This chapter describes several important concepts which need to be clarified to better understand pain.

First, it is important to understand the distinction between acute and chronic pain. Acute means temporary pain. Acute pain goes away with natural healing or appropriate medical treatment. This handbook is written for those who suffer from chronic rather than acute pain.  Chronic means that the pain is either persistent or recurrent. The pain has lasted at least three months and most probably for several years.  In some cases, chronic pain is associated with a chronic and incurable medical condition such as arthritis. In other cases, the pain persists long after an injury has healed. In still other cases, the exact medical causes of the chronic pain condition are unknown or poorly understood. The following chart summarizes some of the key differences between acute and chronic pain.

Nearly everyone has experienced acute pain. Many people have never experienced and don't understand chronic pain. A common mistake among those who are unfamiliar with chronic pain is to assume that chronic pain should follow the same rules as acute pain. Sometimes those with chronic pain are blamed for their condition or made to feel like they were making it all up in order to get drugs or disability payments. We know that chronic pain is very real, but it is different from acute pain.

Because chronic pain is often incurable from a strictly medical standpoint, it is useful to consider approaching the problem from several different angles. You have already been exposed to the medical approach which relies heavily on medications. This book is primarily about an alternative approach, Self-Management.

Seven Pain Concepts

There are several additional pain-related concepts which need to be distinguished and clarified in order to arrive at a fuller and more accurate understanding of chronic pain. Unfortunately, the failure to understand these concepts is responsible for considerable confusion on the part of both pain patients and their doctors.

These seven concepts are: 1) The experience of pain, 2) Pain behavior, 3) Physical injury/damage, 4) Medical test findings, 5) Disability, 6) Suffering, and 7) the Chronic pain syndrome.

1.    The experience of pain

• Personal, subjective experience of painful sensations known only to the person with pain
• Includes a mental and emotional component in addition to awareness of painful physical sensations
• Cannot be objectively measured, confirmed, or disconfirmed by another person
• May or may not be associated with physical injury or disease; i.e., it is possible to honestly experience painful physical sensations in the absence of any current physical damage; it is also possible to have physical damage and yet have no experience of pain
• Pain is a normal and inevitable part of human existence; those who are born without the ability to experience pain are in serious trouble

2.    Pain behavior

• Outward, observable expressions of pain and actions taken to cope with pain
• Includes complaints of pain, non-verbal expressions of pain (e.g., limping, slow and guarded movements, grimacing, groaning, taking pain medication, laying in bed, withdrawing in silence, etc.), and pain coping behaviors (e.g., taking medication, reclining in bed, trying to ignore pain through distracting activities)
• Relationship with the experience of pain is variable; can be pain experience with little pain behavior or minimal pain experience with much pain behavior
• May be influenced by one's immediate environment and early learning

3.    Physical injury/damage

• Assumed cause of both acute and chronic pain
• Normally associated with an immediate experience of pain in the area where the injury has occurred
• Relationship with chronic pain is variable. There may or may not be identifiable physical damage, or the nervous system may be sending faulty messages regarding the nature or location of the injury

• Results of the physical examination and medical test procedures (e.g., lab tests, x-ray, CT scan, MRI, electrodiagnostic tests, etc.)
• Represents the doctor's attempts to identify the nature and origin of the pain problem
• Medical test findings may or may not be correlated with the experience of pain; i.e., some people report painful physical sensations in the absence of any medical test findings, and other people have positive medical test findings indicating disease or injury, and yet report little or no pain
• There are no medical tests which directly measure pain

• Refers to perceived inability or difficulties in performing certain valued physical activities
• Usually refers to inability to do the things that you used to do
• Caused by many factors in addition to actual physical impairments, e.g., degree of motivation or effort, attitudes, mood states, general physical health, etc.
• Distinguish subjective perception of disability from definitions and criteria used by various disability compensation systems

• Refers to negative emotions and thoughts commonly associated with pain and disability, e.g., anxiety, fear, frustration, anger, depression, and general misery
• It is not always the pain per se that produces suffering, rather it is the way you see and react to pain that determines the degree of suffering;  i.e., some people have significant pain, but very little suffering, whereas others have little pain and significant suffering
• It is very important to learn how to distinguish pain from suffering; unfortunately, for most persons with chronic pain, the two become entwined together

Refers to the collection of additional problems which frequently accompany chronic pain conditions. They may include any combination of the following:

• Interference with work and leisure-time activities
• Decreased income, increased financial pressures
• Activity intolerance
• Reduced social activities, social withdrawal
• Feelings of depression & discouragement, anger & irritability, tension & worry
• Decreased interest in previously enjoyed activities combined with increased preoccupation with pain
• Interference with concentration and memory
• Decreased self-confidence and self-esteem
• Negative attitudes regarding self, others, and life in general
• Misuse of pain medications or alcohol
• Development of secondary physical problems and complaints
• Sleep difficulties
• Decreased sexual interest and/or problems with sexual performance
• Conflicts with medical providers and disability compensation systems

Not everyone with chronic pain possesses all features of the chronic pain syndrome. In fact, it is possible to have chronic pain and not possess any of the above characteristics

Conclusion Regarding Pain Concepts

Failure to understand the differences among these pain-related concepts has resulted in much confusion on the part of doctors, pain patients, and their families. The primary goal of self-management is to decrease or even eliminate disability and suffering, as well as other negative features of the chronic pain syndrome.

The Myth of Physical vs. Psychological Pain

One of the most harmful and erroneous views held by many medical professionals and laypersons alike is the idea that pain must be either physical or psychological in origin. According to this commonly held and misleading idea, physical pain should be readily identified and successfully treated with medical diagnostic and treatment procedures. When the patient's pain complaints are not successfully verified through medical diagnostic procedures and/or the patient fails to respond to medical/surgical treatment procedures, it is assumed by doctors that the patient's pain is psychological. Another commonly used term for psychological pain is "psychosomatic." The idea that the patient's pain is psychological rather than physical is further reinforced if the patient shows signs of emotional distress, presents "exaggerated" pain complaints (from the viewpoint of the doctor), or admits having other life problems. Patients who hold this incorrect view usually assume that the doctor is incompetent if their condition is not adequately diagnosed or treated through medical means. According to this myth, pain that is physical in origin is real or legitimate, whereas psychological pain is seen as unreal, imaginary ("all in the head"), and illegitimate.

This distinction between physical and psychological pain is based on the philosophy of dualism which has pervaded Western medicine and culture. Dualism, which is commonly attributed to the French philosopher, Rene Descartes, separates mind and body. As emphasized throughout this Pain Handbook, we reject the philosophy of dualism. Mind and body are not separate. Pain is not physical or psychological, it is both. Pain is ultimately processed and experienced by the mind-brain system which includes both physical (sensory), mental, and emotional components. This is further discussed in the next two chapters, "Biological Aspects of Pain" and the "Biopsychosocial Model of Pain."

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