Well-integrated pain observers modulate aversive arousal through late top-down neural processes

By Robin Caryn Rabin

Can looking at the photograph of a loved one make pain go away? Numerous studies show that strong social connections have benefits for health. People who have active social lives seem to live longer than those who are isolated, and married cancer patients have a better outlook than divorced cancer patients. Now, a study suggests that merely looking at a photograph of a loved one can relieve the sensation of physical pain.

Psychologists at the University of California, Los Angeles, recruited 25 women who had steady boyfriends. Using a tool that applied heat to the women’s forearms, they turned up the temperature until it was slightly uncomfortable and asked the women to rate the pain they experienced on a scale of one to 20.

The researchers manipulated the heat and recorded the women’s reactions under different conditions: while she was looking at a photo of her boyfriend, or a photo of a complete stranger and a chair. They also had the women rate the pain while they held the hand of a stranger hidden behind a curtain, and as they held their boyfriend’s hand or a squeeze ball.

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Mark Gertskis

The growing misuse of powerful prescription opioids has prompted calls for the approach of managing chronic pain to be reconsidered.

Dr Penelope Briscoe, Dean of the Faculty of Pain Medicine at Australia and New Zealand College of Anaesthetists (ANZCA), said Australia was heading towards the situation in the United States, where more people were abusing prescription drugs than cocaine, heroin, hallucinogens, ecstasy and inhalants combined.

She said there was anecdotal evidence emerging of the growing abuse of strong opioids such as morphine and OxyContin (oxycodone), despite a lack of a comprehensive study.

“It’s really hard to know and that is something that we should be looking at,” Dr Briscoe told Pharmacy News.

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Walter Van der Broek

There is a significant decline in empathy occurs during the third year of medical school. This decline occurs during a time when the curriculum is shifting toward patient-care activities.

  • There is a significant decline in empathy during third year of medical school, regardless of gender or specialty interest.
  • Every year women scored significantly higher than men.This seems to be regardless of population studied. It also appeared in Italian Physicians and Japanese medical students.
  • Except for scores at baseline, students interested in people-oriented specialties scored significantly higher than students interested in tech-oriented specialties.
  • The magnitude of the decline (effects) was much smaller for women and students interested in people oriented specialties. 

Why is empathy important?
Responsiveness to the emotional state of another plays a fundamental role in the patient doctor relationship (PDR) as well as in other human interaction. Sympathy and empathy are not the only responses in the PDR. Other responses can be consolation, kindness, politeness,compassion, and pity.

What is empathy (the long version)?
The most clarifying definition of empathy is based on viewing it as a process. This process of empathy consists of the following stages.

  • The patient expresses feelings by way of verbal and non-verbal communication. Patients are not always aware of these expressions.
  • The doctor also notices these emotions in himself more or less voluntary, more or less conscious. He or she coming aware of these feelings usually comes after the fact (affective empathy).
  • Realizing these feelings as being from the patient is the cognitive empathy. Together with everything the doctor knows about the patient as a patient and as a person, he or she is coming to know the inner feelings of the patient(cognitive empathy).
  • The doctor can now express these feelings for the patient or act on them for the patient(expressed empathy).
  • The patient receives this empathy (received empathy).

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The definition is as follows: 

“An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. 

Note: The inability to communicate verbally does not negate the possibility that an individual is experiencing pain and is in need of appropriate pain-relieving treatment. Pain is always subjective. Each individual learns the application of the word through experiences related to injury in early life. Biologists recognize that those stimuli which cause pain are liable to damage tissue. Accordingly, pain is that experience we associate with actual or potential tissue damage. It is unquestionably a sensation in a part or parts of the body, but it is also always unpleasant and therefore also an emotional experience. Experiences which resemble pain but are not unpleasant, e.g., pricking, should not be called pain. Unpleasant abnormal experiences (dysesthesias) may also be pain but are not necessarily so because, subjectively, they may not have the usual sensory qualities of pain. 

Many people report pain in the absence of tissue damage or any likely pathophysiological cause; usually this happens for psychological reasons. There is usually 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. This 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”.  


1. The first sentence in the defintion associates pain with tissue pathology. What follows in the Note refers to the ‘subjectivity’ of pain. There seems to be an epistemic priority in play between the ‘objective’ measure of pain in terms of tissue insult and the ‘subjective’ criterion of when to categorize an experience as pain. The definition appears to accord authority on the nature and amount of pain to the patient (first-person authority). If this is correct, then pain researchers are studying the objectively observable causes of a subjective experience, but not pain characterised as an objective physical state. According to the definition, all objective measures of pain (eg, neuroscientific explanations) are logically prior to the subjective ones. Is this analysis accurate? Not quite. The IASP definition is compatible with neuroscientific discovery of pain experiences as states of the brain; for then objective measures will likely have not less than equal epsitemic authority. Still, it is curious the definition grants this, but leaves open the question of the nature of pain. 

2. What might explain the epistemic priority in the IASP definition? I suggest that it is the first-person authority (near-infallability) of pain self-report. Consider the statements (1) and (1*): 

(1) I am in pain. 

(1*) Susan is in pain. 

What does ‘being true’ amount to in these statements? I think it amounts to something quite different. The truth of (1) is guaranteeed by truthfulness, since it is not liable to mistake or error, only to insincerity. I give three reasons for this claim: 

– (1*) can be verified, but not (1). Is there such a thing as my ‘finding out’ that I am in pain or ‘recognizing’ pain from my sensations?

– (1) cannot allow of error or doubt, but (1*) can. The subject of pain cannot misidentify himself/herself or misapply pain language (‘I thought I had a pain, but it was an itch, and it was Susan’s, not mine’ seems nonsensical);

– (1) does not express a knowledge claim, but (1*) does.

Courtesy of Jessica Palmer, Biophemera


Jeanna Bryner,

A social snub can deliver a seemingly painful blow. Now, it turns out that sting may be real. A gene linked with physical pain is also associated with a person’s sensitivity to rejection, a new study finds.

The discovery doesn’t suggest that being chosen last for a pick-up ball game, say, will send you limping off the field. Rather, a rare form of the so-called mu-opioid receptor gene (OPRM1) is likely involved in the emotional aspect of physical pain — essentially, how much a person is bothered by a throbbing leg, for instance.

In the study, 122 participants indicated how much they agreed or disagreed with statements, such as “I am very sensitive to any signs that a person might not want to talk to me.” Their saliva was also analyzed for OPRM1. (People with a rare form of OPRM1 experience more physical pain than others.)

Then, the researchers used functional magnetic resonance imaging (fMRI) to scan the brains of 31 of the participants during a virtual ball-tossing game. Initially, each participant was included with two virtual players before being excluded when the virtual players stopped throwing the ball to them.

Individuals with the rare OPRM1 variant were more sensitive to social rejection. The mutant-gene carriers also showed more activity in brain regions linked with physical and social pain, including the dorsal anterior cingulate cortex and anterior insula.

Such social pain may have benefited our ancestors. “Because social connection is so important, feeling literally hurt by not having social connections may be an adaptive way to make sure we keep them,” said study researcher Naomi Eisenberger of UCLA.

She added, “Over the course of evolution, the social attachment system — which ensures social connection — may have actually borrowed some of the mechanisms of the pain system to maintain social connections.”

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JM Livengood,

The author, a psychologist in a pain control center, was asked by the editor of The Clinical Journal of Pain to relate her personal experience with neuropathic pain. Her chronic pain began six years previously when her car was rear-ended by a large tractor-trailer truck. After several weeks of traction, rest, and a cervical collar, healing began. One year later she was re-injured in a fall and in addition to the cervical injury also injured her lumbar spine. She experienced right upper and lower extremity numbness, loss of fine motor skills in the right hand, and difficulty walking. Despite her neurosurgeon’s urging to maintain strict bed rest for two months, she put herself on a walking program to prevent muscle atrophy. She continued to have chronic pain with occasional flare-ups.

Several months later, in the process of building a patio lounge chair, her already weakened spine was again injured. She required surgery, including a fusion at C4-5, along with removal of a ruptured disc and removal of several fragments from the spinal canal. Presurgical nerve damage caused prolonged motor weakness and numbness. Also, when the bone graft was removed from the iliac crest, injured nerves left her with neuropathic pain in the left thigh and leg. During the subsequent healing months, the author learned personally about definitions of complex regional pain syndrome (CRPS), allodynia, dysesthesia, hyperesthesia, and about listening to patients in pain and believing their story. She discusses several “do’s and don’ts” for surgeons and for patients, related to her personal experience. Probably the most valuable advice for pain management professionals is to listen to your patients. Ask them what is wrong and they will tell you. It is common to ask patients questions which relate to the experience of chronic pain, but do not seem to relate to CRPS symptoms. For example, “When is your pain worse?” “What positions worsen pain?” While these activities do relate to chronic pain, there is no mention of experiences that affect neuropathic pain such as encountering a sudden blast of water while in the shower, walking into an air conditioned room, or walking outside on a windy day. Also, questionnaires contain descriptions of chronic pain symptoms but not CRPS symptoms such as crawling ants, stinging bees, and soft cotton being rubbed across one’s skin. The author describes the feeling of cold air from air conditioning or wind contacting her skin feeling like lightning-sharp goose bumps like cactus spikes. She experienced an intense burning, stinging sensation as though a swarm of angry yellow jackets was stinging profusely and unrelentingly. Areas of her skin felt hot and cold simultaneously. She had a feeling of soft puffs of cotton containing shards of razor-sharp steel being rubbed agonizingly slowly over her skin where the bone graft was taken. Also, she described a feeling of a soft feather being rubbed tortuously slowly and softly over her skin. These are symptoms which the author feared no one would believe if she actually described how they felt.

As a psychologist, she never actually disbelieved, but did doubt patients who told her they hurt too badly to comply with their relaxation and visual imagery exercises. She never disbelieved, but did doubt patients who reported that their pain “moved” or increased after receiving a nerve block. As a patient, she learned what they meant.

She emphasizes the importance of treating patients with empathy, respect, and explanations of treatments. One of the most beneficial things she gained by being a patient is to listen to her patients and try to actually hear what they are telling her, instead of listening for what she thinks the patients should say in order for her to impose a known treatment on a familiar sounding problem. She believes persons stereotyped as “professional” patients may simply be patients seeking professional help.

Journal: Clin J Pain, 12(2):90-93, 1996. 0 References Vanderbilt Pain Control Center, 401 Medical Arts Bldg., 1211 21st Ave., South, Nashville, TN 37232 (Dr JM Livengood) JAC.03 OC9608/278 ©1996.


Claudia Campbell,

Pam and John are currently in physical therapy following similar car accidents. They both are receiving therapy for strained necks. However, Pam appears more “down” and catastrophizes that her physical therapy sessions are more painful than helpful. John, on the other hand, routinely trades jokes with his physical therapist during each session and remarks positively on the improvements to his health and functioning. Why do these two patients have such different responses to pain, and are their responses linked to their personalities or their gender?

A variety of characteristics, from genetics to psychosocial processes, contribute to how people perceive pain. A person’s sex (a more biologically-driven term)/gender (a sociocultural term) emerged as a critical factor in shaping the experience of pain. Over the last 15 years an explosion of research has documented differences between how men and women respond to pain and analgesic medications meant to reduce pain (see Greenspan et al., 2007 for a comprehensive review).

Women are more likely than men to report acute and chronic pain, and they use pain-relieving medication more often, even when equating for pain severity. Women also have greater prevalence (in many cases, 50-100% higher relative to men) of many chronic pain conditions including headache, temporomandibular joint disorder (TMD), fibromyalgia, irritable bowel syndrome, and arthritis8, and they report greater pain than men in experimental models, where healthy individuals undergo standard noxious stimuli2.

A number of psychosocial and interpersonal variables also contribute to pain; a few of the well-studied factors include age, race/ethnicity, mood, and coping. A great deal of study has focused on catastrophizing, a maladaptive coping strategy characterized by a negative cognitive and affective response to pain (like feelings of helplessness, magnification, and ruminative thoughts about pain), which is more common in women. Sex differences in catastrophizing may mediate the difference between men and women with chronic pain and in experimental settings1. Similarly, depressive symptoms are more frequently reported by women and have been found to predict future musculoskeletal disorders like low back pain.

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