Thoughts on the privacy of pain – #1

Gordon, also known as “Whipped Peter”, a former enslaved African American man, shows his scarred back at a medical examination, Baton Rouge, Louisiana, on 2nd April, 1863. The scars were the result of whipping during his time as an enslaved person at a Louisiana plantation. (Source: Wikimedia Commons)

A reason for thinking that pain is private – hidden to external observers – is the uncertainty that affects our judgements about the pain of others.

When someone appears to be in pain, it seems self evident that what matters is not the pain behaviour that we observe, but the pain experience that lies ‘behind’ the behaviour. We find it natural to say that ‘pain is private; we infer it only inconclusively from the behaviour.’

We naturally think: first-person experience is certain; third-person observation is uncertain. The person in pain has privileged, or immediate, access to his or her pain. Doubt is excluded in the first-person case.

Is this thinking correct?

Following the philosopher Wittgenstein, doubt in the first-person is excluded, not because pain is a private experience, but because the practice of pain excludes it. In the practice of pain, the individual has the role of expressing pain experiences; these expressions include a diverse range of verbal and non-verbal behaviours. In the swing and play of the practice, we treat these behaviours as authentic. To introduce doubt here would alter the practice of pain; importantly, it would undermine our concept of the person.

In clinical settings, this is reflected in McCaffery’s maxim that “Pain is what the person says it is, and exists whenever he or she says it does.” This brings the person to the fore, and makes patients the authority in their pain experience. This approach to pain assessment is also aligned with the principles of patient advocacy and ethical clinical treatment.

Why can’t a person be wrong about his or her own pain? The reason Wittgenstein proposed is that assigning the individual the role of expressing pain means there is no gap between what the person sincerely says her experience is, and what it really is. If we are trying to determine the effect of pain on a person’s quality of life, it is what the person says, and not anyone else, that is correct.

The point is not that the individual feels pain only she can feel, but that we treat her as a person, and on the basis of her behaviours, including self-report, assign to her particular sensations, thoughts, and moods. The ‘privacy of pain’ reflects not the intrinsic privacy of pain experience, but our practice of pain based on the notion of a person whose behaviours are treated as authentic expressions of pain.

Still, a person’s utterances may only partly signify the complexities of pain experience, and some situations warrant people be careful what they reveal. Some pain behaviour may therefore reflect perceived best interests, and this is contextual. Care-delivery in pain settings can involve a threat to the caregiver, and is conditional on the authenticity of pain behaviour. As observers of pain behaviour, we are sensitive to signs of exaggeration, suppression, or malingering. Thus, fine shades of behaviour are important in the evaluation of ‘what is going on’ in the setting of pain, and lead our relation to each other as persons. The practice of pain does not always connect behaviour and pain experience in a rigid way.

Navigating these complexities can make patient-clinician interactions challenging.

Reply: Todd Hargrove’s post “Is Pain a Sensation or a Perception?”

Todd argues for these claims:

  1. The debate is not substantive or of practical import. It does not involve disagreements about pain physiology, what causes pain, or how pain should be treated. Instead, the debate is semantic.
  2. The debate is easily resolved by simply looking at textbooks that describe how the terms sensation and perception are conventionally defined and used.
  3. These textbooks make clear that it is completely appropriate to refer to pain as a perception, and it doesn’t make much sense to say that pain is a sensation but not a perception.
  4. In any event, it doesn’t matter that much how we use these words in practice, because they are inherently fuzzy and often used interchangeably.

I think Todd’s post is a decent contribution to the question, and will make a positive difference to some patients and HCPs.

Below, some thoughts from me; Todd, if you read this, your response is very welcome.

Todd: “…the terms sensation and perception are inherently nebulous and there’s no bright line between them. Why not? Because they encompass a vast number of different physiological processes happening at every level of the nervous system…”

Me: The terms ‘sensation’ and ‘perception’ are ordinary language terms, and do not capture neurophysiological or genetic differences, but differences in the kinds of behavioural and perceptual capacities human beings are interested in. We are social by nature. Human languages include psychological terms because of our need to describe, explain, predict, and otherwise understand the behaviour of other human (and non-human) animals, and because of the need to provide such information to other humans.

Of course, psychological terms can be defined or characterised scientifically, but the original ‘home’ of our psychological vocabulary is the ordinary language we use every day.

Todd highlighted the indeterminacy of our psychological terms, such as ‘sensation’ and ‘perception’; e.g., ‘…there’s no bright line between them’; ‘…are inherently fuzzy, and are often used interchangeably’.

Me: I think the possibility of disagreement or uncertainty about pain in others reflects this indeterminacy. In our ordinary pain language, that indeterminacy is not due to neurophysiological or genetic factors, but to social patterns of behaviour: our concept of pain is flexible because pain behaviour, and our complex reactions to it, is diverse and unpredictable. Care-giving in pain settings can involve a threat to the caregiver, and is conditional on the authenticity of manifest pain behaviour. As observers of pain behaviour, we are sensitive to signs of exaggeration, suppression, or malingering, in behavioural displays of pain. Accordingly, our concept of pain does not always connect behaviour, situation, and personal experience, in a rigid way.

What could follow if we always connected behaviour, situation, and personal experience, in a rigid – necessary – way? To propose a simple, but rather extreme, illustration: suppose a group of people defined pain in terms of a particular neurophysiological biomarker, and used a sophisticated scanner to test for this marker. In their practice, the scanner’s verdict, and not the individual’s utterances or behaviour, is treated as definitive.

Would we want to call this practice a concept of pain? Would this practice be desirable or even possible for us? Would we, for example, accept that an apparent malingerer was in pain, if the scanner said so? Or, that a friend wasn’t, despite her facial grimaces? Would the absence of an abnormal scanner finding be held against a person applying for health benefits?

The new practice with its unanimity and clarity would be a far cry from our current, indeterminant, one. Although some people might engage in this practice, the fact that they do so perhaps makes them a different type of people from us?

Is pain a “thing”?

Neuropsychologist Paul Broks on Wittgenstein

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

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

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

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

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

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

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

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

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

What are the potential sources of underestimation?

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

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

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

The meaning of coping with chronic pain – video presentation recording

Presented at the International Network for Research into Psychosocial Adjustment to Long-term Conditions (INRePALC)

1st International Online Networking Event
13th–17th September, 2021

Session Description: Let’s discuss what it means to cope with chronic pain – this is not a data presentation. Instead, I attempt to create a sense of enquiry and self-reflection on how to take the meaning of coping with chronic pain and apply it in the clinic. Thinking about what we do, and what the doing represents in the clinic, can be rewarding.

The meaning of coping with chronic pain

Presented at the International Network for Research into Psychosocial Adjustment to Long-term Conditions (INRePALC)

1st International Online Networking Event
13th–17th September, 2021

Session Description: Let’s discuss what it means to cope with chronic pain – this is not a data presentation. Instead, I attempt to create a sense of enquiry and self-reflection on how to take the meaning of coping with chronic pain and apply it in the clinic. Thinking about what we do, and what the doing represents in the clinic, can be rewarding.

View here.

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)


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.


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


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).


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.


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.

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

Chantal Berna

Collage by Alexey Kondakov

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.

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

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.