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

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Meanings of Pain_Volume II_Cover

  • 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.

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 


Read the article here.

Improving established MS therapies

How can long-term understanding of established therapies for multiple sclerosis (MS) be harnessed to improve the patient experience? Watch clips from this virtual satellite symposium to:

  • Learn about the tolerability and possibilities with intramuscular administration of peginterferon beta-1a
  • Discover new research showing how a different fumarate chemical structure can affect gastrointestinal (GI) tolerability and work productivity while maintaining bioequivalent levels of the circulating active compound mycophenolate mofetil (MMF)
  • Explore how subcutaneous (SC) administration of natalizumab can reduce the burden of treatment for patients and the healthcare system, a topic of particular relevance during the pandemic
  • Keep up to date with how long-term safety data is changing the use of established MS therapies
  • Consider new data and guidelines for MS therapies as they relate to COVID-19

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Could CDK4/6 inhibitors be a standard of care for advanced breast cancer?

  • Identify suitable patients with advanced breast cancer to try CDK4/6 inhibitors
  • Learn the latest CDK4/6 inhibitor survival data from our breast cancer experts
  • Optimally manage CDK4/6 inhibitor safety in your patients

CDK4/6 inhibitor clinical trials in advanced breast cancer

The cyclin-dependent kinase 4 and 6 inhibitors (CDK4/6 inhibitors) abemaciclib, palbociclib, and ribociclib have been approved by the FDA and the EMA for the treatment of hormone receptor-positive (HR+) and human epidermal growth factor receptor 2 negative (HER2-) advanced breast cancer (ABC).

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Meanings of cancer-related pain – Australian Pain Society Annual Scientific Meeting, April 2021, Topical Session

Presented and recorded at the Australian Pain Society Annual Scientific Meeting, April 2021 virtual event

Topical Session
3C: Meanings of Cancer-Related Pain
Tuesday, April 20, 2021
11:15 AM – 12:30 PM

Session Description: Cognitive factors are important determinants of cancer-related pain experience. Simon van Rysewyk describes how cancer-related is particularly sensitive to cognitive factors and describes some common cognitions that people with cancer-related pain have and how they influence patient outcomes. Xiangfeng Xu (Renee) presents on the cultural and social factors that influence cancer pain management of Chinese migrants and what culturally congruent strategies may be implemented to improve their pain outcomes. 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. Lovell outlines 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 what meanings influence specific patient outcomes
– 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
– Impact of culture on Chinese migrants’ perspectives and responses to cancer pain and recommendations for clinical practice

Presenter Duties
Chair: Dr Simon van Rysewyk, University of Tasmania
Organiser/Presenter 1: Dr Simon van Rysewyk, University of Tasmania
Presenter 2: Dr Renee Xu, University of Sydney
Presenter 3: Associate Professor Melanie Lovell, University of Sydney

How do people learn to live with long-term conditions?

FREE Online Networking Event – September 13-17, 2021

Hosted by the International Network of Research into Psychosocial Adjustment to Long-term Conditions – INRePALC

Book here to participate.

What the face reveals: the experience of pain

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.

Clinical value beyond price alone: biosimilars improve patient access to treatment

Immune-mediated inflammatory diseases (IMIDs) are chronic conditions characterised by altered immune regulation causing chronic inflammation in bodily organs or systems. Despite the clinical benefits of biological medicines for IMIDs, the cost of these medicines is relatively high. The high cost of biologics, combined with a stringent regulatory environment in Europe, have created several patient needs, such as access to treatment for IMIDs. As many biologics have now reached patent expiry, several cost-effective biosimilars have been developed and are available for patients with IMIDs.

Biosimilars have enabled lower-cost biologics to enter the market, thereby reducing healthcare spending and releasing budgets that can be reallocated to other disease areas or healthcare services. Cost savings from biosimilars could lead to parity between reimbursement criteria and European clinical guidelines, potentially improving early access to treatments and outcomes in some patients with IMIDs. Improved access can reduce costly surgery and hospitalisations in patients who have benefited from earlier access to biologics.

It is hoped that biosimilars will continue to reduce inequities in the use of biologic medicines for IMIDs and potentially to meet patient needs associated with biologics.


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De/Constructing the Body: Ancient and Modern Dynamics

Workshop 3: Trans-Formation, Friday 9 April 2021

Meanings of cancer-related pain – Australian Pain Society Annual Scientific Meeting, April 2021

Australian Pain Society Annual Scientific Meeting, April 2021
virtual event

Topical Session
3C: Meanings of Cancer-Related Pain
Tuesday, April 20, 2021
11:15 AM – 12:30 PM

Session Description: Cognitive factors are important determinants of cancer-related pain experience. Simon van Rysewyk describes how cancer-related is particularly sensitive to cognitive factors and describes some common cognitions that people with cancer-related pain have and how they influence patient outcomes. Xiangfeng Xu (Renee) presents on the cultural and social factors that influence cancer pain management of Chinese migrants and what culturally congruent strategies may be implemented to improve their pain outcomes. 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. Lovell outlines 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 what meanings influence specific patient outcomes
– 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
– Impact of culture on Chinese migrants’ perspectives and responses to cancer pain and recommendations for clinical practice

Presenter Duties
Chair: Dr Simon van Rysewyk, University of Tasmania
Organiser/Presenter 1: Dr Simon van Rysewyk, University of Tasmania
Presenter 2: Dr Renee Xu, University of Sydney
Presenter 3: Associate Professor Melanie Lovell, University of Sydney

What the face reveals: the experience of pain

Abstract submitted to Workshop 3, De/Constructing the Body: Ancient and Modern Dynamics

Pain is not an action; yet it reveals itself in those gestures which cannot fail to disclose and to compromise the person with pain. 

During pain, body-parts are subject to massive involuntary transformations. 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 meherenow. 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. The most meaningful features in displays of pain are the eyes, followed by brows, eyelids, mouth, head, forehead, and then other body-parts. Intentional control of pain through facial movements is normally judged by observers to be an insincere expression of pain, and open to doubt. Thus, involuntary facial changes show the person with pain “as he really is” because he does not fully control them, and observers are more obliged to offer help when movements are most involuntary. 

Collage by Alexey Kondakov

The loss of voluntary control over my body during pain, and its dominion over me, 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 with pain feel answerable for what he or she experiences. The expression on a face is an offering in the world of mutual responsibilities: it projects into our inter-personal 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. This feature is perhaps at the heart of what it means to treat and monitor pain.

Keywords: face; facial expression; pain; meaning; body; involuntary.

A Healing Journey with Chronic Pain: A Meta-Ethnography Synthesizing 195 Qualitative Studies

Francine Toye, Joletta Belton, Erin Hannink, Kate Seers, Karen Barker

Collage by Alexey Kondakov

As part of the Pain Medicine special series, ‘Meaning in the Context of Pain’.

Abstract

Objective
There is a large body of research exploring what it means for a person to live with chronic pain. However, existing research does not help us understand what it means to recover. We aimed to identify qualitative research that explored the experience of living with chronic pain published since 2012 and to understand the process of recovery.

Design
A synthesis of qualitative research using meta-ethnography.

Methods
We used the seven stages of meta-ethnography. We systematically searched for qualitative research, published since 2012, that explored adults’ experiences of living with, and being treated for, chronic pain. We used constant comparison to distill the essence of ideas into themes and developed a conceptual model.

Results
We screened 1,328 titles and included 195 studies. Our conceptual model indicates that validation and reconnection can empower a person with chronic pain to embark on a journey of healing. To embark on this journey requires commitment, energy, and support.

Conclusions
The innovation of our study is to conceptualize healing as an ongoing and iterating journey rather than a destination. Health interventions for chronic pain would usefully focus on validating pain through meaningful and acceptable explanations; validating patients by listening to and valuing their stories; encouraging patients to connect with a meaningful sense of self, to be kind to themselves, and to explore new possibilities for the future; and facilitating safe reconnection with the social world. This could make a real difference to people living with chronic pain who are on their own healing journeys.

Read the paper.

Sorting pain out of salience: assessment of pain facial expressions in the human fetus

Lisandra S. BernardesMariana A. CarvalhoSimone B. HarnikManoel J. TeixeiraJuliana OttoliaDaniella CastroAdriano VellosoRossana FranciscoClarice ListikRicardo GalhardoniValquiria Aparecida da SilvaLarissa I. MoreiraAntonio G. de Amorim FilhoAna M. Fernandes, and Daniel Ciampi de Andrade, Grupo de Estudo da Dor Fetal (Fetal Pain Study Group)

Introduction:

The question of whether the human fetus experiences pain has received substantial attention in recent times. With the advent of high-definition 4-dimensional ultrasound (4D-US), it is possible to record fetal body and facial expressions.

Objective:

To determine whether human fetuses demonstrate discriminative acute behavioral responses to nociceptive input.

Methods:

This cross-sectional study included 5 fetuses with diaphragmatic hernia with indication of intrauterine surgery (fetoscopic endoluminal tracheal occlusion) and 8 healthy fetuses, who were scanned with 4D-US in 1 of 3 conditions: (1) acute pain group: Fetuses undergoing intrauterine surgery were assessed in the preoperative period during the anesthetic injection into the thigh; (2) control group at rest: Facial expressions at rest were recorded during scheduled ultrasound examinations; and (3) control group acoustic startle: Fetal facial expressions were recorded during acoustic stimulus (500–4000 Hz; 60–115 dB).

Results:

Raters blinded to the fetuses’ groups scored 65 pictures of fetal facial expressions based on the presence of 12 items (facial movements).

(A) Initial items from neonatal facial coding system and 2 supplementary items. 1. Brow lowering. 2. Eyes squeezed shut. 3. Deepening of the nasolabial furrow. 4. Open lips. 5. Horizontal mouth stretch. 6. Vertical mouth stretch. 7. Lip purse. 8. Taut tongue. 9. Tongue protrusion. 10. Chin quiver. 11. Neck deflection. 12. Yawning. (B) Final items from the Fetal-5 Scale. 1. Brow lowering. 2. Eyes squeezed shut. 3. Deepening of the nasolabial furrow. 4. Open lips. 5. Horizontal mouth stretch. 6. Vertical mouth stretch. 7. Neck deflection.

Analyses of redundancy and usefulness excluded 5 items for being of low discrimination capacity (P>0.2). The final version of the pain assessment tool consisted of a total of 7 items: brow lowering/eyes squeezed shut/deepening of the nasolabial furrow/open lips/horizontal mouth stretch/vertical mouth stretch/neck deflection. Odd ratios for a facial expression to be detected in acute pain compared with control conditions ranged from 11 (neck deflection) to 1,400 (horizontal mouth stretch). Using the seven-item final tool, we showed that 5 is the cutoff value discriminating pain from nonpainful startle and rest.

Conclusions:

This study inaugurates the possibility to study pain responses during the intrauterine life, which may have implications for the postoperative management of pain after intrauterine surgical interventions.

Read the full article here.

Do we mean to ignore meaning in pain?

Simon van Rysewyk, Melanie Galbraith, John Quintner, Milton Cohen

Although Pain Medicine is a rapidly developing clinical discipline, medical explanations about pain are often unsatisfactory. The problem seems to be with meaning: some people with pain do not find meaning in clinical discussions of pain, and clinicians typically are not looking for it. For patients with pain, biomedical information can be perceived as lacking meaning in relation to their personal experience. By contrast, patient narratives and stories about pain, clinical encounters and therapies, cautionary tales, and common-sense experience seem to offer meaningful and actionable information.

No biomedical explanation of pain, however useful it might be to a pain clinician, could describe the personal meaning or burden of pain to the individual. Traditionally, scientific research has had much to say about the physical nature of pain but much less about pain experience. It seems that one limitation in the ability of clinicians to effectively treat pain or pain-related suffering is an incomplete appreciation of ‘pain experience.’

This special series in Pain Medicine focuses on a pivotal aspect of this problem: how to understand the meaning of pain, for both the patient and the observing clinician.

Read the full article here.

“Explicit validation of pain and the person is essential” – Joletta Belton on One Thing

The team at One Thing asked 10 experts in pain medicine to share the one thing they want people challenged by pain to know about.

View Joletta Belton’s response.

Interview with Joletta Belton on One Thing

One Thing is the initiative of Dr Joshua PateDr David Kennedy, and Dr Lincoln Tracy.

“Learning doesn’t happen to you” – Lorimer Moseley

The team at One Thing asked 10 experts in pain medicine to share the one thing they want people challenged by pain to know about.

View Lorimer Moseley’s response.

Interview with Lorimer Moseley on One Thing

Transcript

One Thing is an experiment.
We don’t know where it will lead. But we are clear on one thing: getting these incredible ideas ‘out there’ has amazing potential to help people (people challenged by pain, their loved ones, clinicians, researchers, academics etc!).

A brief interview will be released each Friday!

One Thing is the initiative of Dr Joshua Pate, Dr David Kennedy, and Dr Lincoln Tracy.

The Wedding at Cana (John 2:1-11)

Collage by Alexey Kondakov

In 1983, David Copperfield made the Statue of Liberty disappear and reappear on live TV. The illusion was impressive, perhaps astounding, and I think most of us who saw it gazed on in amazement.

In contrast, consider the spectacle of Jesus turning water into wine at the wedding of Cana. At the wedding, Jesus’ mother told him, “They have no wine.” Jesus replied, “Oh Woman, what has this to do with me? My hour has not yet come.” His mother then said to the servants, “Do whatever he tells you” (John 2:3-5). Jesus ordered the servants to fill containers with water and to draw out some and take it to the chief steward (waiter). After tasting it, without knowing where it came from, the steward remarked to the bridegroom that he had departed from the custom of serving the best wine first by serving it last (John 2:6-10). John adds that: “Jesus did this, the first of his signs, in Cana of Galilee, and it revealed his glory; and his disciples believed in him” (John 2:11).

What makes the Marriage at Cana a miraculous event and not a magical act, like a Copperfield illusion?

One difference must be that some people who witnessed the water change into wine immediately saw it as the expresssion of the Holy Spirit embodied in Jesus. Without noticing this aspect, the event would be astonishing, perhaps strange, but not a religious miracle. Like Copperfield’s Statue of Liberty illusion, people would respond out of incredulity or astonishment, but no more.

The significance of the person who commits the act is the meaning of the event as a relgious miracle, not the event itself islolated from this context, and is what witnesses are supposed to see, from a religious perspective. Without this understanding, the Wedding at Cana is simply an impressive illusion.

Including People with Lived Experience of Pain in the Research Process: Do It Early and Often

Kayt Sukel / RELIEF (December 13, 2020)

“More and more, we see the value of taking a more patient-centered approach, at every step of the research process,” said Captain Robyn Bent, director of the ongoing Patient-Focused Drug Development (PFDD) initiative, which was established at the US Food and Drug Administration (FDA) in 2012. “In the early stages, that patient input can help researchers understand the impact of the disease and existing treatments, helping us better understand what we need to measure to see if something has worked or not. Once we get to clinical trials, patients can help us understand what aspects of those trials need to be better tailored to fit the needs of the people who will end up participating in those trials. And once a treatment is available, patients can help us understand how to best communicate information to both patients and doctors to facilitate shared decision-making.”

Kayt Sukel. Including People with Lived Experience of Pain in the Research Process: Do It Early and Often.

Read the article in RELIEF here.

Neural Plasticity and the Malleability of Pain

Grant Gillett

Collage by Alexey Kondakov

Abstract
Pain is a product of our neural networks painstakingly formed through phylogeny and ontogeny. Neural pathways form within neural nets as a result of long term potentiation and other dynamic mechanisms that subserve learning and memory and are modified so therefore form a key part of what Foucault calls “a volume in perpetual disintegration,” constantly reinforcing connections that capture points of experiential association and gradually dismantling networks that are no longer relevant to the organism’s affordances (points of biological significance in a stimulus environment).

Human pain, seen as an experience with a pivotal role in human interactions, and with a number of psychologically inflected varieties and meanings, is therefore not only a neural phenomenon, but also a moral one. It is moral in that it reflects influences from our engagement in a context of human adaptation that is discursive and interpersonal, one that is heavily inscribed by cultural stereotypes and practices that shape who we are and how we understand and give an account of ourselves. To be, in that sense, is to be humanly engaged in the world, including the world of the clinic and its mores whenever and wherever we enter into it.

Unlike experiences mediated by brain pathways designed to transmit and analyse information that tracks and details affairs in the world around us, pain impulses “diffuse” themselves in order to excite reactions and responses such that the primary destination is not the perceptual and analytic areas of the cortex, but areas which convey the impact of the world upon the subjective body and set in motion the body’s highly mediated reaction to contingencies (the touch of the real).

A major feature of complex and mediated cognitive and conative reactions is that, whereas animal drives reflect a simple psychic economy adapted to the natural world, human drives reflect a transformation into terms adapted to a life-world where we tell ourselves and others what is happening and negotiate what should be done to meet the challenges we face.

Gillett G. Neural Plasticity and the Malleability of Pain. In: Meanings of Pain. 2016. (pp. 37-53). Springer, Cham.

Request a pdf copy here.
Published in Meanings of Pain, Volume I. Purchase here.

Mental Imagery in Chronic Pain: An Access to Meaning Beyond Words

Chantal Berna

Collage by Alexey Kondakov

Abstract
Mental images are cognitions, which take the form of sensory experiences in the absence of a direct percept. Images can be opposed to verbal thoughts, i.e. cognitions in the form of words. From the perspective of clinical cognition, verbal thoughts and mental images are different phenomena, with mental images having tighter connections to emotion than verbal thoughts. Recently, cognitive psychology research has focused on spontaneous mental imagery, i.e. involuntary intrusions of often vivid mental images that appear in one’s mind. Spontaneous mental imagery is now viewed as an important part of psychopathological processes across psychological disorders, a potential emotional amplifier and a therapeutic target in its own right.

Pain is a personal experience, so exploring and understanding the patient’s thoughts about pain might contribute to therapeutic success and favour personalized care. In the field, thoughts about pain have been mostly studied as verbal thoughts. Yet, a growing literature is investigating thoughts about pain in the form of imagery.

Clinical Implications
Studying chronic pain patients’ mental imagery provides unique insight into their personal experience, integrating information about somatosensory perceptions, emotional experience and meanings of pain. The study of imagery in pain also gives insight into possible reinforcing mechanisms of pain, and a basis for a powerful, individualized therapeutic approach through different mental imagery therapy techniques.

This chapter describes current knowledge about mental imagery as intrusive cognitions in the context of pain, considers the neuroscientific investigations that have been undertaken, and discusses the therapeutic potential it yields.

Request a pdf copy here.
Published in Meanings of Pain, Volume I. Purchase here.

Further Reading
Berna C, Tracey I, Holmes EA. How a better understanding of spontaneous mental imagery linked to pain could enhance imagery-based therapy in chronic pain. Journal of experimental psychopathology. 2012 Apr;3(2):258-73.

After the Tango in the Doorway: An Autoethnography of Living with Persistent Pain

Bronwyn Lennox Thompson

Sculpture by Fabio Viale

Abstract
Persistent pain is a common health problem and increasingly, qualitative research is being used to explore the impact on daily lived experience. Stigmatisation and “othering” is reported in these studies, and health professionals indicate they struggle to know how best to help this group of people.

In this autoethnography, I provide an account of my life as a clinician, educator, researcher and social media commentator who lives with fibromyalgia. Through this narrative, I consider the social factors influencing my attitudes towards my own pain over time, and the position I hold as a member of many different social groups discussing persistent pain management.

Clinical Implications
• People seeking help for their pain are influenced by family habits and attitudes towards healthcare and accepting clinical opinion.
• Although persistent pain is common, “othering” or the tendency to see those with persistent pain as different from clinicians (in a negative way) is frequently encountered. This may be inadvertent but results in stigma.
• Information about pain mechanisms is insufficient for supporting a new way of living life for people with persistent pain.
• People with persistent pain may reject the narratives of people who have learned to live well with their pain, and this can be isolating and difficult to deal with.
• There is little research investigating how clinicians advise people of their persistent pain diagnosis, leaving a gap in our understanding of the best way to convey this information.
• Researchers who themselves live with persistent pain provide a unique insight into what it is like and may offer new ways for clinicians to carry out their work.

Keywords Othering · Health professional attitudes · Persistent pain ·
Autoethnography

Download a pdf copy here.

Published in Meanings of Pain, Volume II. Purchase here.

Exploring the Meanings of Pain: My Pain Story

Joletta Belton

Sculptures by Fabio Viale

Abstract
First-person narratives of the lived experience of pain, and the meanings of that experience, are uncommon, especially from persons who are not also clinicians or researchers. Yet such narratives could be particularly useful in understanding pain. First-person accounts, stories of pain, can lend unique insights into the lived experience of pain, how individuals make meaning of it, how they come to those meanings, and how those meanings can change over time. Such narratives could lead to new areas of inquiry and explorations of new possible treatment paths.

This chapter provides such a narrative, offering a glimpse into one person’s lived experience of pain and its meanings. It demonstrates how our individual narratives, our stories, help us make sense of our experiences, including pain. It demonstrates how our narratives can change over time as new information and understandings lead to new meanings, and how such changing narratives and meanings can be a part of a therapeutic process that can lead to better outcomes for patients and clinicians alike.

Clinical Implications
This chapter provides a first-person account of the lived experience of pain and recovery. It explores the meanings of pain, how they came to be, and how those meanings change over the course of time, from early onset of pain through worsening, unexplained pain to recovery from pain.

Keywords Lived experience · Pain · Chronic pain · Narrative · First-person
phenomenology · Meanings of pain · Patient experience · Recovery · Healing

Download a pdf copy here.

Published in Meanings of Pain, Volume II. Purchase here.

Common Meanings of Living with Diabetic Peripheral Neuropathic Pain from the Perspective of Patients

Zehra Gok Metin

Sculpture by Fabio Viale

Abstract
Contemporary pain medicine is necessary to explain pain and to help in
its treatment; yet, preference for biomedical explanation of pain in the field has
meant that attention to the personal experience of pain and to the meanings of pain
experience remain a blind spot in knowledge. Thus, the pain literature includes
limited information about the common meanings of living with diabetic peripheral
neuropathic pain (DPNP) from the perspective of patients.

The purpose of this chapter is to describe some of the common meanings of pain in patients with DPNP, as currently reported in the literature, how these meanings interact with other common factors in pain experience, including specific negative emotions or moods (depression, anxiety, anger), or the psychosocial context surrounding pain, and to describe available evidence on the effectiveness of cognitive behavioral therapy (CBT) for patients with DPNP. Further quantitative, qualitative or mixed methods research is needed to more fully understand common experiences of pain in patients with DPNP, and the common meanings ascribed to these experiences.

Clinical Implications
Pain in patients with DPNP involves a range of threatening pain sensations, including sensations with burning, shooting, tingling, or cramping qualities, and additional more cognitive meanings linked to persistent pain, including a sense that pain disrupts daily life in an intrusive way. Pain affects many aspects of daily experience that are meaningful to patients with DPNP; some describe ongoing physical difficulties, others describe work-related problems or challenges in sexual intimacy. Given the heavy personal burden that DPNP imposes on patients and the considerable challenge of managing the condition pharmacologically, clinical use of non-pharmacological therapies such as CBT for painful diabetic neuropathy might be warranted in individual patients.

Keywords Diabetic peripheral neuropathic pain · Interpretative Phenomenological
Analysis (IPA) · Lived experiences · Meaning of pain · Pain experience

Request a pdf copy here.

Published in Meanings of Pain, Volume II. Purchase here.

Faith and pain intensity: levels, forms, and faith beyond religion

Sculpture by Fabio Viale

Levels of faith and pain intensity
Research studies show significant relationships between strong spiritual well-being, increased pain tolerance[1] and an ability to cope with pain.[2]

A recent study demonstrated that spirituality well-being, and faith particularly, as measured by the Functional Assessment of Chronic Illness Therapy – Spiritual Well-Being-Extended scale (FACIT-Sp-Ex), was significantly related to reduced pain intensity in some study participants over a course of pain treatment.[3] What accounts for this relationship? The authors speculated that:

“It may be that a strong element of “faith” is associated with a greater confidence or trust in health professionals and a greater likelihood of following their advice. It is also possible that those with higher levels of “faith” are more likely to improve because they are more likely to engage with a program that seeks to incorporate a spiritual and existential component. It is also possible that they are more eager to please the program providers and report better outcomes. All of these possibilities would need to be explored further and cannot be answered in the present study.”[3]

The quotation suggests that higher levels of faith might be associated with reduced pain intensity in some people with pain.

Forms of faith and pain intensity: a hypothesis
A hypothesis is that, in addition to levels of faith, particular forms of faith, or combinations of faith forms, could reduce pain intensity.

So, what forms of faith are there? The following forms are commonly distinguished in philosophy of religion (Table 1).

Faith formName in philosophy of religion
A feeling of existential confidencethe ‘purely affective’ model
Knowledge of specific truths, revealed by Godthe ‘special knowledge’ model
Belief that God existsthe ‘belief’ model
Believing in (‘trusting in’) Godthe ‘trust’ model
Practical commitment beyond the evidence to one’s belief that God existsthe ‘doxastic venture’ model
Hoping the God who saves existsthe ‘hope’ model
Table 1: Common forms of faith identified in philosophy of religion[4]

Scientific study could investigate if some forms of faith are significantly related to reduced pain intensity compared to other forms, or combinations of forms, of faith. These same forms of faith could be used prognostically by clinicians to predict improvements in pain intensity in some patients, or in other outcomes, such as quality of life or pain-related disability. Qualitative research could investigate if patient conceptions of faith accurately map onto faith forms, as identified by philosophers.

Faith beyond religion
Can faith exist without commitment to any religion? Tennant wrote that: ‘faith is an outcome of the inborn propensity to self-conservation and self-betterment which is a part of human nature, and is no more a miraculously superadded endowment than is sensation or understanding.’[5] He thinks that ‘much of the belief which underlies knowledge is the outcome of faith which ventures beyond the apprehension and treatment of data to supposition, imagination and creation of ideal objects, and justifies its audacity and irrationality (in accounting them to be also real) by practical actualization.’[5]

If faith exists beyond religion, then people who commit themselves to a view based on a particular interpretation of reality exclusive of the objective verification of the truth, are people of faith. Faith of this kind may be religious without being theistic, as in Buddhism or Taoism. Or, it may be scientific when people propose that reality is no more than what is discoverable by the natural sciences (e.g. ‘scientific atheists’, ‘naturalists’).

Conclusion
Study of the interaction between faith and pain could investigate relationships between forms of faith and pain intensity, in addition to other psychosocial outcomes. Such forms span broadly across traditional orthodox religious thesim, relgious non-theism, scientific atheism or naturalism. Interaction between forms and levels of faith, and pain outcomes, is a further possibility. Personal faith could be a useful tool in the clinical armamentarium.

References
[1] Lysne CJ, Wachholtz AB. Pain, spirituality, and meaning making: What can we learn from the literature? Religions 2010;2(1):1.

[2] Keefe FJ, Affleck G, Lefebvre J, Underwood L, Caldwell DS, Drew J, et al. Living with rheumatoid arthritis: The role of daily spirituality and daily religious and spiritual coping. J Pain 2001;2(2):101-10.

[3] McCabe R, Murray R, Austin P, Siddall P. Spiritual and existential factors predict pain relief in a pain management program with a meaning-based component. J Pain Manage 2018:11(2):163-170.

[4] Bishop J. Faith. In: Stanford Encyclopedia of Philosophy. Available at: https://plato.stanford.edu/entries/faith/

[5] Tennant FR. 1943/1989. Faith [Tennant, 1943, Chapter 6]. In T. Penelhum (ed.), Faith, London: Collier Macmillan, 99-112.

The Importance of Pain Imagery in Women with Endometriosis-Associated Pain, and Wider Implications for Patients with Chronic Pain

Christopher J. Graham, Shona L. Brown, and Andrew W. Horne

Sculptures by Fabio Viale

Abstract
Pain imagery is “like having a picture in your head [of your pain] which may include things you can imagine seeing, hearing or feeling.” Pain imagery may offer a unique insight into a patient’s pain experience. This chapter summarises findings from international pain imagery research in women with endometriosis-associated pain. Endometriosis is a chronic inflammatory condition associated with debilitating pain that affects 5–10% of women of reproductive age worldwide.

Our international research has found that pain imagery is experienced by around half of women suffering from endometriosis-associated pain, and is associated with higher levels of catastrophising, depression, and anxiety. However, coping imagery is also reported, and prevalent, at 30%. Pain imagery in women with endometriosis falls into themes: sensory qualities of pain; loss of power or control; attack (by someone, “something,” or self); pathology or anatomy envisaged; past or future catastrophe; pain as an object; and abstract images. Imagery content may therefore reveal the meanings of pain or endometriosis to these women.

This chapter explores pain imagery content and its personal significance to patients, both for women with endometriosis-associated pain and for patients with other chronic pain conditions. The chapter concludes by discussing the clinical application of imagery, with example patient cases to contextualise the practicalities and therapeutic potential of imagery techniques.

Clinical Implications
Pain imagery was reported by half of women with endometriosis-associated pain in our international study and associated with higher levels of catastrophising, depression, and anxiety. Imagery content is extremely varied but can be categorised into themes, which may offer unique insights into each woman’s pain experience. Coping imagery was prevalent at 30%.

We believe imagery techniques may be particularly helpful for women with endometriosis associated pain and discuss these techniques, which should be of interest to professionals involved in pain management.

Keywords Endometriosis · Persistent pelvic pain · Chronic pelvic pain · Pain
imagery · Coping imagery · Imagery-based therapies

Request a pdf copy here.

Published in Meanings of Pain, Volume II. Purchase here.

Spiritual Well-Being in People Living with Persistent Non-Cancer and Cancer-Related Pain

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Another excellent paper in the Pain Medicine special issue I guest edited with Melanie Galbraith, John Quintner and Milton Cohen –

Spiritual Well-Being in People Living with Persistent Non-Cancer and Cancer-Related Pain
Melanie Lovell, Mandy Corbett, Skye Dong, Philip Siddall

Existential and spiritual factors are known to play an important role in how people cope with disability and life-threatening illnesses such as …

Source: Spiritual Well-Being in People Living with Persistent Non-Cancer and Cancer-Related Pain

Looking for Meaning in Labour Pain: Are Current Pain Measurement Tools Adequate?

labour pain

Happy to announce the first of four papers in the special issue of Pain Medicine – ‘Meaning in the Context of Pain’ – I guest edited with Melanie Galbraith, Dr John Quintner, and Prof Milton Cohen.

Looking for Meaning in Labour Pain: Are Current Pain Measurement Tools Adequate?
Laura Y Whitburn and Lester E Jones

With great advances in understanding the mechanisms of pain, new definitions [1] and classifications [2] have been developed to describe pain conditions…

Source: Looking for Meaning in Labour Pain: Are Current Pain Measurement Tools Adequate?

‘Meanings of Cancer-Related Pain’

Sculpture by Fabio Viale

Australian Pain Society Annual Scientific Meeting, April 2021
virtual event

Topical Session
3C: Meanings of Cancer-Related Pain
Tuesday, April 20, 2021
11:15 AM – 12:30 PM

Session Description: Cognitive factors are important determinants of cancer-related pain experience. Simon van Rysewyk describes how cancer-related is particularly sensitive to cognitive factors and describes some common cognitions that people with cancer-related pain have and how they influence patient outcomes. Xiangfeng Xu (Renee) presents on the cultural and social factors that influence cancer pain management of Chinese migrants and what culturally congruent strategies may be implemented to improve their pain outcomes. 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. Lovell outlines 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 what meanings influence specific patient outcomes
– 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
– Impact of culture on Chinese migrants’ perspectives and responses to cancer pain and recommendations for clinical practice

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

“Me seeing you seeing my pain”

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.

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: open

“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.


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.


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.


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

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 Cohen3
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.

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

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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)

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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.

I am sitting on a veranda

I am sitting on a veranda on a summer afternoon.

The trees gently sway in the sunlight.

A quiet joy beings to arise in me,

a rejoicing in the world that includes myself,

these swaying trees, this blue sky,

and everything else that unfolds beyond all that I am perceiving.

The world, completely, and all at once, is fulfilled.

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 Hybrid Bottom-Up and Top-Down Approach to Machine Medical Ethics: Theory and Data by Simon Peter van Rysewyk and Matthijs Pontier

Abstract

The perceived weaknesses of philosophical normative theories as machine ethic candidates have led some philosophers to consider combining them into some kind of a hybrid theory. This chapter develops a philosophical machine ethic which integrates “top-down” normative theories (rule-utilitarianism and prima-facie deontological ethics) and “bottom-up” (case-based reasoning) computational structure. This hybrid ethic is tested in a medical machine whose input-output function is treated as a simulacrum of professional human ethical action in clinical medicine. In six clinical medical simulations run on the proposed hybrid ethic, the output of the machine matched the respective acts of human medical professionals. Thus, the proposed machine ethic emerges as a successful model of medical ethics, and a platform for further developments.

Here.

Why does dream pain occur? A brief review of current theories

The International Association for the Study of Pain (IASP) defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” The IASP definition of pain includes in its notes, “Pain is always subjective”. The term “subjective” emphasizes that pain is a conscious experience rather than simply a causal result of unconscious nociceptive processing. The intuition underlying the IASP definition of pain is that if a pain is not being consciously felt by its owner then it does not exist.

Up until the late twentieth century, it was widely believed by pain researchers that conscious pain could not be felt by humans in sleep because sleep is an unconscious state. This pre-scientific intuition about pain has since been undermined by numerous scientific studies showing that both stimulus-induced and non-stimulus induced pain reported during rapid eye movement (REM) sleep does not always result in subject wakefulness and that pain can also feature in dreams (e.g., Nielsen et al. 1993; Zadra et al. 1998; Raymond et al. 2002; Knoth & Schredl, 2011). Concerning dream pain, Zadra et al. (1998) found that 48.2% of subjects reported that they have had at least one pain dream in their lives, although only 0.62% of recorded dreams in home diary studies contain clear reference to pain feelings and meanings. In some subjects, dream pain continues to be felt following wakefulness; in other subjects, it is rapidly terminated after awakening. These divergent findings prompt the causal question: Why does dream pain exist and have the nature it does?

To explain dream pain, Schredl (2003) proposed that there is continuity between wakeful and dream pain such that pain regularly felt when awake is causally efficacious concerning its occurrence in dreams. Raymond et al. (2002) investigated Schredl’s “continuity hypothesis” in hospitalized burn patients and healthy control subjects and found that patients reported a significantly higher rate of dreamed pain than controls. The burn patients also reported marginally more intense pain during wakeful medical procedures, a finding which was interpreted by Raymond et al. (2002) to support the continuity hypothesis. The patients reported constant pain during wakefulness, which further supports the continuity hypothesis. However, there are three further competing interpretations of the data presented in Raymond et al. (2002). Since dreamed pain was not always reported as located in injured body regions or in bodily areas patients reported pain in during the night and following awakening, Raymond et al. (2002) speculated that dream pain might not be causally continuous with wakeful pain experiences, but with a personal pain memory trace formed after wakeful pain experiences. In support of this interpretation of the data, Jantsch et al. (2009) showed the existence of a reliable long-term memory trace for experimentally induced pain sensations. This finding would explain the rarity of reported dream pain in controls since pain is rare in their everyday experience. A competing causal explanation of the data in Raymond et al. (2002) is that some dreamers report pain they had never experienced in real life (e.g., dream pain in a fictional fight situation) (Schredl, 2011). In support of this view, Danziger et al. (2009) found that people with congenital insensitivity to pain show patterns of brain activation in shared-circuits for “self” and “other” pain while observing pain in other persons. This finding leads to the proposal that pain observed externally in others or in electronic media might also explain dream pain (Borsook & Beccera, 2009).

Thus, the three explanations on offer to explain why dream pain occurs are: (1) Dream pain is causally continuous with wakeful pain experiences; (2) Dream pain is causally continuous with personal pain memories formed after wakeful pain experiences; and (3) Dream pain is causally continuous with pain observed externally in others or in electronic media during wakefulness. These competing explanations show that the task of explaining why dream pain occurs is still very much an open question in the field, and more research on the topic is needed.

References

  1. Borsook D, Becerra L. Emotional Pain without Sensory Pain-Dream On? Neuron 2009; 61(2):153–155.
  2. Danziger N, Faillenot I, Peyron R. Can We Share a Pain We Never Felt? Neural Correlates of Empathy in Patients with Congenital Insensitivity to Pain. Neuron 2009; 61(2):203–212.
  3. Jantsch HHF, Gawlitza M, Geber C, Baumgärtner U, et al. Explicit episodic memory for sensory discriminative components of capsaicin–induced pain: Immediate and delayed ratings. Pain 2009; 143(1–2):97–105.
  4. Nielsen TA, McGregor DL, Zadra A, et al. Pain in dreams. Sleep 1993; 16: 490–498.
  5. Raymond I, Nielsen TA, Lavigne G, et al. Incorporation of pain in dreams of hospitalized burn victims. Sleep 2002; 25: 765–770.
  6. Schredl M, Erlacher, D. Lucid dreaming frequency and personality. Personality and Individual Differences 2004; 37(7): 1463–1473.
  7. Schredl M. Continuity between waking and dreaming: a proposal for a mathematical model. Sleep and Hypnosis 2003; 5: 38–52.
  8. Zadra AL, Nielsen TA, Germain A, et al. The nature and prevalence of pain in dreams. Pain Research and Management 1998; 3: 155–161.
  9. Zappaterra M, Jim L, and Pangarkar, S. Chronic pain resolution after a lucid dream: A case for neural plasticity? Medical hypotheses 2014; 82(3): 286–290.

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, 2nd 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

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.