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When the International Association for the Study of Pain (IASP) arrived at a definition of pain that included the “emotional experience,” as well as the “unpleasant sensory experience associated with actual or potential tissue damage,”1 they were acknowledging the impact of pain on our human capacity for sentience and reflection and, by extension, suffering. By the time pain has become chronic in an individual’s life, it has almost certainly achieved the status of a major source of stress. More than merely an unpleasant sensory stimulus, chronic pain can come to affect the whole individual by becoming, itself, the source of a broad range of psychosocial stressors. The following case report illustrates the extent to which this is possible.


Case 1


A 42-year-old married man was referred to a pain management center, 8 months after suffering a work-related, crush-type injury to his hand. His pain, which had been diagnosed as complex regional pain syndrome, type 1 (CRPS-1), had remained intractable to conservative measures and surgical intervention. According to the patient, several trials of medications had left him with uncomfortable mental status changes, and a reparative surgery and several procedures had exacerbated his pain considerably. He reported his distress as “worse than ever” and indicated that he was unable to work or pursue any of his previous recreational outlets. Although his primary care physician and surgeon supported his claim to disability, his worker’s compensation carrier’s representatives insisted that he should be able to return to light duty at his previous job. As a result, the patient had entered a lengthy and frustrating process of litigation, which had proved exhausting and overwhelming. As his anxiety escalated concerning his loss of income, mounting legal fees, and inability to resume work and provide for his family, he became increasingly withdrawn, irritable, and depressed. His marriage and relationships with his children and friends suffered; and, by the time he arrived at the pain management center, he reported feeling angry, helpless, hopeless, and suicidal.


Cases such as this are familiar to everyone who specializes in the treatment of chronic pain. The challenge, where successful medical resolution is concerned, is to maintain the focus on the whole of the individual’s experience, both sensory and affective, because the development and course of chronic pain represents a progressive series of complex interactions among the biologic, psychological, and social dimensions of an individual’s life. Purely physiologic explanations cannot account for its impact.2 Nor can an exclusive reliance on the interventions that spring from such a limited understanding ordinarily bring the enduring relief and solace sought by many patients with chronic pain.3


The quality, intensity, and duration of pain are influenced by a myriad of psychological and social factors, which—while they may have arisen in the context of pain—are by no means less influential or consequential than the unpleasant sensory experience arising from actual or potential tissue damage.4 Such factors may, indeed, ...

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