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It is important to consider how we conceptualize pain. Our views of pain will influence our evaluations of patients who report pain and the nature of the interventions that we use to treat them. The way in which we conceptualize pain depends largely on the nature of the information acquired and the models we were exposed to during our training. In the first section of this chapter, we review the traditional conceptualizations of pain. Although these models are not necessarily inaccurate, they are incomplete. We propose that a broader, multidimensional perspective is required to understand pain and to treat patients appropriately. We describe the role of behavioral, cognitive, and affective factors that have been shown to be relevant to the experience of pain, disability, and response to treatment. We provide data demonstrating that these psychological factors may have an effect on both patients’ behavior and physiology. Finally, we raise the issue of the “patient uniformity myth” and describe the subgroups of pain patients based on psychosocial and behavioral characteristics. We provide preliminary data suggesting that knowledge of such patient subgroups may serve as a basis for matching patients to treatments based on their characteristics.

[Preparation of this manuscript was supported by grants from the National Institute of Child Health and Development (P01 HD33989) and the National Institute of Arthritis and Musculoskeletal and Skin Diseases (R01 AR 44724) awarded to the first author and the National Institutes of Health/Shannon Director’s Award (R55 AR44230) awarded to the second author.]

Historically, pain has been understood from the perspective of Cartesian dualism wherein pain was viewed as purely sensory, reflecting the degrees of incoming noxious sensory stimuli. This perspective assumes that there are two ends to a pain pathway. At the periphery are sensory receptors where noxious information is received; at the other end, regions located in the brain where information is registered passively. From this perspective, noxious stimulation inevitably results in the sensation of pain, as if pulling a string at the periphery activates a bell located in the brain. Variations of this model have been prominent since first proposed by Aristotle.

A central belief of sensory models is that the amount of pain experienced is a direct result of the amount, degree, or nature of sensory input or physical damage and is explained in terms of specific physiologic mechanisms. Clinically, it is expected that the report of pain will be directly proportional to the amount of pathology. This model dictates that assessment should focus on identifying the cause of the pain. Once identified, treatment should involve removal of the cause or severing the specific pain pathways by surgical or pharmacologic means.

Sensory models continued to maintain a prominent position in medicine despite the inability of this model to account for a number of observations. For example:

  • Patients with equivalent degrees and types of objectively determined tissue pathology vary widely in their reports of pain ...

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