Is pain a “thing”?

Neuropsychologist Paul Broks on Wittgenstein

On the Exploring Pain: Research and Meaning group on Facebook, Phil Greenfield asks:

“Seeing pain as a ‘thing’ is somewhat inevitable. Pain is so immediate and unpleasant that sufferers naturally want rid of ‘it’. This has spawned a whole raft of of therapeutic models turning out technicians who would claim to be able to remove that ‘thing’ for you.

The experience of pain also has a noun assigned to it (pain) making it even more likely to be seen as a ‘thing’.

The big issue is, how can we uproot that rather persistent problem, and reframe our view of pain as being more akin to love, or grief, or anger, insofar as it has certain sensations associated with it, but that those sensations are not by any means the whole story”.

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My response to Phil’s question was (edited):

As I argued in the group here and here, the word ‘pain’, like ‘nausea’, or ‘itch’, is a name of a sensation, but not in the way in which ‘table’ or ‘chair’ are names of furniture. We can point at a table and say that ‘table’ is the name of this (pointing gesture) piece of furniture, but I don’t think we can point at a sensation and say that ‘pain’ is the name of this (pointing gesture) sensation.

I think to say that ‘pain’ is the name of a sensation is to say that there are typical behavioural manifestations of pain, which support statements like ‘Bob is in pain’, and that people who self-report pain are not describing a hidden (Cartesian) object ‘in the mind’, but are signalling to others what is going on with them.

Still, we find it natural to think that pain behaviour is the external sign of a mental object private to the sufferer, which in principle is hidden from observers. In the context of pain underestimation, Kenneth Prkachin writes:

“Evaluating others’ pain is a classic case of decision-making in uncertainty. The difficulty of the task is complicated by the fact that the clinician must try to “look inside” another person. In an ideal world, the clinician would be able to use some kind of “mental dipstick” to slide inside the patient’s consciousness, capture her or his current state, and, on the basis of this reading, recommend further action.

What are the potential sources of underestimation?

A first answer to this question harkens back to the dipstick problem. Because observers do not have direct access to sufferers’ internal experiences, their judgements are reliant on sources of evidence in the sufferer’s behaviour or context. In the setting of most empirical studies, access to that evidence is limited.”

We tend to think that the sole purpose of language is to represent reality; but pain behaviour, including linguistic self-report, does not function to accurately represent a private pain ‘object’. It sounds odd to say, but pain behaviour is not caused by the pain sensation!

Pain behaviour promotes the survival of our species, and is linked with caregiving and care-solicitation; resource allocation and conservation; charity and responsibility toward other members of our big family.

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Pain and perception – clarifying the concepts

Is it accurate to say that you have a pain in your left foot because you feel – perceive – the pain there? Is pain a perception?

Many publications in the scientific pain field say so; e.g.:

“Pain is a complex, multidimensional perception that varies in quality, strength, duration, location, and unpleasantness.”

“The role of the cortex in human pain perception remained controversial until the advent of non-invasive brain imaging technologies. Over the last fifteen years solid evidence was generated indicating that multiple cortical and subcortical structures are involved in human pain perception. The general assumption from the studies performed in healthy subjects and studying primarily pain after acute, experimental stimuli, is the notion that activation of a fixed set of brain structures evoke this percept…”

Pain is a perception, not a sensation – Mick Thacker – One Thing

The way the sky looks is blue. The colour blue, however, is not an experience. Rather, it is a property of material phenomena. In this case, a property of the sky.

Experiences can be of a blue object, or the colour blue; but to think that experiences can be blue is like thinking that the number two is blue, which is a category mistake.

To make the same point with different examples:
– The white rose I see is white, not my seeing of it.
– The tightness of my new shoes is not tight, the shoes are.
– The bang I hear is loud, not my hearing of it.

The same logic applied to pain experiences:
– The pain I feel is piercing, not my feeling it.
– The burning of my pain does not burn, the pain does.
– The pain I sense is intrusive, not my sensing of it.

I think the view of pain as a perception makes a category mistake: it confuses what is perceived (‘The sky looks blue’; ‘The pain burns’), with a perceiving of it (‘I see the blue sky’; ‘I feel a burning pain’).

The pain is what is painful, not the feeling of it. Therefore, pain is not a perception.

Pain is a material phenomenon of a living organism, a phenomenon characterised by a complex array of distinctive responses and reactions.

Historically, it is correct to deny that pain is a sensation in opposition to the traditional Specificity Theory of Pain. In clinical settings nowadays, it is more accurate to call pain an ‘experience’: “An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.”

Following Wittgenstein, I propose that to feel pain is to have pain – not to feel pain and, in addition, to perceive it. When I feel a pain, there are not two things involved: the pain, and my feeling the pain. Feeling pain is just being in pain.

Wittgenstein: using our world-view to criticise others?

Ludwig Wittgenstein by Fabrizio Cassetta (2017)

Imagine two communities. One community predicts the seasonal weather following the science of meteorology. Another community predicts the same through consulting the trusted indigenous oracle. The two communities could be members of the same society, but this is not relevant to the story.

Suppose it turns out that meteorology is far more accurate at forecasting the seasonal weather than the oracle. The community that uses meteorology to predict the weather cultivates a disdain for the oracle community, and criticises it as foolish and irrational.

Should the oracle community therefore abandon its customary oracle practice?

Even if we grant that the oracle community is irrational in adhering to its oracle practice, this does not mean that the community must discontinue the practice, since its adherence could be based on particular needs, priorities, or others factors.

For example, the oracle practice could be influenced by the previous generations’ observations and experimentation, which are highly valued. The oracle forecasts are derived from local experiences and communicated in local languages by the indigenous oracle, who is well-known and trusted in the community. The practice is simple, recognisable, and coherent to the community, compared with the complex and probabilistic nature of scientific forecasts.

In the Last Writings on the Philosophy of Psychology (Volume I), philosopher Ludwig Wittgenstein invites the reader to imagine a tribe unfamiliar with the concept of simulated pain. They

… pity anyone who indicates that he is feeling pain. They are unfamiliar with the suspicious attitude toward expressions of pain. A traveller coming from our culture to theirs frequently thinks that a complaint is exaggerated, indeed, that its only purpose is to generate pity; the natives don’t seem to think that way.

A missionary teaches the people our language; in the process he also educates them and under his tutelage they learn to distinguish between a genuine and a pretended expression of pain … They learn our expression: “to feel pain”, and also “to simulate pain”, and the question is: were they taught a new concept of pain?

Had those people overlooked something, and did the teacher bring something to their attention?

And how could they remain unaware of the difference if sometimes they would complain when they were in pain, and sometimes when they were not? Am I to say that they always thought it was the same thing? – Certainly not. Or am I to say that they didn’t notice the difference? – But why not say: the difference wasn’t important to them? (Last Writings on the Philosophy of Psychology, Volume I, 203-205)

In On Certainty (286), Wittgenstein discusses the possibility that a community could incorporate a different world view into its own practices. Thus, it is possible that the oracle community could use both oracle and meteorological information for weather forecasting. If we assume that agriculture in the community is rainfed and vulnerable to climate extremes and change, meteorological information could help farmers and pastoralists in the community cope with climate variability or adapt to climate change. Still, the community could regard the oracle as superior in relation to specific, important indicators, such as onset of rainfall, or amount of rainfall.

Further, if the oracle community is geographically remote, meteorological weather forecasts may not be downscaled or location-specific, thus less effective in addressing the local needs of community farmers and pastoralists. The forecasts could lack reliability, or capacity in the community to interpret them is limited. Here, the oracle practice would continue to have an essential, or predominant, role in the community.

Conceptualising pain in critically ill neonates or infants

Emre Ilhan and Simon van Rysewyk

Abstract

The belief that neonates or infants can feel pain is relatively recent development. Historically, major cardiac surgery was performed in some neonates or infants without anaesthesia, based on the belief that infants had immature nervous systems; therefore, they were incapable of pain, and were fatally vulnerable to the side-effects of anaesthesia. What was standard medical practice in the past is now considered medically unsound and morally unjust. Given that neonates or infants cannot linguistically describe their pain, researchers and clinicians have considered behavioural, physiological, and neurophysiological cues to determine pain in neonates or infants. Pain assessment based on behavioural cues is not an ‘indirect’ means of inferring pain in the neonate and infant because pain experience is not totally separable from its behavioural manifestations. Since pre-linguistic neonates or infants do not possess the concept of pain, in social settings involving pain, the neonate and infant expresses pain only by virtue of a courtesy extended to signs of pain by linguistically competent adults who have already mastered the practice of using ‘pain’. Thus, the aim of this paper is to describe how clinicians and researchers have conceptualised neonatal or infant pain, and what implications these may have in the study of neonatal or infant pain. Craig’s social communications model emphasises how intra- and interpersonal factors surrounding assessment of infant pain influences the caregiver’s ability to decode the behavioural, physiological, and neurophysiological expression of the neonate’s and infant’s pain. Although the neonate’s or infant’s ability to express pain through behavioural signs is an essential aspect of pain assessment, the role of pain detection falls heavily on the caregiver. In some circumstances, such as severe disease acuity, neonates or infants may not have the capacity to respond behaviourally or physiologically to pain. Therefore, it is argued, examining the caregiver’s conceptualisation of the pain is even more important in these circumstances, as it has obvious implications for pain management.

Keywords: neonate, infant, pain, neonatal intensive care unit, pre-linguistic, meaning, concept 

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Read the article here.

What the face reveals: the experience of pain

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Presented at: De/Constructing the Body: Ancient and Modern Dynamics, Workshop 3:Trans-Formation, April 9, 2021.

Abstract here.

Slide transcript

Slide 2
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.

As a person, 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 or biological science does not use words like “I”, “here”, or “now”.

Slide 3
The features of personal experience—thought, feeling, speech and action—are amenable to standard scientific explanation as specific changes in the body.

A philosophical assumption held by some neurophysiologists is that a person is identical with his or her body. Person and body are one and the same thing. This assumption is behind the slogan in pain science, “pain is in the brain”.

In terms of personal experience, however, the identity between person and body escapes 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 I am in pain.

Slide 4
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 is lodged in the face.

Slide 5
Pain is not an action, but a personal experience. Yet, pain reveals itself in those gestures, or expressions, which cannot fail to reveal the person in pain.

People in pain communicate their experience through a range of actions, ranging from self-report, to nonverbal actions, which include paralinguistic vocalisations, bodily activity and facial expressions.

Verbal self-report is mostly voluntary, and relies on reflection and deliberation, whereas nonverbal expression is involuntary and reflexive.

Slide 6
But the involuntary transformations revealed in the face are more meaningful than in other body-parts. This is because body-parts do not have the individuating meaning of the face: the meaning of revealing me, here, now. When I observe another’s pain facial expression, I am not perceiving 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.

A person may be perceived by his arm, but not in his arm.

Involuntary facial changes show the person with pain “as he really is”, because he does not fully control them.

We express preference for non-verbal behaviour over verbal behaviour when judging or interpreting the credibility of pain displays.

Slide 7
Pain expressed through the face acquires, for us, an individuality, a personality, that readies us for the human encounter.

Not understanding a face means not seeing where it fits into our gallery of portraits, and therefore not knowing how to properly relate to the person whom it prefigures. One study showed that physicians tended to attribute lower levels of pain to physically attractive patients than physically unattractive patients. Another study found that physically attractive and male patients were perceived as experiencing less pain and disability than physically unattractive and female patients. Finally, in another study, observers judging patient facial pain expressions on video perceived older and less physically attractive patients to be of lower overall functioning.

I can decide to enter into another’s pain expression; or I can decide to remain outside it, as it were, and to see it as a thing apart; perhaps more darkly, as something foreign, or subordinate to my will. How we judge a face may affect the outcomes the patient can achieve.

Slide 8
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 with pain feel answerable for what he or she experiences. Men who adopt a stoical attitude to their pain are less likely to express pain in the presence of others.

The expression on a face is an offering in the world of mutual responsibilities: it projects into our interpersonal relations a particular person’s “being there”. As soon as I notice pain in another person’s face, my responsibilities are engaged. Facial expressions of pain call on you to respond to me.

The face has this meaning for us because it is the boundary at which the other appears, offering “this person” as one in need of help.

Slide 9
However, expressing pain does not always lead to compassionate reactions, and people are careful about when and with whom they express pain.

Voluntary control of pain through facial actions is normally judged to be an insincere expression of pain, and open to doubt. 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 non-human mammals. Human beings can deceive through their faces, and children and adults can use the face to fake, and amplify, or suppress, pain.

The capacity to modulate pain expressed through the face has led to difficulty in interpreting the meaning of facially expressed pain. The fidelity with which facial signs mean “pain” is limited to a narrow range of involuntary facial expressions of pain. It is often uncertain whether the presence or absence of information means “pain” or, if they are exaggerated or suppressed consistent with perceived situational demands.

Slide 10
If there is a configuration of facial actions that signals pain, then assessing its presence is amenable to pattern recognition technologies. Substantial progress has been made toward the development of IT-based analysis of pain facial expression.

These systems raise ethical questions about control of patient information.
As these IT systems are used in health care settings, informed consent will need to be obtained for collecting and storing patients’ images, but also for the specific purposes for which those images might be analyzed by these systems.

IT systems can store data as a complete facial image or as a facial template. Facial templates are considered biometric data and thus personally identifiable information. The notion that a photo can reveal private health information is relatively new, and privacy regulations and practices are still catching up. Clinicians should advise patients that there may be limited protections for storing and sharing data when using an facial recognition tool.

Pain in the brain is like a melody in music

A flash of lightning produces a single sound. Pain in the brain is not like that. Neurons in the brain can excite or inhibit many other neurons, to which they are connected. Pain is not controlled by a single neuron.

A flash of lightning has no intended direction. But pain in the brain is not like that. The synaptic connections between neurons enable coordinated patterns of activation between millions of interconnected neurons. A type of pain is just a type of activation pattern.

Pain in the brain is not conducted like a symphony orchestra by a single individual. It is more like a free-jazz ensemble whose music is produced by loose and coordinated effort among the ensemble members.

‘Do you try to find the real artichoke by stripping it of its leaves?’ Wittgenstein once said. The same can be said of pain in the brain.

The brain is a causal mechanism to convey pain as a sensation. Pain also conveys to us itself. Pain in the brain is like a melody in music. When we feel a pain, the pain doesn’t convey something else that compounds with the activation patterns in the brain. We get the feeling of a pain because pain just is an activation pattern.

In the absence of a general theory of pain or brain function, metaphor and philosophy serve useful placeholder roles.

It is not obvious that experiences of pain are identical to brain activation patterns. In reply, it is not obvious that an ensemble of human beings could produce exciting jazz music, either.

Computers will soon act like human beings – then what?

One day, artificial thought will be achieved.

An artificially intelligent computer will say, “that makes me happy.”

Will it feel happy? Assume it will not.

Still: it will act as if it did.  It will act like an intelligent human being. And then what?

My hunch is that adult human beings will view intelligent computers as simplified versions of  themselves (child-like). Human children will view them as peers; ‘friendships’ will form between children and intelligent computers.

Why? I am reminded of Wittgenstein’s remark: ‘The human body is the best picture of the human soul’.

Look at this video of ASIMO.

How would you interact with ASIMO? What would your reactions be?

It is also remarkable that ASIMO does not possess any physiology.