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Biology 202
2002 Second Paper
On Serendip

Pain: Understanding the Subjective, Objectively

Gavin Imperato

Pain is a universal element of the human experience. Everyone, at some point in their lives, experiences pain in one form or another. Pain has numerous causes, effects, and is itself a highly complex biological phenomenon. It also carries with it important emotional and social concerns. Pain cannot be entirely understood within the context of any one field of scientific inquiry. Indeed, it must be examined across a range of disciplines, and furthermore considered in relation to important non-scientific influences, such as emotional responses and social determinants. I conducted my explorations regarding pain with the following question in mind: to what degree is pain subjective? I found several avenues of inquiry to be useful in my explorations: they are (1) the expanding specialty in the medical profession of pain management; (2) pain in individuals with spinal cord injuries (SCIs) and (3) pain experiences of children. Examining these issues led to the conclusion that pain is in fact a highly subjective phenomenon.

"The philosophy that you have to learn to live with pain is one that I will never understand or advocate," says Dr. W. David Leak, Chairman & CEO of Pain Net, Inc. (1). Indeed, the notion that pain is an essential element of life, and that one must endure pain to achieve something positive (as conveyed in the omnipresent athletic mantra "no pain, no gain") has informed our sense as a society of how pain is to be dealt with. Only recently, with increasing awareness in the health care community that managing a patient's pain is a complex, yet crucial aspect of their care, has society's view of pain and its management begun to change. "Pain Management" is itself a neologism, and the establishment of pain management as a legitimate sub-specialty in the medical profession has no doubt encouraged people previously untreated for serious pain to obtain medical treatment. The existence of pain management clinics and services has altered the greater social understanding of pain from one that posited it as an imperative, to one that posits it as an unnecessary and entirely treatable condition. It is conceivable that formerly, when individuals did not have access to such services, that they conditioned themselves to make their pain less of an issue. Most people have had the experience of being required to actively control their pain, and therefore we can conclude that pain is heavily influenced by such social factors. These factors are almost impossible to understand in any objective sense, but to objectively understand pain, we must realize that they contribute to the notion of pain as a subjective phenomenon:
Pain is not just a physical issue, but effects all aspect of you physical and mental health. Despite centuries of trying to separate mind and body, treatment of chronic pain forces us to admit this can't be done. We will never say your pain is in your head but thoughts and emotion are related to pain. We call this the pain/stress/depression cycle. Biofeedback can give us the opportunity to interfere throughout this cycle. The more places and ways we can interfere with the pain- stress cycle, the more likely we are able to be of lasting help (2).

The recent recognition that pain is a complex entity that is affected by issues such as stress and depression is a recent one. Along with this recognition has come the implication that a satisfactory definition of pain must include what are inherently definition-resistant quantities. How can one scientifically define emotions and stress? That pain encompasses a variety of such issues requires that it be established as a subjective phenomenon.

An examination how pain affects children is also useful in establishing its subjectivity. Evidence suggests that experiences with pain, especially during childhood, are crucial in affecting an individual's subsequent experiences with pain. Indeed, it is recognized that differing levels in individual pain tolerance can be affected by differences in what people have learned about how to respond to pain:
A child's age, past experience with pain, and family and cultural styles, McGrath said, influences his or her response to new, painful situations. Parents serve as models. Young children often fall down, she observed, and then look at a parent for cues on how to react. In general, the younger the child, the greater his or her overt distress, and the more the child has to be physically restrained, she said, the more painful the experience will be (3).

As this excerpt illustrates, pain also has a significant component of learned experience. Individuals exhibit different levels of tolerance to a controlled application of physical pain. If two people touch a hot bowl, they will not necessarily react in the same manner to the apparent discomfort. These reactions may be attributable to how children develop differing thresholds, boundaries, and levels of tolerance of pain via interaction with other people during formative experiences with pain. If pain were an entirely objective phenomenon, the dynamics of these interactions would have no effect on the child's subsequent understandings of exactly what pain is: "Pain is always subjective. Each individual learns the application of the word through experiences related to injury in early life" (4). Interaction with the environment can indeed alter an individual's conception of what they find to be "painful." Therefore, there is no way to objectively determine parameters for what is painful and what is not. The effect of experiences with pain during formative years is thus another way of establishing the subjectivity of pain.

A third manifestation of the subjectivity of pain lies in the experiences of individuals with spinal cord injuries (SCIs). Such injuries have an objective and clinically demonstrable effect on a patient's ability to feel and to sense stimuli. However, this does not mean that individuals with spinal cord injury that renders a part of their body "senseless" do not feel pain in these regions: "In fact, a number of people with SCI experience chronic pain in areas that otherwise have no sensation" (5). By objective medical criteria, patients in such a condition should in fact not be experiencing pain. The reality is that the biological process of pain is something that cannot be entirely understood by the shortsighted idea that pain cannot exist when there it has no apparent physical cause. Pain is more than the sum of the biological interactions that would purport to explain it. Here again the importance of the emotional and psychological aspects of pain can be seen, necessitating the establishment of pain as subjective.

What then, makes us resistant to the idea that pain is subjective? Part of the answer to this question lies in the fact that a good deal of pain has a concrete neurophysiological basis. Indeed, there are a number of scientific measures that can serve as clear indicators of the presence of conditions that are known to induce pain. Imaging studies that reveal tissue or nerve damage are an example of such indicators. Indeed, even less technological methods of assessment can still conclude what exactly is at the root of someone's pain. If a person has injured their knee, it is common for them to be asked to describe the pain they are feeling. Dull pain, sharp shooting pain, pain that waxes and wanes - these different types of pain are each indicators that can be helpful in determining the exact nature of the person's injury. However, one must resist this tendency to view pain as a simple phenomenon with a clear-cut cause/effect duality as there are other factors that must be taken into consideration. An examination of the emergence of the field of pain management, pain in individuals with spinal cord injuries (SCIs), and the dynamic of the childhood experience with pain provides evidence that the emotional, psychological, and social aspects of pain require that it be considered a subjective phenomenon.


References


1)Pain Net, Inc., an organization that provides educational and support services to physicians, and other health care professionals throughout the nation.

2)American Academy of Pain Management.

3)"Children and Pain," from the National Institutes of Health.

4)International Association for the Study of Pain.

5)University of Washington Medical School Department of Rehabilitation Medicine.


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