually this happens for psychological reasons. There is usually no way to distinguish their experience from that due to tissue damage if we take the subjective report. If they regard their experience as pain, and if they report it in the same ways as pain caused by tissue damage, it should be accepted as pain. This definition avoids tying pain to the stimulus. Activity induced in the nociceptor and nociceptive pathways by a noxious stimulus is not pain, which is always a psychological state, even though we may well appreciate that pain most often has a proximate physical cause (IASP-Task-Force-On-Taxonomy, 1994: 207-213).

An apparent immediate and inconvenient fact facing pain reductionism is that pain stubbornly resists identification with only the brain. The original pain identity statement proposed by philosopher U.T. Place, ‘Pain = C-fibre activation’ (Place, 1956), neglects two essential features of pain observed in contemporary pain science:
(1) Conscious awareness of wounding is multimodal and is correlated with integrated visual, kinaesthetic, and enteric sensory modalities in addition to noxious signalling (e.g., Chapman et al. 2008);
(2) Wounding is typically part of overall bodily awareness that is correlated with multiple reciprocal nervous, endocrine and immune states (e.g., Chapman et al. 2008; Lyon et al. 2011; van Rysewyk, 2013; Vierck et al. 2010). Convergent lines of evidence demonstrate that wounding followed by pain is strongly correlated with endocrine and immune operations as well as sensory signaling that together exert an extensive non-neural impact. These operations interact and comprise a defensive stress response to wounding [1].

A consideration of the higher structures of the central nervous system (CNS) alone reveals an extraordinarily complex picture of pain. Unimodal functional brain imaging studies of nociceptive transmission, projection and processing show that signals of wounding reach higher CNS levels via the spinothalamic, spinohypothalamic, spinoreticularpathways (i.e., the paleospinothalamic tract) including the locus caeruleus (LC) and the solitary nucleus, spinopontoamygdaloid pathways, the periaqueductal gray (PAG), and the cerebellum (e.g., Burstein et al. 1991; Price, 2000). The thalamus (THA) projects to limbic areas including the insula and anterior cingulate, which have been identified with the integration of the emotional and motivational features of pain (Craig, 2002, 2003a, 2003b). Noradrenergic pathways from the LC project to these and other limbic structures. Accordingly, pain reveals extensive limbic, prefrontal and somatosensory cortical components. A meta-analysis of the literature described brain operations during pain as a complex network involving THA, primary and secondary somatosensory cortices (S1, S2), insula (INS), anterior cingulate (ACC), and prefrontal cortices (Apkarian et al. 2005). Thus, the brain engages in massive, distributed, parallel processing in response to noxious signaling.

The mechanisms of multimodal integration pose a formidable challenge for pain scientists. Hollis et al. (2004) examined how catecholaminergic neurons in the solitary nucleus integrate visceral and somatosensory information when peripheral inflammation is present. Pre-existing fatigue, nausea, intense physiological arousal, and a systemic inflammatory response induced by proinflammatory cytokines (e.g., Anderson, 2005; Eskandari et al. 2003) are all correlated with sensory signalling in the experience of pain. In addition to Craig (2002, 2003a, 2003b), an increasing number of studies have investigated the integration of information from multiple sensory modalities and central operations correlated with emotion and cognition in pain (e.g., Bie et al. 2011; Liu et al. 2011; Neugebauer et al. 2009). The more we are able to delineate the qualia of pain and map these experiences onto specific multimodal physical operations, the closer we come to identifying pain with those operations.

So, why has Place’s (1956) original pain identity statement survived in philosophy of mind? One reason is that the use of ‘C-fibre activation’ by identity philosophers is merely a placeholder for whatever the eventual mechanisms of nervous systems prove to be. We now know that wounding is identical to specific endocrine and immune operations in addition to sensory signaling. These operations interact and in concert comprise a defensive stress response to wounding. However, the purpose of calling it the identity theory of mind is to separate it from philosophical theories that identify mental states with states of immaterial souls or minds (dualism), abstract machine systems (functionalism), or those theories that reject the reality of mental states (eliminativism). It is not to make any substantive assumption about the sensory modality. This is why Place’s (1956) pain identity claim of C-fibre activation has survived, despite being explanatorily incomplete.

[1] In clinical settings, problems of acute and chronic pain do not easily conform to pain-brain type identities. The persistence of chronic pain as a major problem in medicine may indicate that identifying pain with the brain (‘pain in the brain’) has failed to inform clinicians toward curative interventions (e.g., Chapman et al. 2008).

References
Anderson, J. (2005). The inflammatory reflex-introduction. Journal of Internal Medicine, 257(2), 122-125.
Apkarian, A. V., Bushnell, M. C., Treede, R. D., & Zubieta, J. K. (2005). Human brain mechanisms of pain perception and regulation in health and disease. European Journal of Pain, 9(4), 463-463.
Bie, B., Brown, D. L., & Naguib, M. (2011). Synaptic plasticity and pain aversion. European Journal of Pharmacology, 667(1), 26-31.
Burstein, R., Dado, R. J., Cliffer, K. D., & Giesler, G. J. (1991). Physiological characterization of spinohypothalamic tract neurons in the lumbar enlargement of rats. Journal of Neurophysiology, 66(1), 261-284.
Chapman, C. R., Tuckett, R. P., & Song, C. W. (2008). Pain and stress in a systems perspective: reciprocal neural, endocrine, and immune interactions. The Journal of Pain, 9(2), 122-145.
Craig, A. D. (2002). How do you feel? Interoception: the sense of the physiological condition of the body. Nature Reviews Neuroscience, 3(8), 655-666.
Craig, A. D. (2003a). A new view of pain as a homeostatic emotion. Trends in Neurosciences, 26(6), 303-307.
Craig, A. D. (2003b). Pain mechanisms: labeled lines versus convergence in central processing. Annual Review of Neuroscience, 26, 1-30.
Eskandari, F., Webster, J. I., & Sternberg, E. M. (2003). Neural immune pathways and their connection to inflammatory diseases. Arthritis Research and Therapy, 5(6), 251-265.
IASP-Task-Force-On-Taxonomy (1994). IASP Pain Terminology. In H. Merskey & N. Bogduk (Eds.), Classification of Chronic Pain: Descriptions of Chronic Pain Syndromes and Definitions of Pain Terms (pp. 209-214). Seattle: IASP Press.
Liu, C. C., Shi, C. Q., Franaszczuk, P. J., Crone, N. E., Schretlen, D., Ohara, S., & Lenz, F. A. (2011). Painful laser stimuli induce directed functional interactions within and between the human amygdala and hippocampus. Neuroscience, 178, 208-217.
Lyon, P., Cohen, M., & Quintner, J. (2011). An Evolutionary Stress‐Response Hypothesis for Chronic Widespread Pain (Fibromyalgia Syndrome). Pain Medicine, 12(8), 1167-1178.
Neugebauer, V., Galhardo, V., Maione, S., & Mackey, S. C. (2009). Forebrain pain mechanisms. Brain Research Reviews, 60(1), 226.
Place, U. T. (1956). Is consciousness a brain process? British Journal of Psychology, 47, 44-50.
Price, D. D. (2000). Psychological and neural mechanisms of the affective dimension of pain. Science, 288(5472), 1769-1772.
van Rysewyk, S. (2013). Pain is Mechanism. Doctoral Dissertation, University of Tasmania.
Vierck, C. J., Green, M., & Yezierski, R. P. (2010). Pain as a stressor: effects of prior nociceptive stimulation on escape responding of rats to thermal stimulation. European Journal of Pain, 14(1), 11-16.

Pain in the brain? The question of fetal pain

There is broad agreement among researchers that the minimal necessary neural pathways for pain are in the human fetus by 24 weeks gestation [1, for review]. However, some argue that the fetus can feel pain earlier than 24 weeks because pain can be enabled by subcortical brain structures [2,3,4,5]. Other researchers argue that the fetus cannot feel pain at any stage of gestation because the fetus is sustained in a state of unconsciousness [6]. Finally, others argue that the fetus cannot feel pain at any stage because the fetus lacks the conceptual postnatal development necessary for pain [7,8,9]. If a behavioral and neural reaction to a noxious stimulus is considered sufficient for pain then pain is possible from 24 weeks and probably much earlier. If a conceptual subjectivity is considered necessary for pain, however, then pain is not possible at any gestational age. According to [1], much of the disagreement concerning fetal pain rests on the understanding of key terms such as ‘wakefulness’, ‘conscious’ and ‘pain’.

A motivation for thinking conceptual subjectivity is necessary for pain is the idea that subjective experiences such as pain cannot be reduced to or identified with the objective features of the brain [7,8,9]. All pains are personal experiences and therefore entirely subjective; all brain states are physical events and therefore entirely objective. There is a fundamental divergence between pain and the brain. Thus, pain cannot be in the brain. The basic argument:

1. Pain experiences are subjective.

2. Brain events are objective.

Therefore, since pain experiences and brain events fundamentally diverge,

3. Pain experiences are not identical to brain events.

Is this a good argument? Let’s examine its first premise – ‘pain experiences are subjective.’ On a reasonable interpretation of its meaning, to state that ‘pain experiences are subjective’ is to state that pain experiences are knowable by introspection. However, since brain events are not knowable by introspection, pain experiences cannot be identical to brain events. Here is the argument:

1. Pain experiences are knowable to me by introspection.

2. Brain events are not knowable to me by introspection.

Therefore, since pain experiences and brain events fundamentally diverge,

3. My pain experiences are not identical to any of my brain events.

Once the argument is represented in this form, it is clear that it is fallacious. This can be clearly observed if we compare the argument with the following example:

1. Ibuprofen is known to me to relieve pain.

2. Iso-butyl-propanoic-phenolic acid is not known by me to relieve pain.

Therefore, since ibuprofen and iso-butyl-propanoic-phenolic acid fundamentally diverge,

3. Ibuprofen cannot be identical to iso-butyl-propanoic-phenolic acid.

The premises in the example are true, but the conclusion is known to be false. The argument is fallacious because the core idea of the argument – ‘fundamental divergence’ – makes an erroneous assumption; namely, it assumes that a thing must be known by somebody. But the property ‘being known by somebody’ is not a necessary feature of any thing, much less a property that might establish its identity or non-identity with some thing otherwise known. The truth of the premises may be due to nothing else but my ignorance of what turns out to be identical with what. These considerations challenge the assumed epistemology in the conceptual subjectivity view of pain.

They also challenge the related claim made by proponents of conceptual subjectivity that any description of a pain given in objective scientific terms will necessarily always exclude the personal experience of that pain [7,8,9]. The argument made here is by now familiar: since descriptions of pain in personal subjective terms are different from scientific descriptions of pain, it follows that a pain and its private subjectivity cannot be identical with a brain event and its public objectivity. Only persons can feel pain – brain cells and protein channels can’t. Clearly, the argument begs the issue in question: whether or not the subjective features of a pain I personally experience are identical with some objective features of my brain that might be discovered by neuroscience is precisely the question at issue [10,11].

Besides, in order to understand a scientific explanation of pain, neuroscience does not require of a person that he both understands the explanation and feels pain as a condition of understanding. Neuroscience aims to explain pain, that is its main purpose. Too much is demanded of neuroscience if, in addition to formulating an explanation of pain, it is meant to re-create pain in somebody as a requirement of understanding [10,11]. This expectation is therefore much too strong.

References

[1] Derbyshire SWG, Raja A. (2011). On the development of painful experience.Journal of Consciousness Studies, 18, 9–10.

[2] Anand KJ, Hickey PR. (1987). Pain and its effects in the human neonate and fetus. New England Journal of Medicine, 317(21), 1321–1329.

[3] Anand KJ. (2007). Consciousness, cortical function, and pain perception in nonverbal humans. Behavioral and Brain Sciences, 30(1), 82–83.

[4] Lowery CL, Hardman MP, Manning N, Clancy B, Whit Hall R, Anand KJS. (2007). Neurodevelopmental changes of fetal pain. In Seminars in perinatology, 31(5), 275–282.

[5] Merker B. (2007). Consciousness without a cerebral cortex, a challenge
for neuroscience and medicine. Target article with peer commentary and author’s response. Behavioral and Brain Sciences, 30, 63–134.

[6] Mellor DJ, Diesch TJ, Gunn AJ, Bennet L. (2005). The importance of ‘awareness’ for understanding fetal pain. Brain research reviews, 49(3), 455-471.

[7] Derbyshire SWG. (2012). Fetal analgesia: where are we now? Future Neurology, 7(4), 367-369.

[8] Derbyshire SWG. (2006). Controversy: Can fetuses feel pain? BMJ: British Medical Journal, 332(7546), 909.

[9] Szawarski Z. (1996). Do fetuses feel pain? Probably no pain in the absence of “self”. BMJ: British Medical Journal, 313(7060), 796–797. 

[10] Churchland PS. (2002). Brain-wise: V: Studies in Neurophilosophy. MIT press.

[11] van Rysewyk S. (2013). Pain is Mechanism. PhD Dissertation, University of Tasmania.

Explaining pain: Comment on Robinson, Staud and Price (2013)

Here, I briefly respond to Robinson, Staud and Price⁶ concerning what constitutes the ‘neural signature’ of pain (p. 325), note a logical mistake in their article, and highlight a reason why explaining pain is difficult. It is probable that conscious pain may be subserved by an unconscious physical base with a specific neurophysiological signature. Explaining pain in this direct way aims first to describe the base as a correlate of pain, then ultimately to achieve a reductive neurophysiological explanation of pain. Multiple evidential lines demonstrate that the neurophysiological base of pain need not be limited to one physical location, as Robinson, Staud and Price rightly note (p. 325). Since the hypothetical pain base is probably distributed, and therefore is more akin to the immune system than the liver, it is mistaken to expect that if it is not confined to a single neural region, or a single pattern of functional interaction, then there cannot be a physical signature of pain, as Robinson, Staud and Price appear to think (p. 325). Instead of a region-based view of the hypothetical pain base, it may be more accurate to think of it as a distributed mechanism.^{5, 8}

The mechanism of pain could involve any number of neurophysiological systems (nervous, endocrine, immune), or reciprocal interactions between them, or any number of neurophysiological levels (pathway, network, single cell, molecular), or reciprocal interactions between them.^{1, 7, 8} The probability of a distributed mechanism, combined with the open-ended probability concerning the systems and level at which the mechanism exists, explains why current hypotheses and theories of pain in the literature, including those made in the article by Robinson, Staud and Price, are relatively unconstrained. However, the absence of constraints is not indicative of the likely truth of Cartesian dualism, the futility of searching for neurophysiological pain correlates, or the unreliability of verbal pain self-report. Rather, it indicates that pain science has much to do.

Neurophysiological mechanism and pain experiences can be correlated for a variety of reasons: the mechanism is part of the cause of pain; the mechanism is part of the effect of pain; the mechanism indirectly parallels pain; the mechanism is what pain can be identified with.^{2, 8} Discovering the neurophysiological signature of pain requires the identification of some neurophysiological mechanism with pain. The correlation of mechanism x with pain is informative because x may be the one for identifying pain. Correspondingly, mechanism y that does not correlate with pain indicates that y may not be the one. If there is a pain mechanism with a neurophysiological signature identifiable with pain experiences, the scientific and clinical benefits could be huge. Thus, investigating pain directly is worth a try.

Now, it is quite possible that a scientist may be looking at an instance of the pain signature without comprehending that it is an instance. This will occur if the physical base of pain does not possess an identifying property that is obvious to naïve researchers, but is comprehensible only through the availability of a more complete general theory of brain function.^{2, 3, 4, 8} The limitations in explaining pain are not simply technological. After all, how would a person know, independently of Antoine Lavoisier’s studies on oxygen, that metabolizing, burning and rusting are identical with the same mechanism, but that lightning and sunlight are not? Thus, Robinson, Staud and Price are right in asserting that it is misconceived to replace pain ratings with neuroimaging data, especially at this early stage of pain investigations.

References

Chapman CR, Tuckett RP, & Song CW: Pain and stress in a systems perspective: reciprocal neural, endocrine, and immune interactions. J Pain 9: 122-145, 2008.

Churchland PS: A neurophilosophical slant on consciousness research. Progress in brain research 149: 285-293, 2005.

Frith CD, Perry R, Lumer E: The neural correlates of conscious experience: an experimental framework. Trends in Cognitive Science 3: 105-114, 1999.

Northoff, G: Philosophy of the brain: The brain problem (Vol. 52). Amsterdam, John Benjamins Publishing Company, 2004.

Northoff, G: Region-Based Approach versus Mechanism-Based Approach to the Brain. Neuropsychoanalysis: An Interdisciplinary Journal for Psychoanalysis and the Neurosciences 12: 167-170, 2010.

Robinson ME, Staud R, & Price DD: Pain Measurement and Brain Activity: Will Neuroimages Replace Pain Ratings? J Pain 14: 323-327, 2013.

Tracey I, Mantyh PW: The Cerebral Signature for Pain Perception and Its Modulation. Neuron 55: 377-391, 2007.

van Rysewyk S: Pain is Mechanism. PhD Thesis, University of Tasmania, 2013.

Why are pain patients all unique? A type-token identity theory answer

Variations in response to pain have been reported in clinical settings (e.g., Bates et al. 1996; Cherkin et al. 1994; Jensen et al. 1986; Unruh, 1996; Wormslev et al. 1994). Patients with similar types and degrees of wounds vary from showing no pain to showing severe and disabling pain. Many chronic pain patients show disabling chronic pain despite showing no observable wound. Other patients show severe wounds but do not show pain. Why is it that two persons with identical lesions do not show the same pain or no pain at all? Why are all pain patients unique?

I propose that mind-brain identity theory may offer an answer to this difficult question. There are two main versions of identity theory: type and token identity. A sample type identical property is to identify “Being in pain” (X) with “Being the operation of the nervous-endocrine-immune mechanism” (Y) (i.e., X iff Y) (Chapman et al. 2008; van Rysewyk, 2013). For any person in pain the nervous-endocrine-immune mechanism (NEIM) must be active, and when NEIM is active in a person, he or she is in pain. Thus, type identity theory strongly limits the pattern of covariation across persons. According to token identity theory, for a person in mental state X at time t, X is identical to some neurophysiological state Y. However, in the same person at time t1, the same mental state X may be identical to a different neurophysiological state Y2. Token identity theory doesn’t limit the pattern of covariation across persons; it only claims that, at any given time, some mind-brain identity must be true.

In response to the topic question, I propose a hybrid version of identity theory – ‘type-token mind-brain identity theory’. Accordingly, for every person, there is a type identity between a mental state X and some neurophysiological state Y. So, when I am in pain, I am in NEIM state Y (and vice versa), but this NEIM state Y may be quite different across persons. Type-token identity theory therefore proposes a type identity model at the level of every person (i.e., it may vary across persons). A type-token identity theory implies that group-level type identities (i.e., type-type) cannot fully explain the pattern of covariation in pain responses across persons. Measuring changes of a pattern of psychological and neurophysiological indicators over time may then support a unidimensional model of chronic pain for each pain patient. Thus, being in chronic pain for me is identical with a specific pattern of NEIM activity (Chapman et al. 2008; van Rysewyk, 2013), but for a different patient, the same state of pain may be identical to a different pattern of NEIM activity. In preventing and alleviating chronic pain, it is therefore essential to best fit the intervention to the type-token pain identity profile of the patient.

References

Bates, M. S., Edwards, W. T., & Anderson, K. O. (1993). Ethnocultural influences on variation in chronic pain perception. Pain, 52(1), 101-112.

Chapman, C. R., Tuckett, R. P., & Song, C. W. (2008). Pain and stress in a systems perspective: reciprocal neural, endocrine, and immune interactions. Journal of Pain 9: 122-145.

Cherkin, D. C., Deyo, R. A., Wheeler, K., & Ciol, M. A. (1994). Physician variation in diagnostic testing for low back pain. Who you see is what you get. Arthritis & Rheumatism, 37(1), 15-22.

Jensen, M. P., Karoly, P., & Braver, S. (1986). The measurement of clinical pain intensity: a comparison of six methods. Pain, 27(1), 117-126.

Unruh, A. M. (1996). Gender variations in clinical pain experience. Pain, 65(2), 123-167.

van Rysewyk, S. (2013). Pain is Mechanism. Unpublished PhD Thesis. University of Tasmania.

Wormslev, M., Juul, A. M., Marques, B., Minck, H., Bentzen, L., & Hansen, T. M. (1994). Clinical examination of pelvic insufficiency during pregnancy: an evaluation of the interobserver variation, the relation between clinical signs and pain and the relation between clinical signs and physical disability. Scandinavian journal of rheumatology, 23(2), 96-102.