Intellectual and Moral Tasks in Intersection—Part 2
What Is Sensed and What Is “Felt”
Pain originates as a sensory signal with unique adverse qualities, and the contribution of these qualities to the pain experience is inextricable to the concept of pain qua “pain.” As Nikola Grahek has stated “…the common and distinctive felt quality of pain is the essential or indispensable component of our total pain experience and why that experience is not pain experience when that component is missing.”1 Simply, without this sensation, the experience would not be “pain.” Suffering without the sensation is possible and perhaps even common, yet we do not universally classify this discomfort as pain. Other types of bodily discomfort such as nausea are imbued with an aversive motivational quality and have the potential to cause suffering; however, we can easily differentiate these discomforts from pain by the nature of the sensation. However, the raw sensation of pain is only pain when it provokes an emotional reaction. This component of the pain experience has been referred to by Melzack as the “affective dimension,”2 and it encompasses the ways which pain changes one’s relationship to the body, his/her existence, and “being-in-the-world.” Similarly, Grahek speaks of the “affective-motivational aspect”; Rodriguez notes the mental dimension of pain; Woessner, through Caudill, includes the psychological/cognitive dimension3; and Moskovitz holds that pain is experienced emotionally due to the “…habits, goals, desires, expectations, roles, and attachments threatened by the experience (of pain).”4 Pain changes the existential being of the patient through the intensity and discomfort of the sensation, its impact on normal and enjoyed activities, and the meaning that the patient ascribes to the pain, i.e. the patient’s evaluation of the pain. The problem of differentiating between mind and body is not one we wish to treat here but, if there is indeed a distinction to be made, it is clear that pain affects both body and mind in fundamental ways.
Expression and Expectation
A necessary correlate to the aversive, affective quality of pain is the pain behavior that it inspires. Woessner, Hardcastle, Turk, and Rudy all address the behavioral dimension of pain,5-7 and attest that to understand pain, it is necessary to note and appreciate its behavioral expression. Roselyn Rey states that “…the manner in which pain is expressed has a direct relation to the way in which pain is actually borne, how it is felt.”8 Clearly then, understanding a patient’s behavioral reaction to pain is essential to clinical assessment and diagnosis. A physician must learn the tendency of a particular patient toward stoicism or over-representation to correctly interpret pain behaviors and verbal ratings.
However, the way in which pain is behaviorally expressed often depends upon social, cultural, and environmental factors that interact with the nature of the internal pain experience. Different cultures have distinctly acceptable expressions of, and for, pain. In addition, cultural ideas and conceptions about pain are strongly tied to the psychological response and affect that is manifested.9 In some cultures, the experience(s) of pain are not seen as disintegrative, but as unifying and intensely spiritual occurrences. For example, the Harvest Festival of rural India includes a ceremony in which a celebrant swings from a platform to bless the crops, held up by metal hooks embedded in his back. Participants report feelings of exhilaration in lieu of pain. Rodriguez speaks to the social, cultural, spiritual, and historical dimensions of pain,10 highlighting the importance of language and the potential for tension as different values and interpretations of ethical principles come in conflict. Thus, both the meaning of pain, as well as outer manifestations of that meaning, are mediated by the socio-cultural environment and world-view of the person in pain.
It is important to note that these dimensions are neither comprehensive nor static. When put into practice, they should be integral to the pain being studied, yet remain distinct from one another, and defined relevant to one’s purposes. Turk and Melzack explain that these components do not always co-occur in time or the same configuration in all people.11 McGuire echoes the importance of defining the dimensions of pain on a case-by-case basis.12 Similarly, Clark employed a multi-dimensional scaling procedure to determine the relative intensity, as well as emotional and somatosensory qualities, of pain in various groups (of volunteers and patients) and found that, while the pain intensity dimension was primary for patients, it was the emotional quality that most affected volunteers.13 He concluded that the subjects, not the researcher, should determine the dimensions of pain. Transposing this construct to the clinical setting, we opine that the clinician should not assume that every patient’s pain can be explained by a single model. Rather, each patient’s pain is unique and is affected—to differing extents—by various combinations of physical and emotional dimensions.
Although behavioral expressions are important to interpreting the pain of an other, behaviors are by no means consistent—both in an individual, and across groups of individuals—given that socio-cultural norms provide a relative baseline for typical and/or accepted patterns of expression which can then vary within, and even between, these parameters. There are several tools that can help to depict the social and cultural factors contributing to pain expression; for example, the West Haven-Yale Multidimensional Pain Inventory (WHYMPI), while primarily a comprehensive affective survey, includes a section on the response of the patient’s significant other to pain behavior. Use of this section may help to illustrate any social or cultural pressures present in the home environment that mask, mitigate, and/or exacerbate pain expression.15 Additional insight to factors influencing a patient’s response to pain can be afforded by the Pain Self-Efficacy Questionnaire, which measures the patient’s confidence level relative to the extent to which pain impacts and interferes with the perceived capacity to engage in daily activities.16