Then, taking into account novel perspectives, we propose a new definition of pain that closely tracks that of the IASP but which, in contrast, is based on common factors within the pain experience as derived from psychophysical and phenomenological studies.
Indeed, any attempt to define pain is daunting due to 2 interdependent challenges that transcend different cultures. One is the conceptual challenge of making sense of the mystery of the experience of pain; the other is the linguistic challenge of how to express that process accurately, when constrained by natural language to approach it only indirectly. In proposing a new theoretical framework for Pain Medicine, Quintner et al. However, aporia is also used in rhetoric as a means of expressing doubt, a concept which is relevant to this framework Oxford English Dictionary.
Underpinning this difficulty in understanding and explaining the experience of pain is the limitation of language. On the one hand, the person experiencing pain has no direct language in which either to express that experience to others or to explain it to themselves and thus must resort to simile and metaphor, usually creatively. Although both clinician and patient follow different paths and have differing agendas, including various beliefs and expectations, they arrive at the same destination, which is the clinical encounter.
The person experiencing pain presents for investigation and treatment with the quite reasonable expectation that the clinician will be able to explain their experience using currently available medical scientific knowledge. However, when the clinician does not know how to proceed, the result for both parties can be a crisis of choice, action, and identity. When confronted with their clinician's dilemma, the person experiencing pain is forced to share the very same set of doubt and uncertainty, thereby compounding their own discomfort.
This has potentially negative implications for the therapeutic relationship 9 including physical and emotional harm, whereas within the health care system and society at large, there is the very real risk of the person being stigmatised, a narrative in which their experience is declared invalid, imagined, or immoral. This definition, which attempted to provide a universal characterisation of the human experience of pain, was intended for use by clinicians, although this was not made clear until However, from its inception, it heralded a growing recognition that pain is a subject worthy of study in its own right.
Given the centrality of the current IASP definition of pain to clinical practice and to the scientific and ethnological literature, it is relevant to examine its origins. The experience could be described also in terms of other dimensions, such as spatial and temporal characteristics, and on the variability in labels chosen to describe it. The complexity of responses to the MPQ provides critical insight into the link between a patient's report of pain and suffering due to pain. The IASP definition asserts firstly that pain is not the same phenomenon as nociception and secondly that it comprises both sensory and emotional dimensions.
Smith et al. Price and Barrell 43 proposed that the phenomenology of pain is based on 3 factors rather than Melzack's category of experiences that are common to experiences thereof: 1 its unique sensory qualities; 2 a meaning of intrusion or threat; and 3 related feelings of unpleasantness or other negative emotions. Anand and Craig 1 complained that the definition depends on self-report, thus potentially disenfranchising nonverbal groups such as neonates, infants, and small children, people with intellectual disabilities, degenerative brain disease, linguistic disorders, and all nonhuman animals.
Williams and Craig 53 also considered that verbal reports were being accorded a higher priority than nonverbal behaviours. In defence of the IASP definition, Aydede 2 suggested that in the clinical context, verbal reports are not necessary for detecting if a person is experiencing pain and suggested that nonverbal behaviours such as facial expressions would probably suffice. Such behaviours have an important role in mediating pain assessment in social contexts. Observers prefer nonverbal to verbal behavior when interpreting or judging the credibility of a person experiencing pain.
Price 41 remarked on the postulated association between a sensation, an experience of unpleasantness, and actual or potential tissue damage. An observer can never know with certainty whether the other person is correct in making such an association. On the other hand, through culturally and linguistically determined learning, the sentient person experiencing pain will likely associate the unpleasant sensation with either tissue damage or the apprehension thereof.
Price's 41 criticism is therefore valid only when there is discordance between the judgment made by the observer and that of the person experiencing pain. In such cases, observers do not rely on inference that another is experiencing pain. These situations do not necessarily exemplify that observer judgements of pain in others are necessarily mistaken but rather that they are fallible. In summary, criticisms of the IASP definition include the explicit association of pain with tissue damage, perpetuation of dualistic body—mind thinking and unresolved tension between the primacy of self-report and the privileging of the perspective of the observer.
Aiming to distinguish pain from other unpleasant bodily experiences eg, nausea and fear , Fabrega and Tyma 11 minimised its sensory-discriminative dimensions in favour of boosting its affective-motivational properties and then relying on the judgment of the individual as to whether the particular perception is recognised as pain. In their formulation: Pain is an unpleasant perception which the individual explicitly refers to his body and which can represent a form of suffering.
Olivier 36 argued that, phenomenologically, pain is a mode of bodily perception. Pursuing this argument, he stresses that the experience of pain disturbs the ways in which we relate to our environment: Pain is disturbed bodily perception bound to hurt, affliction, or agony.
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However, this definition is ambiguous because it could imply that someone watching another person being tortured may experience pain directly as a result of the observation. Wright 56 grounded the experience of pain in terms of its presumed evolutionary role. By defining pain as a type of unpleasant experience, he not only avoids linking that experience to activation of nociceptors but also postulates a teleological function for the experience: Pain is the sic unpleasant sensation that has evolved to motivate behaviour, which avoids or minimises tissue damage, or promotes recovery.
Along similar lines, Smith et al. Aydede 2 reworded the definition to emphasise the relationship between the typical phenomenology of pain and its canonical causes: An unpleasant sensory and emotional experience that results from actual or impending tissue damage, or is correctly describable in terms of such damage.
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However, these modified definitions are open to some of the same criticisms as faced by the IASP definition. The definition of Smith et al. Olivier 36 and Wright's 56 definitions do not acknowledge the multiple sensory, cognitive, and emotional dimensions common to pain experience, or the common meaning of pain as immediate intrusion or, attack on the body. By being overly inclusive, the definitions of Williams and Craig 53 and the formulation of Price and Barrell 43 sacrifice the parsimony that typifies the IASP definition. The question arises whether other concepts of pain might have been overlooked in the process of definition.
Pain has been conceptualised in many differing ways by philosophers, poets, experimental physiologists, as well as by physicians reviewed by Zimmermann In this section, we identify common concepts and dimensions of pain, and the interrelationships among them.
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Throughout its history, Western medicine has appreciated the value of pain as a symptom of an underlying injury and disturbed bodily function. So, pain-as-a-symptom carries an implication of a threatening reality. But, chronic pain may occur in the absence of a discernible disease process, thus deflecting pain from being a symptom to being the harbinger of a daunting and at times a terrifying future, for both clinician and patient. From ancient times, pain has been construed as a form of punishment visited on humankind by supernatural forces eg, evil spirits invading the person's body, as a test of the person's faith that a divine being will protect them from bodily injury.
Another view saw pain as the result of an imbalance of the vital fluids. In modern times, psychophysical and phenomenological studies have confirmed the core meaning of pain as a sense of personal intrusion or attack on the body that is sometimes accompanied by immediate and extended negative feelings of anxiety, fear, annoyance, and depression.
Our personal experiences are not simply private events but are connected with other experiences to which publicly shared concepts can be applied. Where do you feel the pain? How long did it last? Is it sharp, burning, or stinging? Are you all right? This is not to deny objective aspects of pain as in the burgeoning knowledge base of neuroscience nor of course its inherent subjectivity. Philosopher Martin Buber — described 2 different approaches through which people can choose to relate to their environment: I-It or I-Thou.
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As he observed during the imaginative play of children, this intermediate area is one in which players agree to mutually construct a relevant culture for a particular purpose. This is a legitimate socially sanctioned and safe communal space in which both parties can accept and negotiate the meanings of the experience, including the testing of boundaries, 4 thereby creating a therapeutic relationship.
As discussed above, the experience of pain is commonly expressed in terms of threat to bodily integrity. American physiologist Cannon 8 postulated the existence of a self-regulatory adaptive mechanism that allowed organisms to maintain themselves in a state of dynamic balance in the face of changing conditions. For this mechanism, he coined the term homeostasis.
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Chilean biologists Maturana and Varela 24 took this concept further by arguing that the unique property possessed by living organisms is a particular circular mechanism of spontaneous autonomous activity contained within a semipermeable boundary, a process which they called autopoiesis, from the Greek, meaning self-producing. These components are ceaselessly regenerated and the system always contains the very network that produces them. The critical variable of a living system then is its self-organization, which determines both the identity and general configuration structure of the system.
Its structure changes constantly as the system continually adapts itself to perturbations unpredictable disturbances in its environment. Loss of the system's organization results in its death. Vernon et al.
By contrast, Tabor et al. If preservation of autonomy is the critical variable of a living system, 52 then pain is a threat to that autonomy and thus to the existential integrity of a living system. Therefore, we propose: Pain is a mutually recognisable somatic experience that reflects a person's apprehension of threat to their bodily or existential integrity. The above discussion emphasises how difficult it is to grasp an aporia. Recognising mutuality in the proposed definition removes the element of doubt and the at times vexed and polarising issues of subjectivity and objectivity when a clinician is attempting to evaluate a patient's experience.