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10 Michael K. NICHOLAS
than to avoid injury. It has more in common
with the phenomenon of hunger and thirst
than with seeing or hearing. e period after
injury is divided into the immediate, acute
and chronic stages. In each stage it is shown
that pain has only weak connection to injury
but a strong connection to the body state.
However, around the same time Mountcastle [48]
described pain as “that sensory experience evoked
by stimuli that injure or threaten to destroy tissue.
Defined introspectively by every man as that which
hurts.”
Not surprisingly, these different perspectives on
pain have extensive historical roots.
Historical Perspectives
e great Roman physician Galen (AD 131–200)
considered that pain was a sensation and, like other
sensations, was centred in the brain. Similarly, in
ancient Egypt pain was also considered to be a
sensation, but one that arose from wounds and
from internal afflictions. In this view, pain was
regarded as a sensation experienced in the heart,
and bodily injuries were thought to communicate
painful sensations to the heart via a network of
vessels. However, Egyptians also believed that pain
could arise from the invasion of the body by evil
spirits that entered via different orifices during
the night; the obvious way of dealing with these
spirits was to eject them from the body by sneezing,
sweating, vomiting or urinating.
In ancient Greece, while Aristotle (384–322 BC)
also considered pain to be felt in the heart. He
differentiated it from the five senses, describing it
as a quality or passion of the soul, a feeling that was
the opposite of pleasure (as Plato had previously
noted when pain was relieved it was followed by
pleasure). Bonica and Loeser [12] noted that this
view of pain as an emotional construct, a passion
of the soul, held considerable influence for the next
2,000 years, at least in Europe. rough that time,
however, the brain came to be seen as a site of all
senses, and pain. Even so, the question of whether
pain was a sensation or emotional experience
continued to be debated.
e idea that pain was an emotional experience
was also popular in the Vedas and the Upanishads
of ancient India. ese texts suggested that the
frustration of desires sets the scene for pain
experiences. us, the intervention should derive
from identification of the frustrated desire, which
may then be addressed. Like the Europeans at
around the same period, the authors of these books
also considered that the heart was the anatomical
seat of emotional experience, whether of joy or
pain.
Between the eighth and the fifth centuries BC,
practitioners of traditional Chinese medicine
developed the view that the vital energy of the
body, called chi, circulates to all parts of the body
via a network of 14 channels or meridians, each
serving an important organ system or function. In
the healthy state, the two opposing life forces (yin
and yang) were thought to be in balance and assisted
the circulation of chi within the body. Disease and
pain were attributed to obstructions (deficiency)
or outpourings (excess) in the circulation of chi,
which, in turn, created an imbalance in yin and
yang. Acupuncture therapy was intended to correct
this imbalance and resolve disease and pain. us,
in this view, pain was a symptom or indication
of an imbalance between the opposing life forces
within the body. e practice of exercises like t’ai
chi was also thought (and still is) to be a way of
restoring the balance between yin and yang.
Pain as A Sensation or
Emotion?
In English, the word pain is derived from the Latin
word poena, meaning “punishment”. is is linked
to the idea that pain was attributable not to demons
or excess vital heat, but rather a sin committed by
the pain sufferer and possibly relievable by prayer or
some type of appeasement of the relevant deity. It is
not difficult to see how pain, sin and punishment
have been linked in (especially religious) writings
and practices, over many centuries.
e persistence of the view that pain is an experience
with strong emotional features, inextricably linked
to meaning, is matched by the persistence of sensory
theories of pain. e sensory theory of pain received
more support in the 19th and 20th centuries as the
physiology of the nervous system was increasingly
described and studied. Terms like “pain nerves”
appeared as a means of linking the experience of
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Psychological Concepts of Pain 11
pain to particular nerve pathways based on the
research of people like Müller and Von Frey. Von
Frey considered there were four main cutaneous
senses: touch, warmth, cold and pain, each with its
own special projection system or pathway to a brain
centre responsible for that sensation. Von Frey also
designated free nerve endings in the body as pain
receptors. From this perspective an intervention
that blocked or destroyed a “pain nerve” might be
expected to relieve all pain, but as has been noted
for some time this is not always successful [41].
e approach to explaining the neural basis of pain
as a separate sensation ultimately led to what has
been described as the “specificity theory” of pain.
is theory was opposed by those who argued
that pain and other sensations, like touch and
temperature, were not separate sensations, but
rather pain was the result of excessive stimulation
of the fibres underlying the other sensations.
is “intensive (later called “central summation”)
theory” was an elaboration of aspects of Aristotle’s
model by people like Darwin, Erb and Goldsheider.
Essentially, this theory stated that pain could be
experienced when stimulation of a sensory system
reached a critical level.
Despite their differences, both the specificity and
intensive/summation theories of pain shared the
view that pain was primarily a sensation.
Philosophically, these sensory theories of pain
(developed during the 19th and 20th centuries) are
generally believed to have drawn on the writings of
Descartes in the 17th century. Descartes wrote of
people being composed of a soul and a body and
considered that the body was “nothing but a statue
or machine” (from a translation of Descartes’ work
by Cottingham et al. [16]). In this dualistic model
of mankind (with its separation between mind and
body), although pain was perceived by the mind
(soul), Descartes indicated that pain could be fully
explained by describing the bodily mechanism that
produced it [5]. is approach, now often described
as a reductionistic view [38], has continued to play
a central role in the debate over definitions and
explanations of pain.
One feature of these sensory models and their
underlying mind-body separation is that they are
reliant on defining pain in terms of a stimulus (e.g.
injury or tissue damage). One implication of this is
that if a person is injured they must have pain, even
if they don’t report it. In other words, these models
appear to imply that it is possible to have pain
without knowing it. From this perspective also, the
corollary that a person cannot have pain if there is
no obvious stimulus must also be true. However,
as many clinicians and researchers have noted,
these conclusions are doubtful and inconsistent
with many clinical observations [67]. More recent
reviews have confirmed the variable nature of the
relationship between pain experience and noxious
stimuli [3, 18, 27].
e idea that pain must be related to a stimulus can
also be seen in a number of early (and even some
more recent) psychiatric and medico-legal texts.
For example, notions that pain can be divided
into summary categories, such as either “organic”
or “psychological” appear in earlier versions of the
American Psychiatric Association’s Diagnostic and
Statistical Manual of Mental Disorders (DSM).
In DSM-III [1], the diagnosis of Psychogenic Pain
Disorder was described and central to this diagnosis
were the implicit assumptions that the cause of all
pain syndromes is known, as well as an implicit
acceptance of a unidimensional model of pain:
namely that pain is either physical or psychogenic
(see Turk and Rudy [59] for more discussion of
this).
e more recent version of this manual (DSM-IV
[2]) has dropped the term “psychogenic” in favour
of just Pain Disorder. e criteria for the diagnosis
are that A) the pain must involve one or more
anatomical sites and be the predominant focus of
the clinical presentation; B) the pain must cause
clinically significant distress and impairment in
important areas of functioning, such as occupation
and social activities; and C) psychological
factors must play an important role in the onset,
severity, exacerbation or maintenance of the pain.
ree subtypes of the disorder were identified
according to the assessed nature and degree of
their association with psychological factors. While
mental health professionals have generally regarded
the more operational approach of DSM-IV as
an improvement over the earlier DSM versions,
criticisms of its handling of pain have remained.
Fishbain [25], for example, concluded that the
pain disorder category “has little utility for the pain
clinician”. Fishbain pointed out that the diagnosis
is over-inclusive (almost all patients attending
a pain clinic would meet the criteria), and that
criterion C not only requires a value judgement by
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12 Michael K. NICHOLAS
the clinician but the assessment of the relationships
between pain report, psychological variables and
medical status is of doubtful validity. Nevertheless,
it should also be recognised that the DSM-IV did
acknowledge that psychological factors could play a
number of possible roles in the experience of pain,
in addition to organic factors, and this idea will be
explored later in this chapter.
A modern version of pain as an emotion might
be seen in the work of those who have promoted
the idea of chronic pain being conceptualised as a
type of depression (e.g. “masked depression” [7]),
especially when no clear organic basis can be found
for the pain. While there is a significant overlap of
the clinical signs and symptoms of depression and
chronic pain (e.g. sleep disturbance, concentration
difficulties and anhedonia), theories that chronic
pain is a type of depression have not been validated
in the research literature. Instead, the weight of
evidence supports the view that depression is more
likely to be a consequence of chronic pain than the
reverse [26, 31]. However, chronic pain patients
who have a comorbid mental disorder (such as
depression) tend to have a more impaired quality
of life than when there is no comorbidity [4]. Also,
treatment outcomes can be compromised when
both pain and a mental disorder are present but only
one of them is targeted for treatment. For example,
higher levels of depression are related to poorer
treatment outcomes for chronic pain patients [14,
37], as well as higher health care costs over time
[23]. In addition, the presence of pain in those who
are being treated for mood disturbance has been
found to interfere with response to treatment [35].
e third major pain theory of the 20th century has
been described as a “pattern theory”. e original
proponents [51, 68] of this theory argued that
pain is generated by intense stimulation of non-
specific nerve endings (or receptors). is theory
argued against the specificity notions in favour of
spatial and temporal patterns of nerve impulses.
is theory was supported into the 1980s. Crue
[17], for example, argued that pain is a central
percept and not a peripheral primary sensory
modality. However, as Bonica and Loeser [12], and
others, have pointed out, the theory ignored the
physiological evidence that there is a high degree of
receptor fibre specialisation.
In an attempt to incorporate the growing evidence
that psychological factors could influence pain
experience some proponents [33] of the specificity
model of pain divided pain into two elements:
the perception of pain and the reaction to pain.
According to this construction, the perception of
pain was seen as primarily a neurophysiological
process that was composed of relatively simple neural
receptive and conductive mechanisms. In contrast,
the reaction to pain was thought to be a more
complex physio-psychological process involving
cognitive functions, such as past experience and
culture, which could influence what they called a
pain reaction threshold. However, as Bonica and
Loeser [12] pointed out, this model, sometimes
called the fourth theory of pain, assumes a one-to-
one relationship between the intensity of a stimulus
and pain perception. In addition, while the idea
of a reaction to the perception of pain, perhaps
operating like an alarm system, does have face
validity, recent studies have indicated that cognitive
functions can also influence the perception of
noxious stimuli as painful. at does not negate the
idea of pain acting as a warning signal, but it does
suggest the process is more complex than a simple
stimulus-response arrangement. is evidence is
examined below.
Modern Perspectives
Since the 1960s, there has been a considerable
expansion of perspectives on pain. ese have
been marked by multidimensional constructs that
have included neurophysiological, emotional,
behavioural, cognitive (meaning) and social/
cultural accounts of pain, either separately or in
various combinations. Kleinman [38], for example,
described a number of social/cultural perspectives
of pain and argued that a reductionist, mechanistic
perspective of pain cannot adequately represent
the range of experiences, especially in relation
to the suffering and impact on lives, reported by
many people in pain. Melzack and Wall’s [44]
Gate Control eory of pain might be said to
represent an example of an attempt to combine
neurophysiological mechanisms with psychological
processes, especially cognitions and emotions. In
this model, pain was not an inevitable consequence
of peripheral stimulation of nociceptors or
summated stimulation, but rather an end-product
of a number of interacting processes in which the
central nervous system, including higher cortical
processes like attention and meaning, played an
active role in determining the nature and degree of
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Psychological Concepts of Pain 13
pain experienced following noxious stimulation at
the periphery. A key feature of the gate theory was
that it provided a means of explaining pain that
was not dependent upon the nature of the noxious
stimulus — a problem that had limited the utility
of the specificity/sensory theories. However, the
possible impact of environmental influences on
the higher cortical functions (such as meaning/
significance; learning; attention), and this might
occur, were not directly considered in the early
versions of the gate theory.
e clinical implications of models of pain like
the Gate Control eory, as well as the social/
cultural perspectives, may be seen in Waddell’s [62]
comment that clinicians dealing with back pain
should be “treating patients rather than spines,
we must approach low-back disability as an illness
rather than low-back pain as a purely physical
disease”.
As a result of these arguments and the evidence on
which they were based, a degree of agreement has
been reached by the taxonomy committee of the
International Association for the Study of Pain [45]
which described pain as “an unpleasant sensory
and emotional experience associated with actual
or potential tissue damage or described in terms of
such damage”.
e following notes were added by the committee
chaired by Merskey [45]:
Pain is always subjective. Each individual
learns the application of the word through
experiences related to injury in early life. It
is unquestionably a sensation in a part of
the body but it is also always unpleasant and
therefore also an emotional experience.
Many people report pain in the absence of
tissue damage or any likely pathophysiological
cause, usually this happens for psychological
reasons. ere is 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. is
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.
Some key points to note about this definition
include:
1. Pain is considered to be an experience,
fundamentally a psychological phenomenon,
not an objectively verifiable condition.
2. In addition, the experience of pain involves
a mix of sensations and affective qualities. In
particular, it is characterised as unpleasant,
though the degree of this is likely to vary
greatly.
3. Finally, there is acknowledgement that the
relationship between pain experience and
injury or tissue changes is variable. us, we
cannot expect to know exactly how “much”
pain a person should have with a given injury
or tissue damage.
While this definition of pain has been generally
accepted by pain researchers and clinicians
since the early 1980s, it should be noted that its
primary focus is the experience of pain and its
verbal communication [46]. More recently, some
researchers have argued that the definition requires
further refinement. For example, Linton [35]
suggested an additional aspect should be included
in the International Association for the Study of
Pain (IASP) definition: that pain is “expressed in
behaviour”. Eccleston and Crombez [19] contended
that the IASP definition does not stress the affective-
motivational effects of pain on an organism within
its natural environment, particularly the role that
pain plays in interrupting attention and behaviour
and the effect of urging action. As noted earlier,
Wall [65] also argued for pain to be seen as a need
state, like hunger or thirst, rather than a sensation
like seeing or hearing. Wall [67] also argued that the
role of attentional processes had been overlooked in
the IASP definition. us, we should not imagine
that the current IASP definition of pain is likely to
be the last word on the matter.
In contrast to the earlier dualistic notions of pain,
where mind and body (pain) were considered as
separate domains that underlie the various sensory
models of pain, more recent models of pain have
emphasised more interactional perspectives. e
most widely known, and accepted, of these has
come to be known as the biopsychosocial model
of pain. Before exploring this it should be noted
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14 Michael K. NICHOLAS
that there is no single, accepted model of this name
as many versions have been reported and this has
led to some confusion in the clinical and research
literature [8].
Biopsychosocial Models of
Pain
Engel’s [21] original biopsychosocial model of
illness (which he later elaborated [22]) posited that
symptoms should be conceptualised as the result
of a dynamic interaction between psychological,
social and pathophysiological variables. Engel’s
model has since been applied to describing pain
phenomena and reviews of empirical support for
this model in relation to pain can be found in Turk
and Flor [57], Turk and Okifuji [58] and Flor and
Hermann [27].
e version of the model applied to pain by
Fordyce [29] and Loeser [40], and later elaborated
by others [27, 63], incorporates the notions that
at the physiological level (i.e. nociception and
neuropathy) changes are initiated by trauma or
pathology; psychological variables are reflected in
the attention and appraisal of internal sensations;
and these appraisals and behavioural responses
are in turn influenced by social or environmental
variables. At the same time, the model also
posits that psychological and social variables can
influence physiological responses, such as hormone
production, activity in the autonomic nervous
system and physical deconditioning [57]. For
example, behavioural responses, such as avoidance
of activity due, say to, fear of pain or expectation of
further injury, can result in physical deconditioning
and/or greater disability [54, 60].
In this model, nociception is not synonymous
with pain. Nociception is only activity in certain
neurons, typically generated by noxious stimuli.
In the case of pain related to changes in the
nervous system (neuropathic pain), there may be
no obvious noxious stimuli. is nerve activity
does not become pain until it is perceived by the
conscious individual — when it is likely to be an
immediate focus of attentional processes [13, 19].
e model also separates suffering or the affective
aspects of pain from pain perception (typically
the more sensory aspects, like burning, sharp,
throbbing). Whether this distinction is justified is
the subject of much debate, but it is true that the
relationship between pain severity (as measured by
intensity rating scales) and distress associated with
pain is variable and can be influenced by factors
such as the use of coping strategies, cognitions and
environmental factors [19, 36].
Evidence for the psychological modulation of pain
experience and its impact on the individual is now
well established. Key constructs that have been
found to be particularly important in this regard are
catastrophising (or excessively negative appraisals of
pain and other noxious events, such as injury) [53],
fear-avoidance beliefs and behaviours [60] and self-
efficacy beliefs (the degree of confidence in one’s
ability to function or achieve goals despite pain)
[49]. Recent research on the role of acceptance of
persisting pain has also suggested that this can play
an important part in a person’s adaptation to their
pain [42]. e ways in which people with persisting
pain try to cope with their pain have also been
found to make an important contribution to their
degree of adjustment. In particular, coping styles
(or strategies) deemed to be passive (e.g. excessive
resting, relying excessively on medication or other
agents and/or other people) have repeatedly been
found to be associated with poorer adjustment
relative to the use of more active strategies (where
the person tries to remain in control as much
as possible, as well as keeping active using self-
management strategies like activity pacing, goal
setting and exercises) [10, 36].
e biopsychosocial perspective of pain can provide
a useful framework to make sense of the observed
variable relationship between pain severity, physical
pathology findings and disability/pain behaviours. It
has been found that many people with chronic pain
seem to manage quite well, with many continuing
to work, to not become distressed or disabled, to
use few drugs and to seek medical attention rarely
[9, 47]. On the other hand, many people with
chronic pain do become distressed and disabled
and seek medical care at levels disproportionate to
their numbers [9, 11, 30, 47]. It is this latter group
that typically appears in pain clinics. By considering
these different groups within the framework of the
elements of the biopsychosocial model we can see
how the impact of different factors might lead to
different outcomes even though other aspects of
different individuals (e.g. their IASP classification
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Psychological Concepts of Pain 15
or diagnosis) might be the same. us, two
individuals could both have the diagnosis of failed
back surgery syndrome/lumbar spinal or radicular
pain after failed spinal surgery, but be quite different
in their levels of disability, distress, pain and use
of health services. By thinking about these cases
in terms of the biopsychosocial model, we might
be able to identify possible explanations for these
differences and then know what to do about them.
A key term commonly associated with this model
of pain is pain behaviours. Fordyce [29] defined
pain behaviours as what people say, do or do not
do which imply to an external observer that tissue
damage has occurred. Pain behaviours may include
talking or complaining about pain (including rating
the severity of pain), taking analgesic medication,
lying down during the day, moaning, grimacing,
guarding, rubbing or holding a part of the body,
ceasing work or domestic chores and visiting a
medical practitioner. ere is no gold standard
or validated definition of pain behaviour, partly
because it is likely to vary from one person to the
next and one cultural context to the next [56]. e
principal test for pain behaviour is that others may
infer the behaviour suggests the person displaying
it is in pain. Despite difficulties of definition, it
is relevant to point out that pain behaviour is the
only observable and quantifiable aspect of pain
assessment. ere are no physiological or strictly
objective indices peculiar to pain. People may
become distressed, display autonomic changes
and withdraw from activities for many reasons
other than pain. us, the assessment of pain is
necessarily dependent upon self-report (by the
person in pain).
Like all behaviours, pain behaviours are likely
to be influenced by both internal (physiological
and cognitive) factors and environmental (social
and physical) factors. In other words, it should
not be assumed that pain behaviours (and pain
experience) are totally determined by nociception
or pain alone [52]. In this context, Fordyce [29]
argued that environmental reinforcement could
provide a mechanism for the maintenance of pain
behaviours independent of nociception. Although
Fordyce was working at a clinical and conceptual
level with no scientific evidence for this view, the
role of reinforcement in the maintenance of pain
behaviours and pain experience has recently been
confirmed in a number of experimental studies
[28, 34]. e contribution of learning mechanisms
in pain has recently been extended further by Flor
and colleagues (see below).
Some writers, like Waddell and Turk [64], have
employed the term “illness behaviour”, developed
by Mechanic [43], rather than “pain behaviour”. But
they are essentially synonymous, although illness
behaviour may be seen as broader in coverage. For
Mechanic, illness behaviour is purely descriptive
and refers to the ways in which individuals think,
feel and act in relation to their health status.
Pilowsky [50] makes the point that illness behaviours
may be either adaptive or maladaptive. Maladaptive,
or pathological behaviours which occur in relation
to pain or other illness, Pilowsky calls “abnormal
illness behaviour”. is, it must be remembered,
is not a diagnosis but refers to a judgement that
illness behaviours (including beliefs about illness or
pain) are inappropriate in the context of a thorough
medical examination ruling out major pathology
and attempts at reassurance proving unsuccessful.
In this situation, if the patient continues to behave
and believe that s/he is ill then these behaviours may
be considered or labelled “abnormal”. Like the term
“pain behaviour”, “abnormal illness behaviour”
is not an explanation of the behaviour — only a
description. Causative or treatment implications
must be determined by comprehensive assessment
of the patient.
e role of personality in the experience of pain
also has a rich history in the pain literature, but
more recently it has been explored mainly within
the framework of biopsychosocial perspectives [32].
While some early writers [20] wrote of concepts
like a “pain-prone personality”, these views have
not been supported in the research literature.
More recent approaches have focused on studying
interactions between personality traits, cognitive
processes, coping skill repertoires and environmental
variables in relation to adjustment to chronic pain.
For example, there is some evidence that people
with personality traits like neuroticism (a tendency
to “experience negative, distressing emotions and
to possess associated behavioural and cognitive
traits” [15]) are more likely to use ineffective coping
strategies and to have more adjustment difficulties
to persisting pain, compared to those who do not
have such traits. us, certain personality traits
might act as vulnerability factors for difficulties
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16 Michael K. NICHOLAS
in adjusting to pain rather than causal factors.
Nevertheless, caution is encouraged in this area lest
patients be unfairly stigmatised by being branded
with pejorative personality labels that could even
act as self-fulfilling prophesies by under-treating
them or giving inappropriate treatment. It needs
to be recognised that methodological shortcomings
(e.g. lack of prospective studies) evident in the
few studies available preclude the drawing of firm
conclusions on the role of personality in this area.
Most authorities advise that the interactional
perspective outlined here is likely to be the most
useful in research into the role of personality and
pain [32].
Pain as a Response Rather
than a Sensation?
Recently, some researchers [6, 27] have argued
that pain may be conceptualised as a response, as
opposed to a purely sensory phenomenon. is
is clearly a major shift from the concepts of pain
as a sensation that have dominated much of the
pain literature (and clinical practice) for many
years. Flor and Hermann [27] described pain as
having physiological, behavioural (motor) and
subjective (verbal) components, which “may or
may not have an underlying pathological basis
in the sense of structural change, but will always
have physiological antecedents and consequences”.
Central to this model of pain is the influence of
learning. Based on evidence from a number of
laboratory studies, Flor and Hermann argued that
learning occurs at the physiological level and that
physiological mechanisms could be modified by
behavioural and subjective (or cognitive) changes.
In this sense, they asserted that the interactions
between these different domains were ongoing
and not unidirectional. ey also considered that
this “psychobiological model”, as they called it,
was consistent with the IASP definition of pain
referred to earlier. But they did suggest that the
psychobiological model places more emphasis on
the integral role of cognitive and learning factors in
the experience of pain as a dynamic process.
Clinical Implications
e clinical implications of the biopsychosocial
model of pain is that to adequately assess a patient’s
pain complaint the clinician(s) must address
not only the possible physiological basis of the
patient’s symptoms, but also the range of possible
psychological and social/environmental variables
that have been found to influence pain, distress
and disability. ese variables, in turn, may then be
targeted by appropriate interventions.
A medical pain specialist may be most interested in
the neuropathic pain generator that is the basis of
the patient’s pain. S/he may also be most expert in
testing whether a nerve block will reduce or eliminate
activity in the fibres and, as a consequence, possibly
reduce or eliminate the patient’s pain. However, if
other factors (whether cognitive or environmental)
are also influencing the patient’s report (and
experience) of pain, the purely physical approach
of this pain specialist could well fail. Similarly, a
psychologist or psychiatrist may be most interested
in the cognitive, affective and environmental aspects
of a pain problem, but ignorance of what might be
happening at the nociceptive or neuropathic levels
could well limit their formulation of the case as
well as the effectiveness any subsequent treatments
or interventions they may offer.
At present, it can be argued that attempts to
integrate information on the various levels of the
biopsychosocial model of pain for any given patient
could be described as not much better than a “rule
of thumb”. ere is no validated way of weighting
the contributions of each level on an a priori basis,
even assuming that we have adequate measures
for each level. Nevertheless, the biopsychosocial
conceptualisation of pain does provide a guide as to
what might be useful to investigate when assessing
an individual and formulating hypotheses to
account for the features of the case — hypotheses
which can then be tested by targeted interventions
patient [64]. Some writers have framed these ideas
into ways of answering the question of what works
for whom in the field of pain [55, 61].
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Psychological Concepts of Pain 17
References
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 3rd edn. Washington; 1980.
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Pain and Assessment
Introduction
is chapter presents a review of the general guidelines for pain
assessment and pain assessment tools. A valid and reliable pain
assessment tool is required to measure pain and show treatment
effects. erefore, both the advantages and the disadvantages
of the various pain assessment tools are deliberated. Validity
and reliability of the tools are addressed. Only commonly
used tools are discussed and they include the visual analogue
scale, numerical rating scale, verbal rating scale, McGill Pain
Questionnaire and the Brief Pain Inventory. In addition,
the use of the term “tool” or “scale” throughout the chapter
in describing the instrument depends on its conventional
naming; in some instances “tool” is a broader term used to
include a “scale”.
Role of pain behaviour in pain
assessment
Pain behaviour is important because an individual’s belief in
appropriate pain behaviour affects their exhibition of pain.
More importantly, clinicians rely on a patient’s exhibition of
pain for diagnosis and treatment, as evidenced by the pain
assessment tools that are used in practice [17, 57, 59, 77].
Understanding the patient’s belief in appropriate pain behaviour
does have clinical implications for medical practice in pain
management [1, 13, 18, 19, 64]. In our diverse health care
facilities, we have a wide range of clients with different cultural
and ethnic backgrounds. Cultural sensitivity is important in
pain assessment [21]. A pain experience is an interaction that
reflects an intertwining relationship among biopsychosocial,
environmental and political elements. Even within the same
culture there can be variation; there is a gender difference
among Hong Kong Chinese in their pain report criteria, i.e. the
PAIN AND ASSESSMENT
Introduction
Role of pain behaviour in pain
assessment
Significance of
multidimensionality in pain
assessment
PAIN ASSESSMENT TOOLS
Visual analogue scale
Numerical r
ating scale
Verbal rating scale
Brief Pain Inventory
McGill Pain Questionnaire
CRITIQUE ON PAIN ASSESSMENT
T
OOLS
Sensiti
vity of unidimensional
scales
Validity and reliability of
unidimensional scales
V
alidity and reliability of
multidimensional scales
RECENT RESEARCH IN PAIN
ASSESSMENT
Need for cultural relevancy in
pain assessment
Assessment of acute pain among
Chinese using a v
erbal rating
scale: an exemplar
Assessment of cancer pain among
Chinese cancer patients: an
exemplar
REFERENCES
Principles of Pain Assessment and
Evaluation Tools
3
Joanne W.Y. CHUNG
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