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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.
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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he became increasingly withdrawn, irritable, and depressed.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.
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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
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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, ...