Pain perception As mentioned earlier, after the nociceptive signals are carried to the cerebral cortex to be processed, interpreted, and responded to, an individual becomes consciously aware of the incoming painful signals, finds them unpleasant, and labels them pain . This might seem to be the same thing as nociception, but it is possible to have pain without nociception (e.g., perceiving pain in a limb that has been amputated, or experiencing “phantom pain”) or nociception without pain (e.g., when an athlete fails to notice that his foot is broken until after the race). In this respect, pain and nociception are different phenomena. The real key here is awareness; sensations are not considered painful until the person consciously notices them, pays attention to them, and labels the experience as pain . The processing of pain signals in the brain involves a large and dynamic network of brain regions working together. These brain regions assess the pain’s location, intensity, and duration, and ascribe a meaning to the pain. Cognitive/emotional responses Once individuals recognize that they are in pain, they may experience any of a broad range of emotions and thoughts related to their pain. If the pain is mild, these emotions and thoughts may be neutral. (“I can ignore this headache; I’ll just distract myself and get through it.”) In some cases, the cognitive/emotional response to pain might even be positive. (For example, someone with a chronic illness may interpret the pain as a reminder that he is still feeling strong and alive.) However, for pain that is chronic and/or severe, emotional and cognitive reactions are commonly negative. Acute responses to pain typically include frustration, anxiety, and a sense of loss of control. Longer-term emotional responses to pain may include chronic feelings of fatigue, depression, and worry, as well as the negative psychological effects of the limitations that pain places on an individual’s ability to perform valued activities. Perhaps because these outcomes are undesirable, the cognitive/ emotional aspects of pain are often referred to as pain-related suffering . Although the phrase “pain and suffering” is common in legal parlance, the two concepts are quite distinct in pain research. Suffering refers to a person’s emotional response to pain, both in the short and long term. A more extensive review of emotional and cognitive responses to pain is presented later Pain behavior includes a broad range of actions taken by an individual in pain to communicate its presence, avoid further discomfort, or alleviate it. Immediate pain behavior includes verbalizations (groaning or saying “ouch!”), facial expressions (wincing, grimacing), and motor behaviors (rubbing the site in this course. Pain behavior Acute versus chronic pain For many years, researchers and clinicians have attempted to make a clear distinction between acute and chronic pain. Traditionally, the difference has been tied to the duration of the pain experience, with chronic pain defined as pain that either persists longer than 3 or 6 months from onset (these being the two most commonly used time frames) or that “persists past normal healing time” (American Cancer Society 2019; Hopkins Medicine 2021). Unfortunately, no consensus exists among pain experts, and neither of these definitions takes into account degenerative processes (e.g., osteoarthritis) that may represent a kind of constant injury. A proposed method for differentiating acute and chronic pain includes two dimensions: time (pain duration) and underlying physical pathology (diagnostic clarity). From this perspective, individuals with low physical pathology (i.e., no clear anatomical or medical explanation for pain) and/or long pain duration are considered to have chronic pain, and those with short duration or high levels of physical pathology are said to have acute pain. This model is depicted in Figure 2.
of injury or rocking back and forth). However, human beings are social animals, and pain behaviors may also include more complex activities, ranging from social withdrawal and isolation to seeking out others for help or reassurance. Environmental reactions Environmental reactions to pain include changes that others make in response to pain behaviors. The immediate social environment changes in response to pain in a variety of ways. For example, a family member might take on the household responsibilities of the pain sufferer or provide more reassurance and comfort. On the other hand, a family member may become frustrated with the intractability of chronic pain and as a result become more stern or confrontational with the pain sufferer. Social reactions and their consequences are discussed in detail later in this course. Impairment/disability Although the two terms are often used interchangeably, impairment and disability are related but separate constructs. Impairment refers to any loss or abnormality of psychological, physical, or anatomical structure or function. This is a medical, organ-based concept. On the other hand, disability refers to a restriction or lack of ability to perform an activity within the range considered normal for someone of a particular age. Impairment is physically based, and disability is task based. Two people with exactly the same degree of injury (that is, impairment) may demonstrate very different levels of disability. For example, a dentist who loses a finger will be very differently disabled compared with a bank manager who loses her finger. The first person will likely be unable to continue her job (i.e., she will be partly disabled), whereas the second person will likely be able to perform her job with limited modifications. The same is true of pain; varying levels of disability may result from similar levels of impairment. Sociopolitical context Individual pain and related concepts such as disability do not inhabit a vacuum, but exist within broader social and political contexts. An appreciation of chronic pain, therefore, must also include an understanding of societal factors (such as social stigma around pain and disability and cultural beliefs about pain and how it should be managed), as well as political realities for the pain sufferer (for example, the amount of funding at the state and federal level for pain treatment or financial support, the existence of workers’ compensation programs for those injured on the job, or federal legislation such as the Americans with Disabilities Act).
Figure 2: Acute Versus Chronic Pain
Note. Based on data from Flor & Turk, 2011.
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