There has been much debate about our painstaking essay, “Questioning Border Between pain and suffering.” We have argued that pain is not simply the cause of suffering, but that the two have a more complex, interrelated relationship. This comes in part from our decades of caring for patients with chronic pain. The standard view of many patients and clinicians is that these patients have one central problem, chronic pain, from which all their other problems stem. But these patients have many problems: medical problems, psychological problems, and social problems that feed on each other. They have both real pain and real suffering.
Modern pain medicine physicians are accustomed to understanding suffering as a consequence of pain, and pain reduction as the primary means of alleviating suffering.. When the relationship between pain and suffering is understood to be bidirectional, suffering can be understood as both the cause and the effect of pain. Suffering and pain can be alleviated by changes in meaning, as well as by reducing the intensity of sensation. More than 300 years ago, Rene Descartes began the modern mechanistic understanding of pain with his description A treatise on man The boy with his feet on fire. This picture created a scientific ideal of meaningless pain mechanisms that should be rejected. We need to put Descartes’ son with his foot in the fire back into context to help explain why his foot is in the fire as well as how the fire causes pain. Years ago, pain pioneer Patrick Wall compared how he felt after hitting his thumb with a hammer to how it felt after hitting someone else’s thumb. This difference cannot be explained by the Cartesian model.
Some pain specialists continue to argue that we cannot explain pain without explaining it in terms of tissue damage and nociception (nerve activation by tissue damage). It ignores chronic pain syndromes that are very common fibromyalgia. They are considered a type of “nociplastic” pain that arises from brain processes and do not involve tissue damage or nociception at all. This type of pain is particularly vulnerable to tissue damage and is believed to have psychological implications trauma.
These pain experts argue that both suffering and pain are experiences, not “things” that cause other things, events, or experiences. This is a version of the philosophical doctrine of “epiphenomenalism,” which recognizes mental experiences such as pain as real but denies them any causal power. According to this view, the brain produces experiences that do not affect brain processes or anything else, including voluntary actions (these are illusions). In this view, only mechanical causes are regarded as real causes, since they act like billiard balls hitting each other. Furthermore, we must ask, if experiences such as pain do not have causal power, how did they develop and persist? How can the development of pain be explained if pain has no causal power or survival value?
Our main argument is that we have too easily separated suffering from pain and understood suffering as a causal product of pain. In its purest form, this perspective describes pain as the product of impersonal causes (eg, tissue damage and nociception) and suffering as the product of personal meanings (eg, threat, danger, and loss). But this is not compatible with modern pain neurologynor with the complex interrelationships of pain and suffering encountered in the clinical practice of pain and pain psychology.
Perhaps we should consider suffering as the cause of pain equally valid for nociception. This shift is easier to apply to chronic pain than to acute pain. But here are the main unsolved problems in the treatment of pain. Indeed, some of the newer psychotherapies such as pain processing Therapy (PRT) and Feeling Mindfulness and Expression Therapy (EAET), targeted experiences of threat, danger, and psychological trauma as a means of pain relief.
The subordination of pain to suffering undermines the medical model of most pain medications. It stops prioritizing pain as a physical cause. Instead, it subordinates pain to suffering understood as an inevitable feature of human existence. This is similar to the Buddhist understanding of suffering philosophy as depicted in the four noble truths. The first of these is the reality of suffering (Dukkha). It means that life by nature contains dissatisfaction, pain and instability. This includes physical pain, emotional distress, and impermanence of pleasure. The rest of the truths explain that suffering is caused by desire, desire, and desire attachment to temporary things. And by giving up craving and attachment, suffering can be ended.
This is not a proposal to turn pain management into a form of religion. It is only to suggest what might happen if our clinical and research concerns moved from the periphery to the center.
