Making a definition of pain work for us

With our new proposal, we are not, emphatically NOT, suggesting that we have arrived at the ideal definition of pain. A definition needs to work for clinical and experimental pain, for humans and for other animals, for excruciating and for trivial pain. It needs to distinguish pain from all other sources of distress, from specific anxieties to existential angst or profound grief.

What we hoped we could do with our Topical Review in Pain [1] – and my co-author, Kenneth Craig, has approved this piece for Body in Mind – was to invite (provoke?) a discussion about updating the IASP definition, and to get clinicians and researchers with expertise in all these areas, and more, to pile in and add their ideas. Out of this, we hope, will come a revised definition that works better.

The existing definition (see below) has been rendered out of date by the very research that it has helped to foster. We have both cited the existing definition, in papers and in teaching, more times than we could possibly count, and have done so because it has served very well. But it does have flaws and gaps that are increasing with age.

What are they?

  • Cognitive and social effects are increasingly evident not only in humans but in, for example, rodents [2,3]; these effects have hardly been addressed in other animals but behavioural changes observed across species [4,5] lead us to expect to find them.
  • The emphasis on subjective report was very important, but so is behaviour, and defining pain in exclusively subjective terms makes it hard to apply to non-human animals.
  • We were concerned to represent the profoundly aversive nature of much clinical pain with a stronger term than “unpleasant” to capture the motivational elements, but of course much experimental pain and some procedural clinical pains (a routine immunisation in an adult, for instance) are mild in intensity, unthreatening because voluntarily undertaken, and quickly forgotten.

Adding cognitive and social components to the definition was straightforward, and we have had some encouragingly enthusiastic feedback about this. Those components, of course, may find behavioural expression, but the definition does not seem the place for attempts to encompass these behaviours in general terms. However, they are important and should be elaborated in a revised note.

The existing accompanying note (who reads this?) is important because it refers to the need to assess pain in people unable to provide self-report [6], such as infants and babies and people of any age with cognitive impairment. But it includes several statements that complicate or contradict the main definition (such as “Many people report pain in the absence of tissue damage or any likely pathophysiological cause; usually this happens for psychological reasons”(!)), and these need to be deleted.

So far, responses to our topical review have tended to raise philosophical issues around definition (which should make clear the way in which the construct defined is unique) and description (which is often an elaboration of the definition but without the requirement that it differentiates the construct from everything else). While this is important, we hope to generate discussion about how the definition is used, and how it could better meet users’ requirements. The existing IASP definition is very widely cited in the animal welfare literature and in debates about animals feeling pain; arguably, a more behavioural and less subjective definition would serve this important field better.

We also hope that we can engage those outside the fields of pain research and treatment. There is still widespread misunderstanding of pain. Patients are often wary of talking about the emotional impact of pain in medical consultations, or being referred to anyone whose profession starts with psych. Educated people frequently ask if by pain I mean “real/physical pain” or “emotional pain”. How can we build a definition that helps people to think in an integrated way about mind and body, rather than to start with this profoundly unhelpful and false dichotomy?

And did we mention that our definition is intended for discussion, revision, and improvement? We do not believe that we have yet found the perfect wording.

About Amanda C de C Williams

Dr Amanda WilliamsAmanda is an academic and clinical psychologist who has specialised in pain for thirty years. She works mainly at University College London researching and teaching; she also works with clinicians in the UCL Hospitals pain team, and in human rights. She is getting rather old and impatient with the rate of change of some ideas in the pain world, so she thought it was time to tackle the definition of pain.

Pain definition

An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.

Note: The inability to communicate verbally does not negate the possibility that an individual is experiencing pain and is in need of appropriate pain-relieving treatment. Pain is always subjective. Each individual learns the application of the word through experiences related to injury in early life. Biologists recognize that those stimuli which cause pain are liable to damage tissue. Accordingly, pain is that experience we associate with actual or potential tissue damage. It is unquestionably a sensation in a part or parts of the body, but it is also always unpleasant and therefore also an emotional experience. Experiences which resemble pain but are not unpleasant, e.g., pricking, should not be called pain. Unpleasant abnormal experiences (dysesthesias) may also be pain but are not necessarily so because, subjectively, they may not have the usual sensory qualities of pain. Many people report pain in the absence of tissue damage or any likely pathophysiological cause; usually this happens for psychological reasons. There is usually no way to distinguish their experience from that due to tissue damage if we take the subjective report. If they regard their experience as pain, and if they report it in the same ways as pain caused by tissue damage, it should be accepted as pain. This definition avoids tying pain to the stimulus. Activity induced in the nociceptor and nociceptive pathways by a noxious stimulus is not pain, which is always a psychological state, even though we may well appreciate that pain most often has a proximate physical cause.

As updated from “Part III: Pain Terms, A Current List with Definitions and Notes on Usage” (pp 209-214) Classification of Chronic Pain, Second Edition, IASP Task Force on Taxonomy, edited by H. Merskey and N. Bogduk, IASP Press, Seattle, ©1994.  http://www.iasp-pain.org/Taxonomy#Pain

References

[1] Williams ACdeC, Craig KD. Updating the definition of pain. Pain 2016;157:2520-3.

[2] Mogil JS. The social modulation of and by pain in humans and rodents. Pain 2015;156(Suppl. 1):S35-41.

[3] Low LA. The impact of pain upon cognition: what have rodent studies told us? Pain 2013;154:2603-5.

[4] Walters ET. Injury-related behavior and neuronal plasticity: an evolutionary perspective on sensitization, hyperalgesia and analgesia. Int Rev Neurobiol 1994;36:325-427.

[5] Williams ACdeC. What can evolutionary theory tell us about chronic pain? Pain 2016;157(4):788-90. doi:10.1097/j.pain.0000000000000464

[6] Anand KJS, Craig KD. New perspectives on the definition of pain. Pain 1996;67:3-6.

Commissioning Editor: Lorimer Moseley;  Associate Editor: Adrian Traeger

Comments

  1. Gerry Daly says:

    Sorry, and disappointed, to see that these comment forums are about to be closed. I sincerely hope that I’m not implicated in the cause of that, but suspect that may be part of it. Just to say, I’ve found this forum to be informative, and challenging, and I will regret its demise.

    respectfully

    BiM Reply:

    Thanks Gerry, we are sorry to see the comments go too but I hope you will continue to enjoy the blog posts!

  2. Gerry Daly says:

    On a definition for pain, I think it’s relatively easy to put a definition on acute pain which could resonate across the board. It’s almost self-defining, in that it comes with obvious limitations and boundaries which are generally understood by all. And it is transient and self resolving…which means there is little conscious resistance to accepting it even when the meaning of its purpose or the origin of it’s initiation might be unknown. It is also fairly easy to empathise or sympathise with another person’s acute experiences , because we may have had similar experiences, and we can imaginatively proxy our experience onto the other person. It’s almost a shared experience, but not always. And it is almost always capable of being proxied for reasons of arriving at a shared understanding.

    With chronic issues, that template for judgement is not appropriate. As someone with a particular chronic issue, even I find it almost impossible to proxy an understanding about someone else’s chronic condition, unless I am familiar with a subjective experience of that condition myself. That really restricts my understanding, empathy and sympathy to my own condition, only. Of course I can do my best to understand the complexities, but I can only ever achieve ‘partial sharing’….and if that partial sharing already comes with certain pre-prejudices, I’m really not going to get very far. For instance, no matter how many times it might be described to me what it’s like to be hit by a bus on the street, I simply can’t imaginatively recreate the entire experience as bit might really happen. We seem to have an inbuilt conscious resistance to even thinking about such matters. That may be one reason why people suffering from grief at the death of a close relative are exposed to such horrendous thoughts….they are suddenly confronted with having to imagine what it might really be like. The established empathy draws them into a sense of reality they would normally avoid.

    So, let’s just say that, with chronic pain, we have a tendency to not share, and that may be as true for patients, as for professionals, as for neutrals. Is it even possible to share another’s chronic pain experience without inducing grieving at the same time ? I think there is always a powerful conscious resistance to sharing if it comes with an emotional price tag….and that is something which any chronic pain assessor would want to avoid. Perhaps it’s even a lot less threatening if the presented chronic condition is assumed to be exaggerated, or imagined, or even that it results from a conscious perception initiated by faulty habitualisation on the patient’s part. Such assumptions might protect the professional from ‘full sharing’, but they might also lead to faulty assessments…..unfortunately.

    In short, chronic pain seems destined to always come up against protective resistant thinking from all parties, including patients when they consider their own condition. As such, a neutral appraisal gets complicated, and becomes open to all sorts of opinion. That’s probably understandable because of the emotional crossover possibilities, but at the same time…..is it really the kind of approach that is likely to prove beneficial ?

  3. ’Where is the great innovator who is prepared to risk their reputation with novel approaches which might result in putting the doubts to rest’

    Good question. It’s a huge risk. Enormous. I often think of artists who pour years of dedicated work into a masterpiece, and the day comes when they unveil it for the World to see. Their whole identity is in that work…. and it’s open not only to constructive criticism, but mud slinging.

    I’ve spoken to a few exceptional healers, and they have a common message. “Be prepared to handle the trauma of having your work trashed because people feel threatened by the results, they don’t like you personally, or it undermines their authority”.

    There’s a neurosurgeon in Sydney called Charlie Teo. Read his story. He criticized the establishment. He chose to treat conditions which were deemed “impossible” by the old school, self-interested surgical hierarchy. He could do what they couldn’t and was pretty vocal about it. He paid a VERY heavy price for this. Physio and medicine is the same. Innovators need to be careful.

  4. Gerry Daly says:

    I see acute pain issues as being intuitively self-explantory, mostly. The patient requires only minimal explanation, and there is a re-assuring expectation of healing which makes everything so much more tolerable. The problem lies in chronic pain conditions where many treatments have been found wanting due to confused understandings of the dynamics involved. I would even go so far as to say that there’s a reluctance to embrace more enlightened approach perspectives because doing so obviously implies a criticism on the previous failing treatments. Nobody wants to have to carry the realisation that treatments may not have been appropriate…..unless , of course, it only refers to medical history in the distant past, in which case it is absolutely fine to pay homage to Lister or Pasteur etc without even accepting that , despite more recent advances, there are still areas which require re-appraisal in a similar complete change of approach manner….chronic pain being a typical example. I’m aware that there are doubts and disputes about chronic pain within the profession, but I am also continually asking myself…’Where is the great innovator who is prepared to risk their reputation with novel approaches which might result in putting the doubts to rest’. As a ‘patient’, I think I deserve more credit for my ‘patience’ !

  5. “At the same time, patients are vulnerable and desperate for solutions, so they often overlook their own best interests in the hope of solving a pain problem”.

    Happens all the time. ‘Resistance to change’ is a fascinating topic. Whenever I observe such resistance operating in myself, I try to recognize that it is a way of avoiding the consequences and flow-on effects which accompany the change. It’s hard because the resistance is almost always unconscious.

  6. Gerry Daly says:

    So, what’s the point in having a definition of something when even the experts are in disagreement about a generally accepted definition ?

    I looked up the legal definition of pain, and discovered it’s actually quite straightforward and relatively unambiguous. However, it does require validation by an ‘expert witness’, who, as we all know, under current badly defined conditions, could have their own personal interpretation of the meaning of pain…..a neurologist and a dentist might have different understandings of what pain might be. So, although the legal definition seems relatively simple to understand, without going into too much detail about varying interpretations……the process of arriving at an accepted meaning for pain before a judge and jury is still vulnerable to ‘expert’ disagreement. In a way, that reflects the lack of certainty and agreement already existing within the professional institutions that surrounds the question of having a definition which all are obliged to honour. I’m sure there are many pain treating practices which could be stopped from operating if they had to first agree an obligation to a standard , legally binding, definition of pain….patients currently have little legal recourse to redress for maltreatment if they have volunteered to partake in certain treatments. At the same time, patients are vulnerable and desperate for solutions, so they often overlook their own best interests in the hope of solving a pain problem. It’s all pretty much loaded against the patient in those circumstances.
    This is an area where a good pain definition, devised by both lay and professionals, could have a beneficial impact. And perhaps also, why it would be wise to include lay opinion in the construct of such a definition. It’s such a big global issue that really it requires an independent international committee to establish an acceptable definition for pain which covers all aspects, and protects both lay and professionals from the repercussions of possible misunderstandings. Without an accepted legal definition, it’s open season for anyone to try their luck.

  7. Gerry Daly says:

    I suppose the bit that concerns me most about a definition of pain composed in the hallowed halls of the profession , is that such an enterprise can sometimes be read as an excuse, or as a diminishing of responsibility, for some pain conditions where clarity in definition has been found wanting. For instance, with some chronic pain conditions, particularly perhaps those with possible neurological causes, there has been inferred suggestion that the patient might be psychologically implicit in the continuation of their complaint. Have to say I find such suggestions outrageous, and yet there is a growing acceptance in the profession that it might be so. To me, that just looks like the profession is protecting itself from criticism by means of manipulated ‘pain theory’. It is important to rise above any biased agendas of that nature, to ensure that the finished definition excuses nothing…..even if it doesn’t quite tell us everything we need to know about pain, at least it should open doors to further investigation.

    The goal is to have a definition which can be rationalised by everyone, not just by those who might feel threatened by a definition which exposes failures in some areas….particularly in the area of chronic pain.

    Gerry Daly Reply:

    PS……………..Edit

    For ‘psychologically implicit’…delete ‘implicit’….insert ‘complicit’.
    Sorry.

  8. Michael Ward says:

    Lots of interesting perspectives and points made – who is the definition for? a very valid directing question.

    I have not had a patient who has asked what is thing called that is unpleasant.

    We desire a definition so that we can explain what we want to the patient, something that might provide a launch pad for discussion and also carries weight cos it comes from an august panel of experts. but I also think that the definition should be simple and as applicable to as many species as can be. Pain in humans might have additional dimensions to it as well as sequelae and this aspect can remain our educational launch pad.

  9. Gerry So with all those words would it be fair to suggest you have beautify described Pain – should medical science make Pain any more complicated than that.

    Kindest regards and best wishes

    Peter Smith Talking Cures

  10. Gerry Daly says:

    Just by way of swinging the discussion back to the intention of the opening article……..when I think of a possible definition for pain which might get everyone on the same page, I tend to just focus on two issues.
    Firstly, there’s the initial conscious perception of pain, which includes an instant awareness of discomfort (pain) sensations at a local site in the body. I am less concerned with how that initial perception pans out consciously, because once initially perceived, it then becomes vulnerable to other conscious influences…and that tends to cause a distraction from the primary coming into existence of the initial perception.
    And secondly, I tend to ask two questions….’What could be the possible cause, and what could be the possible purpose, of that initial perception ?’ Most, if not all, conscious perceptions seem to require some sensory input in order for a perception to materialize. So, what might be the sensory input which inspires a pain perception to suddenly appear. An unexplained sudden appearance of a conscious pain perception doesn’t explain anything, except the fact that it might be inexplicable ! Regarding purpose, I think there is usually nothing that happens on conscious perceptive level which doesn’t have a specific purpose….usually a ‘protective’ purpose of some nature. Such a purpose for pain perceptions can possibly be defined by the reactive responses which the perception inspires….if some reaction happens generally, then it can be assumed that the perception was intended to cause such reactions. That puts a purpose to the event.
    So, in any definition of pain, I think both these issues need to be explained, or at least be visibly excused from explanation because of our uncertainties. And, from there, any definition can proceed towards greater detail about standard effects, standard expectations etc. In other words, a recognition of our inability to agree about the cause and purpose of pain perceptions might be the best definition of pain that can be put forward at this time. That would be a true reflection of the science, and it would inspire more intensive investigations.

  11. Once the word gets out that these sort of changes are possible, the patient population will start to demand it. Big Pharma may get quite a shock and pain practices will close UNLESS they adapt.

    Have a look from 18:48 min ff, where he does quite a few back pain treatments. I know this is real because I do it myself (minus the Jesus refs which are unnecessary).

    https://www.youtube [dotcom] /watch?v=Rjli_SFyz0M

    replace [dotcom with .com].

    Consider what this means when an untrained person can better results than most professionals. This is called “disruptive technology” and the scale is potentially enormous.

    John Quintner Reply:

    EG, now all has been revealed. I followed your lead and this is part of what I found: “Tom (i.e. Thomas Fischer) has ministered to thousands who were healed of cancer, tumours, hepatitis, diabetes, arthritis, paralysis, irregular heartbeat, cysts, epilepsy, multiple sclerosis, various pregnancy issues, sight and hearing issues. He has seen all forms of pain leave. He has also seen and felt bones move, dental cavities fill themselves and a breached baby turn over, as order is once again restored within the body in Jesus name. Additionally, Tom is actively involved in deliverance work, casting demons out of the lives of the afflicted.”

    Mirabile dictu!

    http://www.lasplash.com/publish/LifesJourney/cat_index_grown_up_years/living-the-miraculous.php

  12. I’ve also always wondered about whether a description of persistent pain might be something more like this … (I know that much of the wording needs more precision. And maybe this is the wrong approach, however having discussions about what works and doesn’t for this process of creating a definition is the best way to come to resolution.

    The problems of persistent pain arise from the organism’s protective systems, in which the experience of pain motivates the individual to consciously perform protective actions intended to decrease the pain, but that ultimately limit recovery, and in which the automatic responses of the organism also limit recovery.

    Gerry Daly Reply:

    Just an observation on terms of reference….persistent v chronic. I think the introduction of ‘persistent pain’ as a euphemism for chronic pain, has done a terrible injustice to our understanding of chronic pain. Each term has a different meaning, and that has influenced our understanding of chronic pain in a way which suggests that it might not be ‘chronic’. I fully understand the intentions to soften up our overview of ‘chronic’, but, unfortunately, it’s misleading. Persistent usually means something which was expected to resolve, but hasn’t, and it continues despite expectations. Chronic means something which has had no expectation of resolving, and it continues to have no expectations of resolving. So, totally different meanings, and yet the terms are more and more being accepted as interchangeable. That imposed misunderstanding needs fixing, so that everybody understands the common terminology. It may seem pedantic to question the terminology, but if ‘persistent’ is causing some to have a less than full appreciation of what ‘chronic’ actually means….well, maybe you can see why I might want to make a bit of a noise about it. It’s important if someone has a chronic condition, and someone else is insisting it’s a ‘persistent condition’. There really should be no problem with using ‘chronic’ as a term….it simply means ‘something which continues over an unknown time frame’, which is exactly how a chronic condition behaves.

    EG Reply:

    Yes, it’s hard to consider what a good definition might look like without also studying existing solutions. Because if solutions exist, then then through reverse engineering, the problem can be known with much more certainty.

    I’ve said many times before, that if we want to understand how to hit a golf ball, we shouldn’t be recruiting weekend hackers and putting them in a lab… instead, we should be observing Gary Player in his natural environment. In other words, start with the solution and reverse engineer the process using intuitive reasoning. The intuitive reasoning then leads to rigorous scientific testing of emerging hypotheses.

    Charlie Goldsmith and Bill Bengston would both qualify as expert healers, imo. It’s just too easy to say “oh yeh they are charismatic… patients love them”. It goes well beyond that. Bill has no charisma and his patients are rats! 🙂

  13. And let’s not forget those who have studied the subject of suffering through to completion, many thousands of years ago. Reinventing wheels isn’t cool.

    http://viewonbuddhism.org/4_noble_truths.html

  14. Neil, I feel a bit the same way. Having a ‘perfect fit’ definition of pain will be of no help to patients in the short term. However I think there is very large benefit to be gained in the medium-long term, for both practitioners and patients.

    IMO, the only addition that needs to be made the current popular definition is the inclusion of the self-image. It changes everything in a very substantial way. I’ll keep it brief, but in regards to the self-image, we have two choices.

    1– Improve it, by acting through one’s own core desires, without fear of disapproval… or

    2– Transcend it, through spiritual practices

    In regards to the first approach, there are groups who encourage a “do what makes you feel good” lifestyle. That’s irresponsible. Consider what happens when ‘doing what feels good’ equates to drinking excessively, driving at speed, snorting cocaine or gambling, for example. If it is to work at all, the first approach must have very strict caveats:

    – the desire must be a core desire, not a secondary one
    – acting on that desire must not hurt yourself or anyone else

    To be able to access core desires is extremely hard work, because you have to trick your own brain! Essentially you have to know what it is you’d do if approval, status, admiration and reward were not part of the equation. The egoic mind is so fixated on approval and reward that considering activity just for its own sake, is quite foreign. But that’s where self-esteem lies. And with self-esteem comes pain relief. Contrast this with pleasure-seeking and reward-based activity which at best offers a dirty, short-lived high (and matching, short-lived pain relief).

    Neil Pearson Reply:

    EG … thanks for the thoughts, of which the most important responses I have are these
    – if one is to consider body image, it is difficult to do this without including body awareness. But then the word awareness has not been defined well yet either (it of course is another experience). there is substantial research showing distortions of ability to perceive the body and of body image. I don’t know that they are more important than others, but I do know they are important to have some assessment, and definitely specific consideration during treatment when pain persists.
    – transcending things – there are a many people trying to do just his in some traditions. Within yoga we see how this can lead to injury and pain – in some. Maybe their approach isn’t right …? The WAWADIA project by Matthew Remski is taking a close look at this.

  15. This may be something that has already be considered, but in case … 1. Can you start with why we need a definition of pain? The purpose the definition will serve might assist with some of the posed questions about how to create this definition. I understand that the current definition has many limitations, and wonder if the changes are intending to create a situation in which the definition people use will more closely align with our current views about pain. Will the new definition be more useful to the person in pain, the health agencies, the health professionals, … ? (and can one definition be useful for all who use it?)

    2. Would it help to look at how we have attempted to define other human experiences? Or is it that we attempt to describe other (troublesome) experiences rather than define them? and is it possible to ‘define’ an experience when by its nature it can not be measured except by an individual’s report of their experience?
    Maybe looking at what has been written and discussed about love might help in this process. Yet this all would need to circle back to what is the purpose of creating this definition, and is a definition really required?
    My belief is that whether it is a definition or description, all the changes suggested in this thread are important to consider. And I will add one more based on the following experience – Patients have asked me something so many times over many years of working in pain management and teaching them about pain physiology that it seems very important. I am a PT, so I hear this, “Do any of these changes that can occur in the pain system when one experiences chronic pain from a tissue injury also happen in emotional pain/grieving/spiritual turmoil/PTSD.” There are commonalities in pain regardless of the origin to which we attribute it. There are also commonalities in successful treatment of suffering regardless of our diagnosis. There will be differences, just as there must be differences in how the brain and the organism respond to a social versus a spiritual versus a physical threat. This new ‘definition’ could make this apparent and understood.

  16. Gerry Daly says:

    It’s probably inevitable that ‘linear’ pain, arising from obvious tissue damage/infection/disease , and ‘non-linear’ pain with disputed origins ( such as neurological referred, phantom limb etc etc ), can ever be accommodated within a single definition without lessening the potential impact of the definition. The vast majority of pain experiences are ‘linear’, i.e…. directly related to tissue damage/infection/disease,…. and that demands that any overview definition must concern itself with that aspect first. Perhaps a caveat to the definition could be added, to help explain what we currently understand to be exceptions to the rule….and that would lessen the prospect of contradiction within the definition itself.

    Also, with regard to a definition that might apply to pain across the entire animal kingdom, perhaps a statement like……’ Pain perceptions, with any animal, including human, are entirely dependent on the conscious perceptive ability of that animal…thus the greater the conscious perceptive ability, the greater the pain experience’. Or some such.

    John Quintner Reply:

    Gerry, your pain descriptors “linear” and “non-linear” are new to me but seem similar to the those put forward by the American Academy of Pain Medicine, “eudynia” (good pain) and “maldynia” (bad pain). We found that this proposition had the potential to stigmatise a large group of people in chronic pain [1].

    But your own descriptors also hark back to the days when it was believed that the nervous system was “hard-wired”. We now know that this is not the case. The current IASP definition does make this quite clear.

    Reference:
    [1] Quintner JL, Buchanan D, Cohen ML. Maldynia as a moral judgment [letter]. Pain Medicine 2011; 12: 1130.

    Gerry Daly Reply:

    By ‘linear’ I mean directly related to, or obviously related to, tissue damage/infection/disease….and non-linear to mean indirectly related (referred, radiated mimicked, etc) to an either identified or unidentified source. I would tend to separate both linear and non-linear from pain resulting from other ’emergent’ influences such as memory, or assumed threat, simply because treatments are likely to differ. Yes, that might cause a disparity with evaluations, but for me, that comes with the territory….different classes of pain are not equal by nature….they each come with their own sense of urgency.

    I’m also aware of the ‘hard-wired’ issue, and how the thinking has moved on beyond that overview. However, in terms of the new thinking resonating with the subjective pain experience, I think there’s a problem, and some compromise is required to accommodate and satisfy both perspectives. Most people are pretty much locked into the ‘hard wired’ model regardless of more enlightened explorations within the profession….perhaps it’s up to the profession to prove the new theories produce better outcomes, before completely displacing older perspectives. Our understandings are in transition, until we achieve a formula which suits all, and proposed definitions should reflect that. Compromises, of course, will probably end up satisfying no-one, but, isn’t that a truer reflection of the current state of affairs, rather than pushing for a more precise definition that might only satisfy one school of thought ? For instance, a patient might have little problems with the Cartesian model, whereas they might consider their intuitive sense of their condition being challenged by the newer pain theories. For me, that risks damaging the ‘trust bond’ between patients and operators.
    A transitional compromised definition of pain might be the best thing for opening the matter up for wider discussion. There really shouldn’t be an issue with the profession admitting it has hit a bit of an impasse, and reaching out for new ideas.

  17. John Quintner says:

    Amanda, we welcome the opportunity to respond to your proposal. We applaud your initiative and share your impatience with the slow rate of change of some ideas in the pain world.

    Here are our comments for further discussion:

    1. If by “us,” you include clinicians and people experiencing pain, then any proposed definition needs to embrace “intersubjectivity”. Neither the IASP definition nor the one that you and Ken Craig propose fulfils this criterion.

    2. We presume that, by requiring a definition to “work”, you are asking that it have broad utility?

    In our opinion, no single definition will embrace the many and varied contexts of “clinical and experimental pain, for humans and for other animals, for excruciating and for trivial pain” and be able to “distinguish pain from all other sources of distress, from specific anxieties to existential angst or profound grief.”

    3. If a definition of pain is to be extended to other animals, then it has to be grounded in terms of the shared biology of response to existential stressors.

    4. The IASP definition (i.e. “sensory and emotional experience”) is intended to apply to humans only. Your proposed definition falls into the same category.

    By introducing behaviour to the (subjective) definition, you risk falling into the trap of separating mind from body, which you have rightly referred to as a false dichotomy.

    5. We agree that “unpleasant” does not capture the aversive motivational elements of the pain experience.

    6. One point that has not been discussed is the linking of the experience to “tissue damage” or the “threat thereof”. In our opinion, this linkage is clumsy and has the potential to disenfranchise those experiencing pain without evidence of discernible tissue damage.

    7. Adding “cognitive” and “social” components not only sacrifices the parsimony of a definition but also attempts to capture in it a conceptual framework that itself requires elaboration.

    We agree with that the IASP definition can be improved and hope that our comments will stimulate further discussion to this end.

    David Buchanan
    Milton Cohen
    Melanie Galbraith
    John Quintner
    Simon Van Rysewyk

  18. Michael Ward says:

    Maybe science has no business in defining a word of common usage. It cannot take for itself what was not it’s in the first place. Maybe if science wants a definition suitable for itself it should construct a word that meets its need but is translatable to the ‘pain’ of common usage – perhaps dolor but if not….
    I think a definition should incorporate the concept of balance of processes (maybe better than ‘sum’). Perhaps (the threat of actual or potential…) but this maybe associated with fear
    The sum unpleasant experience associated with actual or potential tissue damage or conceptualized/ experienced in that context.

    Gerry Daly Reply:

    That’s interesting. The very word itself….. pain, comes with such baggage that it manages to disguise its own meaning. Perhaps a new term of reference would wipe the slate clean, and allow a fresh approach. “Demanding Conscious and Physical Discomfort’ is just the first thing that springs to mind for me, but it would be interesting to see if a change of terminology would help to pinpoint what we all assume to be the common, but much disputed, meaning of ‘pain’. Let’s assume, for a moment, that the earth orbits the sun, and thus allow the resulting relationships to become ‘self-explanatory’ ! It really is remarkable that, in the 21st century, we don’t have a formula for pain which works for all circumstances. Not for want of trying, though !

  19. Dear Barry

    Now there is a response that warms the cockles of the Minds Heart.

    Are we already on a Dawn of new understandings – that is but one Pain and that falls into Two Sub Sets.

    1. Pain that self repairs.
    2. Pain that never repairs because it is as you so eloquently say – it is not in the Body at all and never was.

    There but one exception. Pain caused by an impact – there for the briefest of seconds and then for ever stored in the Mind as a Memory.

    Kindest regards and best wishes.

    Peter Smith Talking Cures

  20. Brian Griffiths says:

    I am puzzled by Dr. Williams question “How can we build a definition that helps people to think in an integrated way about mind and body rather than start with this profoundly unhelpful and false dichotomy?”
    I would have thought that those who ponder upon pain are confronted most acutely with the mind body dichotomy. Pain is an experience of a conscious person; a mind phenomenon. The brain (i.e. the body), does not feel pain; the person does. There may be occasions when it is helpful for the pain sufferer to be informed of the distinction between what is going on in her body and what she is experiencing (mind, psychological, phenomenon). However one deals with it the mind body issue, or if one prefers, the brain consciousness issue, confronting that issue is inescapable. It is currently the most challenging problem in the philosophy of mind.
    This is something of an aside. Nothing of any importance in Dr William’s interesting article hinges on this matter, but one really ought not dismiss the mind body distinction as if it is of little significance.

  21. Gerry Daly says:

    I think the opening article was referring more to a ‘generalised’ acceptable definition for pain, rather than something which includes individual interpretations of the functionalities and meaning of the pain event. The disputes which already affect individual interpretations should be excluded from any ‘generalised’ definition. The exercise is not about exposing differences….it’s about finding an all-encompassing definition, hopefully not too watered down, which might satisfy on a general level, most who would encounter it. That means compromising convictions and agreeing a majority acceptance. Think of it as an ‘umbella’ definition, under which the ‘minor’ disputes can continue at another time. The definition needs to appeal to as many as possible, without, at the same time, committing them to any particular overview of the intricacies of the functionalities and meaning of the pain event.

    John Quintner Reply:

    We should also remember that definitions can serve a variety of functions, and their general characteristics will vary according to their specific functions and the context in which they are to be used.

    Furthermore, as Merskey [1994] explained, a definition should be as concise as possible and state what it includes and, if necessary, what it excludes.

    The IASP definition is indeed concise and excludes the necessity for nociception. Revising it and at the same time retaining its general acceptability will indeed be a challenging exercise.

    As a quite elderly and very impatient person, I support Amanda in her initiative.

    Our “ad hoc” writing group is preparing a response.

    Reference: Merskey H. Logic, truth and language in concepts of pain. Quality of Life Research 1994; 3: S69-S76.

    Gerry Daly Reply:

    It seems we might only be capable of deciding a definition of pain according to who we think it might be directed towards….professionals or patients. The needs of each are, apparently, different. A patient looks for reassurance, whereas a professional looks for reasoned explanation. Finding the middle ground is bound to be difficult, but at the same time, it is imperative, so that both are reading from the same page when choices must be made. Whatever definition there is, I think that the fact that it’s the patient who must live with the outcomes of any therapies demands that the definition must primarily be directed at them, whilst also reflecting the differing theories within the profession…emergent, Cartesian etc.

    Perhaps a broad definition initially, with no particular emphasis, followed by a brief sub-set of opposing theories, all on equal terms. The only problem I see with that is the ensuing squabbling to get every idiosyncratic theory on board ! Already I’m thinking…’here’s an opportunity to develop something new and cutting-edge !’. So, I think I’ll have a go at this myself….from a ‘patient perspective’, and see what I come up with. Perhaps this thread could be kept open for suggestions to accumulate.

    Gerry Daly Reply:

    PS………. Separate definitions for Acute, source identifiable, pain, and Chronic Pain with identifiable source, or unidentifiable source, might be a good idea in an attempt to be all inclusive, without allowing the explanations for each to conflict within a single definition.

  22. Dear Amanda

    Our paths cross again for, via Dr Charles Pither (London) whom I first met at a Pain conference “The Changing Face of Back Pain Management” In Chester UK March 1997 where he was one of the presenters of the day.

    It was Charles, who in 2000 sponsored and you kindly seconded my short-lived membership introduction to the Pain Society of London.

    Interesting question you ask.

    I have since your posting; re-read with interest Dr Charles Pithers. “Why Pain Management.”
    file:///F:/0001%20Data%20FIles%2030%2007%2015/01%20ALL%20HEALTH/01%20Reserch%20Treatment/NHS%20Complimentry/Dr%20Charles%20Pither/IE%207/painSupport%20Web%20Site.mht

    And observed in real successful terms nothing has changed in the management of Pain – if anything it is worse now than then, despite the advances in understanding Medical Science demonstrates it has achieved.

    Let us start Pain is Pain and it needs no further description than this, any other description is for the clinician-researcher to relieve their anxiety only and never ever for a Person in Pain.

    Thus to start a new definition of Pain – first we have to accept nothing has ever managed pain for longer that it takes for the body to excrete the medications or in with the inclusion of some physical management technique, the heat of the therapists hands to leave the body.

    Therefore if we are going to start to understand pain then we have to Scientifically accept we first have a Mind and second; it is the memories stored within the Mind that create all illness let alone Pain.

    Moreover as we are scientifically proven to be Genetically Unique. Then the only definition, coming from the entire medical profession, which I would support is…

    “We Pain specialists on behalf of Medical Scientists, now, after all of the years of intense study have scientifically proven. “All illness is a process of the Mind and the Body requires help whilst it makes the necessary adjustments to its entire body chemistry to resolve the illness – this medication is too assist the Mind, thereby enabling repair of the illness/pain to take place.”

    Kindest regards and best wishes.

    Peter Smith Talking Cures

  23. I forgot to add my definition:

    Pain is the unpleasant sensory experience resulting from threat to the self-image.

    The word “emotion” need not be included since emotions are known to us only because they create somatic unpleasantness. We don’t need to separate emotions and soma. Emotions *are* somatic.

  24. — Pure, somatic nociceptive input without an emotional reaction is rare but possible. What creates the emotional reaction is the self-image (ie. the thought “I exist as this body”). Without a self-image, nociception isn’t in any way unpleasant, therefore a non-issue. It’s the emotional reaction which gives nociception salience and meaning.

    — Emotional reactions to nociceptive inputs I’d call ‘suffering’ (or maybe ‘pain’).

    — Most somatic complaints presenting to a physio clinic are the end result of suppressed painful emotions, too difficult to handle consciously. This is why it’s possible to use words and imagery to make the ‘somatic’ pain vanish in minutes. The results I get would seem completely impossible to most practitioners, such is the depth and speed of relief.

    — Unpleasant sensations such as numbness can also be healed completely and rapidly using the mind only. [I did my first successful treatment of numbness with this approach a few weeks back].

    — Pain resides *in* the self-schema. Knowing this gives me a huge advantage. I simply remove the pain from the body-schema and it ceases to exist. On rare occasions, this can even happen in seconds.

    — This approach to the treatment of pain is so powerful that it shocks many patients. And here’s the kicker – many patients are unprepared for this change, and underlying emotions can get exposed before they are ready. The other potential problem is the situation where the pain has formed part of the patient’s identity. If you remove the pain, that can represent an enormous threat, understandably. I’m currently working on ways to word a preparatory statement which asks the patient if they really understand that the whole pain may disappear today…. and what that would mean for them. Negative consequences of pain removal need careful consideration.

  25. Gerry Daly says:

    Glad to see the ‘ this usually happens for psychological reasons ‘ being dropped, as such a description might amount to a validation for an ‘assumed’ opinion on pain. Otherwise, a fair and neutral overview, besides being perhaps a bit too ‘theoretical’ for the lay person. It would be good to have a reasonable definition that cannot be misunderstood by either professionals or lay.
    I would be inclined to also include brief definitions of ‘acute’, ‘persistent’, and ‘chronic’, pain, again so that misunderstandings might be negated at the outset. For instance…Acute Pain being pain, usually related to tissue damage, which has a healing expectation within a specific time frame ; Persistent Pain being acute pain which has lingered beyond that time frame; and ‘Chronic Pain’ being a less well defined pain which currently has no healing expectation in any known time frame. There may be some dispute about those suggested definitions, but at least that gets the discussion going.

    I would also like to see a ‘one sentence’ opening overview of pain definition, which would help people to focus on a similar understanding of pain, before ploughing ahead into the varied therapies. Perhaps something like…’ Pain is a conscious only perception which results in a sense of discomfort, which, in turn, can lead to identifying a possible source for the pain, and subsequent appropriate treatments ‘.