Introduction

The Concept of Pain

Usefulness of Pain

Experimental Investigation of Pain

Causes of Pain

People Who Do Not Experience Pain

Relief of Pain

Pain and Personality

Conclusion

References

On undertaking this study of pain as part of the requirements for a course in personality study, several of his colleagues questioned the author about what personality has to do with pain. After considerable research through the literature on the subject the author has found the answer to that question to be "practically everything." This paper is a summary of the implications of pain for people and the effects that personality has on the perception of pain.

The phenomenon of pain is rather complex. To understand its relationship to people we should have a concept of what pain is, evaluate the usefulness of pain, examine the experimental investigation of pain, understand the causes of pain, study people who do not experience pain, evaluate the methods used to relieve pain, and evaluate the effect of personality on the perception of pain.

Pain is a complex experience that is not measurable or observable by anyone other than the person experiencing the pain. To a person in pain, there is no ambiguity, no difficulty in knowing what pain is, and no need for discussion of its objectivity or subjectivity. To him, pain is painful and it hurts. To someone studying pain, however, it is necessary to begin with a concept of what pain is and what it is not as far as his purpose for studying pain.

Pain to the physician usually implies a perceived physical sensation, whereas to the theologian pain probably means mental or spiritual anguish more than physical suffering. The point of view of this study is more from the physical sensation of pain than mental anguish, although it appears there is no dividing line between the two concepts.

A definition of the subject matter is always a good starting point in any study. Along with attempting to define the subject it will be helpful to examine inferences of pain in others, and theories of pain.

Sternbach (1968, pp. 11-12) attempts to define pain considering the fact that pain is something that cannot be simply defined without the risk of circularity or omission. He defines pain as:

...an abstract concept which refers to (l) a personal, private, sensation of hurt; (2) a harmful stimulus which signals current or impending tissue damage; (3) a pattern of responses which operate to protect the organism from harm. These responses can be described in terms which reflect certain concepts, i.e., in neurological, physiological, behavioral, and affective "languages."

This is the general concept of pain that this paper will use.

To study pain, it is necessary to know when it is occurring in others. Although one person can never experience the same thing that another is experiencing, it is possible to make inferences about what another person is experiencing by observing his responses and ongoing behavior.

Zborowski (1969) lists five general groups of behavioral responses made by individuals in pain: (1) motor responses (twisting, wriggling, movement of the body or its parts, walking, jumping, clenching teeth); (2) vocal responses (moaning, groaning, crying, screaming); (3) verbal responses (complaining, cursing, talking about pain, asking for help); (4) social responses (withdrawal from people, changes in communication patterns, changes in social manners or personal appearance); (5) the absence of manifest behavior (hiding of pain or suppressing external signs of pain). An individual's behavior in pain may be any combination of these response categories. According to Barber (1959), the response to a noxious stimulus normally includes at least four components: the sensation of pain, discomfort, withdrawal movements, and some measurable physiological alteration such as a change in blood pressure. The latter two responses are the only ones that are observable to someone other than the person in pain.

Although we all know pain, it appears that our inferences about pain in others are limited to only a few observable behavioral characteristics.

Melzack and Wall (1965) summarized two historical concepts of pain and the various theories supporting those concepts. One concept, or theory, holds that pain is a specific modality like vision or hearing, with its own central and peripheral components. This theory, called specificity theory, proposes that there are specific pain receptors in body tissues which project to a pain center in the brain. It maintains that free nerve endings are pain receptors that generate pain impulses carried by specific nerves and neural tracts to a pain center in the thalamus. The lateral spinothalamic tract in the spinal cord has generally been considered to be the transmission tract for these impulses.

Problems with this theory derive from the requirement for specific receptors and physiological as well as psychological specializations of central nervous system components. This implies that stimulation of these receptors must always elicit pain and only pain. It also implies that severing the pathways or destroying the pain center in the brain would eliminate the experience of pain while leaving other modalities intact. Studies discussed later in this paper indicate that, in fact, these things do not obtain.

An opposing theory, called the pattern theory, holds that intense stimulation of nonspecific receptors produces the nerve impulse pattern for pain since there are no specific nerve endings. This theory proposes that stimulus intensity and central summation are the critical determinants of pain.

The coding of neural impulses described in this theory involves which neurons are firing, the rate at which they are firing, and the excitatory or inhibitory influences on their transmission to the brain. Pain, in this theory, is a particular pattern of neural activity that the brain receives. The particular parts of neurophysiology involved in this coding, transmission, and receipt of pain impulses vary among several different theories, but they generally agree on the concept of special coding for pain. The authors propose their own theory of "gating" to resolve many of the problems with the two basic theories. The gating theory proposes that neural impulses are directed, controlled, and eliminated at various levels of the nervous system. Their theory attempts to answer the many experimental and clinical observations that did not support the other two basic theories of pain.

Rather than considering pain from these restricting viewpoints, Murray (1969) discusses pain in the dimensions of physiological, cognitive, and affective components of the total pain experience. Physiologically, pain is usually discussed in terms of peripheral or cutaneous pain, and visceral pain.

If the skin were explored or mapped with suitable instruments such as a needle point, warmth or coldness, or a feather, it would be evident that sensations associated with these distinct types of stimuli are not distributed evenly throughout the body. The tips of the fingers provide delicate sensitivity to touch or pressure, and so does the eyeball. The eyeball is very sensitive to pain, whereas the finger tips are relatively insensitive to pain.

The sensitive spots on the skin surface vary in frequency in descending order as follows: pain spots, touch spots, cold spots, and warm spots. Other skin sensations are considered to be variations of these four basic sensations.

This mapping of skin sensitivities led to the idea that there must be different receptors in the skin for the different sensations, and considerable work has been done along this line. However, later studies have shown that there appears to be little support for specialized nerve receptors. A pin that pricks and causes pain also produces the sensation of pressure and if it is heated or chilled, will also produce the sensation of warmth or cold.

Visceral pain may be subjectively different from cutaneous pain. Visceral pain often seems more severe, long-lasting, and less well localized, having a diffuse irradiating quality that makes it difficult for physician or patient to pinpoint the source. Sympathetic nerves carry most visceral pain impulses; however, there are exceptions.

The parasympathetic pelvis and vagus nerves convey pain impulses from organs that they innervate. At times, visceral pain may appear to arise from an area on the skin surface. Various hypotheses have been offered to account for such pains. Irritation of pain pathways from the skin by the neighboring visceral pathways may occur. Afferent nerves from visceral and cutaneous areas converge into the same neurons at the spinal cord, so the information whether the impulses began in visceral or surface areas may be lost.

Pain has other than physiological components. Physiology has been unable to explain pain; therefore, the cognitive and affective aspects of pain must also be considered. Pain is related to unpleasantness, but in what way painful stimuli are directly appreciated in experience is not known. Clearly experience influences the interpretation of pain and that pain is amplified by the behavior it evokes.

Anxiety is a basic element in the reaction component of painful experience, especially pain arising from pathology and trauma. The role of anxiety in the experience of pain is not only one of being produced by pain or anticipation of pain, but also one of having a pronounced effect on the pain experience itself. Anxiety appears to increase sensitivity to pain and to lower tolerance of pain. Pain need not be related to amount of injury, but more to the person's perception of the painful situation.

Although some have argued that pain is a useless evil because often it arrives too late to serve the useful function of warning as in cancer, or often pain is present when no warning is needed, most people view pain as useful. Sternbach (1968, p. 106) summarizes the views on the utility of pain. He observes that it is true that much pain serves no function that can be determined. Pain does serve as a warning signal for impending injuries. It causes most of us, most of the time, to avoid sprains, fractures, burns, etc., that would otherwise leave us crippled and open to severe infections. As a result of early experiences with pain we now behave in such a way as not to damage ourselves.

The cases of people who were insensitive to pain dramatically point out the problems that occur without the ability to experience pain. Because of the protective function that pain provides, although sometimes ineffective or incorrect, we cannot say that pain is only a senseless and unnecessary evil as some have done. Zborowski (1969, pp. 24-25) discusses the utility of pain from the viewpoint of biological utility in the preservation of life. He states that its primary function is to warn the organism against dangers threatening its integrity.

Painful agents carry a potential danger of destruction. Their contact with the organism produces the sensation of pain and a state of alarm. This state of alarm is manifested in protective activities of a reflex nature that are directed toward avoidance or escape from the source of pain and thus protect the body from injury. The organism tries to withdraw from the noxious stimulus if it is external or to expel it if it is internal. If withdrawal or expulsion is impossible, the organism mobilizes its resources to fight the danger and counteract its effects.

On a cognitive level the sensation of pain causes a state of anxiety, which stimulates the organism to take steps necessary to protect itself against the threatening agent. The sensation of pain does not indicate a potential danger, however, because the sensation has been found in the laboratory to begin with the actual beginning of tissue destruction. Thus on the biological level the function of pain is to mobilize automatic and cognitive activities directed toward the defense of the organism from noxious agents that may present a threat to the survival of the individual.

Through conditioning or other forms of learning, the biological significance of the pain sensation becomes associated with the noxious stimulus--the pain-producing object. In these cases the pain stimulus or object becomes a symbol for pain and the organism learns to avoid pain by avoiding these objects. Any sensory perception of the pain symbol may have the same effect as the actual perception of pain and the organism reacts appropriately to it. Thus, when burned one withdraws his hand from the fire and avoids all possible contact with burning objects.

Sternbach (1963) describes cases where pain perception has been absent and presents a dismal outlook for those who cannot experience pain, particularly young children. Young children with this syndrome have mutilated themselves by chewing off the tips of the fingers and tongue, by picking off the nares, and by suffering severe burns when leaning against stoves or sitting in scalding baths. Reported instances of unknown physical damage are varied. An 11-month-old infant chewed its fingers and tongue, banged its head on the wall, and showed no withdrawal from pinprick or painful heat stimuli. One patient sustained a painless fracture of the leg in a football game, another died of a ruptured appendix and painless peritonitis, another suffered extensive skin and bone trauma that contributed directly to her death.

Sternbach also indicates that there are some valuable effects derived from insensitivity to pain. A mother who was insensitive to pain was more than usually sensitive to signs of disease in her seven children who had the same disorder. Because of this she has been able to prevent serious damage from developing from minor traumas. One of her children suffered painless appendicitis with peritonitis. The mother's prompt reaction to his casual remark about a "stiff stomach" saved him. Another benefit from the syndrome came to this mother's aunt who died of extensive cancer but felt no pain--only some discomfort in the terminal week.

Sternbach also noted that there is a high incidence of injury among those who are congentially insensitive to pain. He also noted that injury occurs relatively infrequently among those who are indifferent to pain such as those who are lobotomized or are receiving morphine.

The usefulness of pain becomes immediately apparent when case histories of people who do not experience it are examined. Ogden, Robert, and Carmichael (1959) studied a 14-year-old girl who was completely indifferent to pain and from all available evidence appeared to have been born with the deficit. When she was 10 months old her parents noticed that she chewed her tongue, causing large ulcers that eventually led to the destruction of the tip of her tongue. When she was 2 years old a playmate pulled out handfuls of her hair. When she was 3 years old she smashed her fingers in a door; at 4 she had a severe laceration of the forehead. In each of these injuries she showed no evidence of pain, and her injury was unsuspected until noticed by her parents. At the age of 6 years her right hip became swollen over a period of two weeks. Initially she limped slightly, but the limp became progressively worse until eventually she could not move her leg. Three weeks after the onset she was admitted to a hospital where a fracture of the right femur was diagnosed.

At the age of 10 years she fell while playing and noticed on getting up that her wrist bent the wrong way. She had a compound fracture of the left wrist that was completely painless. As she grew older she matured considerably and made a better adjustment to her disability. She became more careful to avoid injury and was generally successful except occasionally she found blisters on her fingers from burns of which she had been unaware.

0n initial examination of this girl the authors found a multiplicity of scars on her tongue, elbows, hands, knees, feet, and buttocks. Her right femur was slightly shorter than the left and her right knee was badly deformed and swollen in size. Undoubtedly, this girl would have been immeasurably better off is she was able to experience pain.

There has been much criticism of investigating pain in the laboratory because of the difference between experimentally-produced pain end pathological pain. Obviously, pain produced by the dolorometer is different from pain produced by cancer, but laboratory study of pain seems to be essential if proper experimental controls are to be used.

Sternbach (1968, pp. 21-26) concluded that it may be entirely possible that pain responses may be produced in the laboratory that are comparable to those found in pathological pain if certain stimulus conditions are met. Given certain minimum characteristics of intensity, duration, etc., it is possible for experimental subjects to respond in ways that do not distinguish them from patients with pathological pain.

Anxiety is an important component in the pain response and as such must be controlled if experimental pain is to approximate pathological pain. It appears that fairly intense physical stimulation and a moderate degree of anxiety can elicit pain responses in the laboratory that are virtually indistinguishable from pathological pain as seen in the hospital.

There are two basic psychophysical procedures that have been used in the investigation of pain perception and measurement. The first yields a measure of pain sensitivity in intensity and involves the detection of painful stimulation when various controlled intensities are presented at a fixed stimulus duration. The second provides a temporal measurement of pain sensitivity and involves the detection of a transition from subjective warmth or heat to pain. This procedure involves a painful stimulus of fixed intensity applied to a subject who is instructed to terminate the stimulation when it becomes painful (Dillon, 1971).

Murray (1971) described the method of producing pain by means of muscle ischemia. This method of producing experimental pain consists of a blood pressure cuff inflated above systolic pressure that stops blood flow to the arm. A measurement of pain tolerance is obtained by requiring subjects then to do work with the hand or arm muscles such as making a fist or squeezing a rubber bulb that displaces a measurable amount of water. Subjects can signal verbally when the sensation in their arms turns to pain and can stop the work when pain becomes intolerable.

Many methods of inflicting pain experimentally have been employed. Some of these are electrical shocks to teeth, pinpricks, chemical agents, and tourniquets. Hardy, Wolff, and Goodell developed a method ofmeasuring pain compared to amounts of heat on the skin. This became the preferred experimental method. This type of experimentally produced pain did not change dependably with morphine or other powerful analgesic agents, whereas pain of pathological origin as encountered in medicine always responded in some degree to analgesic agents.

On the assumption that these experimental pain methods may have produced a pain that was too sudden and fleeting for the analgesic agents to have effect, tourniquet pain was used. With pain produced in this manner morphine was found to be consistently effective in alleviating the development of pain. This was a significant development because now, experimentally contrived pain could be shown to respond to morphine in the same dependable manner as pathological pain. With this it became possible to study the pain-relieving effects of different analgesic agents without using patients who have pathological pain.

Pain is not the same thing as discomfort or suffering. It can be caused by a variety of noxious stimuli, by damage to brain structures causing central pain, and by psychogenic factors. A variety of stimuli and events not associated with stimulation can arouse physical sensations of pain. This is called central pain or psychogenic pain.

Generally, very little is known about causes of pain other than those associated with noxious stimuli. Noxious stimuli can invade a person's experience and produce discomfort, pain, or a variety of other sensations. When noxious stimuli are discriminated, differentiated and localized, pain may be experienced but not discomfort or suffering. The few cases that have been reported of congenital insensitivity to pain suggest that an individual may be able to sense a noxious stimulus and yet not show withdrawal movements, physiological alterations, or discomfort. Also, discomfort and suffering can be minimized or totally eliminated in some people by placebos, opiates, prefrontal leucotomy, and hypnotic suggestion without necessarily altering the sensation of pain or elevating the pain threshold. These people perceive pain but they are not disturbed by it (Barber, 1959).

Arousal of pain by noxious stimulation occurs in several ways. Severe mechanical, thermal, chemical, or electrical stimulation can induce pain at the skin surface. Distensions of various visceral organs also cause pain. Severe arterial dilation and constriction have been shown to produce pain. Inflammation has the effect of lowering the pain threshold rendering a person more sensitive to pain (Murray, 1969).

A pain stimulus is one that produces or threatens to cause some tissue damage and which elicits an escape or avoidance response. This includes the entire spectrum of kinds of physical energy, including mechanical, electrical, thermal, chemical, etc. The change can be described in terms of magnitude, intensity, concentration, rate, etc.

Implicit in this view of pain stimuli is the assumption that the stimuli for internal pains are also changes in physical energy. These changes can be of mechanical origin such as vascular changes, or chemical from the action of bacteria, viruses, hormones, etc. This view does not consider or explain pains that persist in the absence of continued changes in physical energy that are known to exist (Sternbach, 1969, pp. 28-29).

Barber (1959) asserts that the generally accepted view, that pain has its own peripheral receptors and its own pathways in the central nervous system, is misleading. Noxious stimuli activate various types of nerve fibers that travel in more than one pathway in the spinal cord and brain stem and which project from thalamic and extrathalamic pathways to wide areas of the cortex.

The response to a noxious stimulus is apparently brought about when a spatiotemporal pattern of neural activity set off by the noxious stimulus differs from the neural pattern set off by other stimuli. This difference involves the relative number of fibers of different sizes that are activated, the different energy values of the different fibers, the different frequency of responding, and the duration of responding.

It has generally been assumed that the free nerve endings, which are found widely scattered near the surfaces of the skin and viscera are the specific receptors for noxious stimuli. However, neuron studies have shown that people can discriminate cold, heat, touch, and prick. Then can discriminate just as well from the ear pinna, which contains only bare nerve endings and a basketlike network around the hair follicles, as they can from the skin of the forearm.

Additionally, it has been demonstrated that when suitably stimulated the free nerve endings of the skin cause a wide range of sensory experience that includes reports of cold, touch, warm, prick, itch, and sharp pain. Also, touch, warmth, and cold experiences are reported in addition to pain when appropriate stimuli are applied to the center of the cornea which contains only free nerve endings (Barber, 1959).

Sternbach (1968, pp. 27-28) points out that intact and functioning pain structures are not always associated with pain experiences or responses, and conversely, pain experiences and responses can occur in the absence of fuctionally intact pain structures. What is necessary and sufficient for the production of pain is that at some time early in the individual's development, the nervous system subserving pain was intact and pain responses did occur. Once this happens, other systems and events become equally important.

In attempting to answer the question of what causes pain perception to be a part of an organism's experience, Melzack and Scott (1957) performed an experiment on Scottish terrier dogs involving sensory deprivation early in life. Six litters of the dogs were used with an experimental group consisting of 10 dogs and a control group consisting of 12 dogs.

The experimental dogs were reared in isolation from puppies to mature dogs in cages that were designed to eliminate all sensory stimulation possible, and all social contact. The control dogs were reared normally in the laboratory and in private homes as pets. The restricted dogs were released from their cages after about eight months of age, and then they received the same opportunities for social and sensory stimulation as the normally reared littermates. Testing of the dogs was begun about three to five weeks after the restricted animals were released. In two tests involving strong electric shock, the restricted dogs required significantly more shocks before they learned to make the proper avoidance responses than their free-environment littermates. Some of the restricted dogs never learned to avoid the shock.

A test where the experimenter thrust a burning match toward the dog's nose while holding the dog showed normal avoidance responses such as moving the head end trying to get away in the free-environment dogs. In sharp contrast, however, the restricted dogs showed no avoidance behavior and allowed the experimenter to burn their noses with the match. Some even sniffed of the burning match and put it out. Similar results were obtained from pin-prick stimulation where the experimenter jabbed a large, sharp dissecting needle into the dog's skin at the sides and hind thighs about three or four times.

The outstanding feature of the behavior of the restricted dogs was their inability to respond adaptively and intelligently to the variety of stimuli that were presented to them. There can be little doubt that this kind of early deprivation has a significant effect on the perception of pain in adulthood.

The restricted adult dogs obviously felt the electric shock because their disturbance by it was marked and unmistakable. Some of the restricted dogs also reacted in some way to the pin-prick and contact with fire. However, their reactions appeared to be of a reflex nature and they appeared to be unable to learn to make avoidance responses.

The inadequacy of these dogs to cope with noxious stimuli cannot be attributed to inadequate response mechanisms alone. The lack of any observable emotional disturbance apart from the reflex movements in four of the dogs following pin-prick and seven following nose-burning indicates that their perception of the event was highly abnormal. This experiment suggests that perceiving and responding to pain requires a background of early, prolonged perceptual experience.

A cause of pain that is frequently overlooked by physicians treating the patient with chronic pain is a condition caused by trigger points in the muscles (Travell & Simons, 1983). Trigger points, also sometimes called myofascitis, are excessively tense spots in the muscles that have exquisite focal tenderness to pressure. There is a taut, palpable band of muscle fibers extending lengthwise for the length of the muscle. This band is sensitive to pressure and gives a local twitch response when moving pressure across the band.

A common characteristic of trigger points is the referral of pain to locations distant from the trigger point. Pressure on the trigger point often reproduces this referred pain and continued ischemic pressure on the trigger point usually causes considerable relief of the pain.

Although the brain is insensitive to pain, lesions in the central nervous system can produce the sensation of pain indirectly. Cassinari and Pagni (1969) have labeled pain of this type of origin as central pain. In the literature, they have found many accounts of central pain arising from spontaneous lesions and from surgical operations on the central nervous system.

Paradoxically, most of the operations were performed to suppress pain of peripheral origin but instead produced even greater pain from a central origin. Once surgeons have produced central pain in this manner, seldom have they been able to relieve or eliminate it before the death of the patient. One can readily appreciate the dilemma of a surgeon preparing to use stereotatic surgery against one form of pain only to face the possibility that the patient may have to suffer pain even more atrocious than that which brought him to the operating table (Cassinari & Pagni, 1969, p. 2).

Pain can be psychogenic as well as organic in origin. Sternbach (1968, p. 124) described an instance of severe psychogenic leg pain that was associated with a superficial ulcer. The man with this pain insisted on having the leg amputated and the surgeons accommodated him. This man then developed a superficial ulcer and severe pain in his remaining leg, and begged to have the remaining leg amputated. This time, however, he was successfully treated by psychotherapy and amputation was not carried out. Psychogenic pain need not follow the medical model of pain, which presupposes anatomic and physiological derangements that happen involuntarily. Psychogenic pain is best approached from the viewpoint that pain is purposeful rather than biologically necessary. The psychotherapist should watch for the consequences of pain rather than the causes (Murray, 1971).

It is interesting to look into the case histories of people who, for various reasons, are unable to experience pain. The most interesting are the cases of congenital insensitivity to pain. Other cases involve neurological disease or deficit that can be directly determined to be the origin of the deficit, and some people appear to experience pain but are indifferent to it. These latter cases are termed asymbolia for pain rather than insensitivity to pain. Sternbach (1963) states that three similar deficits in the ability to sense pain can be distinguished by a careful neurological examination. These three syndromes are: (l) progressive sensory radicular neuropathy, a hereditary disease which begins with degeneration of the sensory neurons in the extremities; (2) nonprogressive sensory neuropathy, of unknown etiology, which may involve cranial and thoracic nerves as well as the limbs, and which differs from congenital insensitivity to pain in that deep tendon and axon reflexes are absent in the involved areas, there are other sensory deficits than pain, and demyelination is apparent in sensory nerve biopsies; (3) congenital insensitivity to pain, in which sensory nerve biopsies appear normal.

Sternbach (1963) also distinguishes between congenital insensitivity to pain and indifference to pain (asymbolia for pain). For a case to be classified as congenitally insensitive to pain, the definition of each word in the name of the syndrome serves as a criterion to be met. Thus, the defect must be present from birth, rather than acquired as a possible secondary manifestation of a disease process or traumatic injury. There must be a general insensitivity to pain, that is, an insensitivity to a variety of potentially noxious stimuli over the entire body, with no or slight involvement of the other sensory modalities. There must also be no general mental or physical retardation. Asymbolia for pain is a condition where the person feels pain but is indifferent to it and who makes no avoidance responses due to the pain itself.

Ogden, Robert, and Carmichael (1959) defined the term "congenital indifference to pain" by stressing that the term should only be applied to people who, perceiving correctly the nature of stimuli at normal thresholds, fail to react in the usual defensive manner with withdrawal of the offended part, acceleration of pulse and respiration, and elevation of blood pressure as in a healthy person. Futhermore, they should not be mentally deficient, and should have normal deep tendon and cutaneous axone reflexes and normally innervated skin on histological examination. The authors also require the condition to have been present from birth. These qualifications seem to be extreme and if followed literally would probably exclude many people from this category who otherwise exhibit most of the symptoms of the syndrome.

Sternbach (1963) in a survey of the literature before that time concluded that congenital insensitivity to pain is very rare. When he imposed the requirements for all the criteria he described, he could report that he found no cases that he considered certain. He considered only 17 probable.

Ogden, Robert, and Carmichael (1959) reported the case of a girl who had an otherwise normal sensory apparatus except for deficits in taste and in smell. The authors attributed her inability to taste sugar, salt, quinine, or tartaric acid to extensive scarring of her tongue due to self-inflicted tongue damage when she was an infant.

This girl had a Terman-Merrill IQ of 126, and a psychiatric examination did not elicit anything suggestive of a hysterical reaction. Her tendon reflexes were present, plantar responses were flexar, and the corneal reflexes could be elicited but were less brisk than normal. Her sensory perception of light touch and tickling, small ranges of movements at the joints, vibration, and point discrimination were all normal.

She could easily distinguish small differences in temperature of an object placed against her skin, and she could distinguish between the sharp and blunt ends of a pin. She was also able to recognize the nature of objects placed in her hands when she closed her eyes. Her sensory threshold was normal everywhere except near her knees, where it was slightly elevated. This elevation of threshold near her knees was attributed to the trauma that her knees had undergone in past years.

Most noticeable about this girl was the fact that the reactions usually associated with pain could not be produced even with the strongest of stimuli. Electrical stimulation up to 100 volts was used, but caused her no discomfort although it occasioned violent muscular contraction. The examiner found 100 volts to be intolerably painful to himself.

Several other attempts were made to try to elicit pain in the girl by using devices known to produce pain in normal people. These included inflating a blood pressure cuff on her arm and having her make a fist 130 times (a normal person experiences severe pain after only 40 to 60 fists), immersing her hand in water at temperatures of 1C and 65C, deep pressure on the Achilles tendon, intravenous injection of histamine, and pressure on her eyeball.

Histamine produces severe headache in normal people, but she reported only a bad taste in her mouth and a throbbing in her head, but no headache. Pressure on her eyeball caused her heart rate to drop from 96 to 84 per minute but no expression of pain. Other attempts were made to compare her perceptions with normal people--one of which was to dust her skin liberally with itching powder. Her skin made the usual reaction except that she reported no sensation of itching.

None of the procedures used elicited the reported experience of pain from her. Since her neural system appeared to be normal and intact, yet she evidenced these abnormal reactions, the authors were unable to propose an explanation. They hypothesized: "It is possible that it may result from some congenital anomaly of an undetermined order."

McMurray (1950) reported on a 22-year-old white woman, Canadian born of British ancestry and a university student, who had all sense modalities intact except that of pain. She did not sneeze or cough and corneal reflexes were absent in both eyes. She could distinguish warmth from coldness, even when the difference was not great. Histamine produced a slight taste in the mouth, a throbbing sensation, specks before the eyes, an increased pulse rate, and throbbing of arteries in the neck, but no headache. There was no pain on a muscle ischemia test with a hand dynamometer, or with electric shock, or from inserting a stick up through the nostrils. No significant alterations in blood pressure, heart rate, or respiration occurred in response to cold water, hot water, or electric shock. She reacted to these stimuli as did normal people to a difficult size discrimination test, mirror drawing task, and exercise.

Her IQ was 128 on the Wechsler-Bellevue test, and her personality as judged from Rorschach, Thematic Apperception Test, Cornell Index, McFarland-Seitz Psychosomatic Inventory, and interviews, appeared to be normal.

She died in 1955 at the age of 29 from bronchopneumonia and amyloidosis. A month before her death she complained of discomfort, tenderness and pain in her left hip, which x-rays showed to be due to partial destruction of the femoral head. The pain was relieved by analgesic tablets.

Baxter and Olszewski (1960) reported on her autopsy that they failed to demonstrate any anatomical abnormalities of those nervous system structures thought to be concerned with the transmission, elaboration, and perception of pain impulses. They postulated that the defect might have been either submicroscopic such as slight variations in fiber size or malposition of the nodes of Ranvier, or in terms of organization rather than structure such as slight changes in synaptic relationships.

Osuntokun, Odeku, and Luzzato (1968) reported the case of two siblings who exhibited congenital indifference to pain along with congenital auditory imperception. The cases were two Nigerian children of Yoruba parentage who were completely indifferent to pain. The children were brought to the hospital mainly because of their language difficulties. These seemed to be centered around a lack of comprehension of spoken words although both children could communicate with sign language with no difficulty. They could both speak, but their vocabularies were very limited and their manner of speaking was an unintelligible semblance of normal speech.

Both children were physiologically normal with their only noticeable abnormalities being speech problems and indifference to pain. Their sensory apparatus was apparently normal. They could tell when they were being subjected to such noxious stimuli as a pin prick through the skin, intense pressure on the Achilles tendon, and hot water at 75C.

They appeared to enjoy being subjected to these noxious stimuli during the evaluation. When one of them became the subject of curiosity seekers with needles, he seemed to discover that people regarded himas a freak. He soon developed a strong dislike for needles and pins. He would fly into an uncontrollable rage and temper tantrums at the sight of a pin or needle. He would allow people to subject him to other forms of noxious stimuli while exhibiting pleasure at the events.

A re-evaluation eight months later showed him again to be completely indifferent to needles and pins. This supported the idea that his emotional responses in the hospital were the result of conditioning rather than pain.

The authors attempted to relate the indifference to pain and auditory imperception to a neurological defect in the brain that he inherited by way of a recessive gene. They made no attempt to relate either deficit to other than neurological causes although the boy who became extremely antagonistic to needles and pins may have undergone a learning process.

Although some think the selective loss of the pain sense argues for a physiological-anatomical independence of the pain system, Sternbach (1963) argues that this view is not valid since the same peripheral fibers respond to light touch, pressure, temperature, and pain. He argues that if it were assured that peripheral defects might account for pain insensitivity, this hypothesis would require total bodily distribution of uniform defects, which is a very stringent requirement.

He believes that the anatomical and clinical evidence supports the idea that the neural deficit is not a peripheral one, but rather a central one. Furthermore, he believes that the deficit must be present at the level of some central structure where coding of afferent impulses occurs.

He proposes that several sites may be implicated with no reason to believe that a deficit hypothesized at one site is any more parsimonious than another. He postulates sites involving the dorsal horn of the spinal cord, the paramedial medulla and the ventral tegmentum of the midbrain, and the spinothalmic and central gray pathways.

He states that any of these structures may be the sites where defects in neural organization exist in those who are congenitally insensitive to pain. The failure to detect any anatomical alteration in a careful histological study of one such person autopsied (Baxter & Olszewski, 1960) suggests that the deficit must be a very slight one. He also states that due to the great variability apparent among people with the syndrome, he believes the locus of the deficit must be variable from person to person.

Sternbach (1963) reported a study of familial incidence of insensitivity to pain. He concluded there was strong evidence to support the view that the deficit is hereditary and is due to a dominant genetic factor with varying degrees of penetrance.

The fact that cultural definitions of symbols of pain can be transmitted to members of human society along with other cultural information has a considerable significance for survival of people who cannot experience pain. An animal deprived of its ability to perceive pain will perish because of the inability to identify the agents of danger in its environment. On the other hand, a human whose sensory equipment for pain perception is impaired or absent can adjust himself to life. He does this merely by following the collective experience of society and learning in that manner to avoid pain-producing stimuli (Zborowski, 1969, p. 26).

Sternbach (1963) states that whereas healthy physical survival is greatly impaired in the absence of a sense of pain, no such generalization seems possible about the development of a normal or healthy personality. He cites several examples of pain-free individuals and families that were judged completely normal based on extensive psychological testing and personal knowledge of the people involved. He believes that pain is not a necessary component in normal personality development.

People spend considerable time and money in the search for pain relief. From the simple aspirin tablet to the drastic neurosurgical operations that are performed, the desire to escape from pain causes people to attempt a wide variety of methods of achieving relief. To understand how pain relief can be accomplished a study of the factors influencing the pain experience is necessary. These factors suggest various methods of achieving relief. Some that have been found to be effective include drugs, placebos, attentional mechanisms, hypnosis, audioanalgesia, electrical stimulation of the brain, and surgery.

Barber (1959) indicates that morphine and other opiates give pain relief without necessarily altering the pain threshold. The opiates also give pain relief without altering the awareness of pain or the sensation of pain. The pain sensation is perceived and is recognized as pain with no difficulties. Apparently the sensation of pain in itself is not necessarily painful.

The relief of suffering from pain that follows the administration of opiates appears to be one component of a more generalized effect on the patient that is conceptualized as contentment or freedom from anxiety. Evidently the effect that opiates have on pain is similar to those produced by prefrontal leucotomy. The patient experiences the pain as before, but it doesn't bother him.

Placebo effects must be considered in alleviation of pain. It is generally accepted that the actual placebo effect is based on the person's comprehension and emotional response to the drug administration. Both comprehension and emotional response depend in a large part on the instructions or suggestions given to the person. The administration of an active drug includes many of the same variables that are involved in the placebo effect. Because of this, active drugs are in part placebos, and the observed effects of drug administration are a combination of drug and placebo effects. A consistent universal analgesic would require two properties: (l) it would produce a physiological effect that was independent of the initial psychological state of the person, as well as of the effects of mood or expectancy; (2) the drug would produce a pattern of subcortical and cortical excitation and inhibition, and a pattern of somesthetic stimuli that would allow only one interpretation by the person. At present, no analgesic or tranquilizing drug has these properties.

To follow the action of analgesics and tranquilizers it would be necessary to examine the interaction of the following factors: (1) the drug; (2) the permanent and transient physiological states and sensitivities of the person; (3) the context of treatment; (4) the implied and explicit suggestions accompanying drug administration; (5) the psychological history of the person (Murray, 1971).

In determining the factors that influence the experience of pain, several different things have been proposed. Blitz and Dinnerstein (1971) suggested that attentional mechanisms serve a major function in producing analgesic effects. They state that one of the mechanisms which people frequently report using in their attempts to control pain is that of regulating their focus of attention.

This skill in self distraction varies with individuals and can be affected by contextual variables. The authors believe that studies of the masking of pain by concurrent stimulation might be viewed as contextual control of processes related to attention. They also believe that it is plausible that the analgesia shown by some schizophrenics and by practitioners of oriental philosophies, such as Yoga, is achieved by a type of dissociation in which extreme concentration is attained.

The authors performed an experiment to help determine the potential effect of instructions in producing dissociation and analgesia in normal people. Their subjects when placing their hands in freezing water were instructed to dissociate their experience of coldness from that of pain and concentrate on the coldness. One group did this alone; another group was additionally instructed to attempt to interpret the cold as pleasant. The control group consisted of an initial trial for each person from both experimental groups; thus each person served as his own control.

The authors found that the instruction significantly increased the pain threshold for all groups. However, they found that the instructions had no significant effect on the maximum pain that could be tolerated. They also found significant sex differences both in threshold and in maximum pain tolerated. Males showed significantly greater increases in pain threshold after instruction than females--partly because females had a higher threshold in the control condition.

The authors were unable to explain the sex differences obtained, although they did note that there was a wide range of individual differences in response to the instructions. Many subjects reported that as the pain became more intense they could no longer divert their attention from it.

According to Murray (1971), because hypnosis may reduce fear and apprehension, it can be valuable as an adjunct to sedatives by reducing tension aroused by the prospect of chemical anesthesia, and posthypnotic suggestions may minimize postoperative reactions. Hypnosis may even be an acceptable replacement for those who are hypnotizable. Under hypnosis, sensitivity to pain remains, according to electromyographic studies, but in deep hypnosis the brain centers seem to ignore the messages of pain.

Barber (1959) reports that experimental evidence indicates that when given appropriate hypnotic suggestions to induce analgesia some good hypnotic subjects do not show a pain response to some noxious stimuli. They do not give a verbal report of pain; they do not withdraw from the stimulus; they do not show discomfort by wincing, tremor, or restlessness; and they do not show significant alterations in blood pressure, heart rate, pulse rate, or respiration. Barber also states that clinical reports suggest that hypnotic methods, with some patients, may be as effective as morphine and other opiates in minimizing pathological pain and in mitigating or totally eliminating the discomfort-suffering component of the pain response during a variety of surgical procedures.

Hypnotic methods have been successful with some patients in minimizing or eliminating the discomfort-suffering component of pain during childbirth, terminal cancer, fatal burns, and other pain syndromes. Barber emphasizes that in the more severe pain syndromes, hypnotic methods are reported to minimize discomfort and suffering; rarely, if ever, are these procedures reported to eliminate completely the total pain response.

Barber gives three conditions that appear to be necessary for the relief of pain by hypnosis to be effective. First, the patient must be a certain type of person who is able to become deeply hypnotized. Unfortunately, people of this type (called somnambulists) are in a minority (5 to 25% of the population). Second, the patient must concentrate on the ideas presented by the hypnotist with a minimum of counter thoughts or critical thought, and the patient must believe that what the hypnotist says will happen, can happen, and will happen. The third condition is that the patient must have confidence in his hypnotist and the hypnotist must give of himself to the patient. The hypnotist must be willing to spend considerable time with the patient and under the proper conditions the hypnotist can appreciably tire himself and sometimes even may feel the symptoms with the patient if the rapport is strong enough. With these conditions met, hypnosis appears to be a useful tool in combating the suffering caused by pain.

Gardner, Licklider, and Weisz (1960) reported that pain could be suppressed by sound. In about 5000 dental operations a procedure that combined music and noise was effective in suppressing pain in all but 10% of the cases. About 65% of the cases where the technique was completely effective were patients who had previously required local anesthesia or nitrous oxide in comparable operations. About 25% of the patients felt some pain but not enough to require additional analgesia over the technique using sound.

During the procedure of audioanalgesia the patient wore headphones and had a control box that he could operate by hand. Before the operation and until the painful procedure began, the patient listened to stereo music. As soon as he anticipated pain or felt incipient pain, he turned up the intensity of noise.

The dentist could judge the patient's state of anxiety by noting whether music or noise was turned on and at what intensity level. The patients reported that noise appeared to suppress pain and masked the sound of dental drills, thereby reducing anxiety from another source. When both music and noise were turned on, the patients had to concentrate to follow the music. This account from the patients implied that the method diverted attention from the pain.

Electrodes have been implanted in the brains of humans to relieve pain. These patients were given a control that allowed them to administer a shock to their brains. One device suppressed pain after about one hour of impulses of nine volts at a rate of 30 per second and caused no irreversible damage to brain tissue. One advantage of this arrangement was that it relieved the patient of the need for opiates. One patient with cancer, who had required large quantities of drugs every two hours, was able to do without the drugs once he began using the brain-stimulating device (Murray, 1971).

It should be emphasized that this type of brain stimulation involves microelectrodes implanted within the brain and is not to be confused with electroconvulsive therapy (ECT) which applies relatively large voltages through large portions of the brain from external electrodes.

In addition to the use of surgery to correct a physical defect causing noxious stimulation such as spinal disc repair or spinal fusion, surgery to affect directly the neural impulses related to pain have been done with varying degrees of success. Barber (1959) summarized some surgical procedures that have been employed for relief of intractable pain. These procedures generally involve cutting certain pathways in the spinal cord and central nervous system.

Some procedures are successful and others are not. Those that appear to be successful involve severing nerves or tracts in the spinal cord that eliminate sensation along with pain. One modality of sensation is never completely abolished alone by these procedures. In many cases, loss of pain from these operations is only temporary; normal pain responsiveness sometimes returns after a time.

Surgical procedures on the brain have been used to eliminate pain and have generally been unsuccessful. It is not known whether the many operations performed which had no effect on pain were improperly performed by severing the wrong pathways or whether the concept is an incorrect one. In any case, cutting or destroying pathways in the brain generally appears to be an unsatisfactory method of eliminating chronic pain.

Certain of the operations such as prefrontal lobotomy, lobectomy, or leucotomy seem to enable the patient to ignore his pain and thus eliminate his suffering. These operations are not performed without far-reaching side effects on the patient's personality, however.

Beginning about 1935 these brain operations were performed on severely disturbed patients as a method of last resort in hopes of making them more comfortable and manageable. These operations typically produced a state of indifference to pain, and they were used sometimes after that in cases of intractable pain. The indifference to pain appeared to come about through a diminution of the prolonged disturbance that constant pain induced rather than through an absence of pain experience. Patients were still distressed by painful events and their pain threshold seemed to be lower than normal; however, their pain experience did not make them feel as bad as before the operation, and they seemed less engrossed in their feelings and made fewer complaints about their situation (Murray, 1971).

The thalamus has been considered the localization area for pain within the brain and as a consequence surgical operations on areas within the thalamus have also been used for the relief of intractable pain. According to Sternbach (1968, pp. 35-36) thalamotomies are preferable to prefrontal leucotomies for relief of chronic severe pain because the leucotomies do not eliminate pain; they only eliminate complaints of pain with the person becoming indifferent to pain.

Sternbach lists three different syndromes produced by thalamotomies. The first syndrome is characterized by profound sensory loss with little or no pain relief. This sensory loss refers to inability or poor ability to distinguish touch, temperature, or pinprick in the innervated area. The second syndrome is one that involves little or no sensory loss in the affected area, but good pain relief. A third syndrome is one that is similar to that produced by prefrontal leucotomy. This syndrome is characterized by a pronounced change in affect with only a slight diminution of pain.

Despite the existence of pain after this procedure, pain and other external stimuli are ignored although present. Because of the extreme and irreversible nature of this type of pain relief and the other methods of pain alleviation available, it is doubtful whether brain surgery should be considered a tool in the conquest of pain.

As mentioned at the beginning of this paper, pain and personality are thoroughly intertwined, and any conceptualization of pain must include the effects of an individual's personality. Not only are individual personality effects extremely important, but social and cultural effects appear to have a strong influence on the way a person perceives pain and reacts to it.

Sternbach (1968, pp. 25-26) is among those who view personality factors as being extremely important in an individual's response to pain. The experience of pain or the emission of pain responses is not entirely a function of any single factor. It is not a matter of the setting although this may be important. It is also not a matter entirely of the intensity of the pain stimulus. The pain responses are also a function of the individual making them. At the extremes some people make stoical responses to extensive pathological trauma, and some people make frantic responses to minor laboratory stimulation.

Although Sternbach does not believe that personality factors are the all-determining ones, he does state that he is tempted to weight the personality factor very heavily. The resistance to pain need not be related to the amount of injury, and the relief of pain need not be related to the amount of analgesic agent administered.

In 15 studies, about 35% of over 1000 patients reported marked relief from pathological pain after receiving a placebo. Most American soldiers who were wounded at Anzio either denied the existence of pain or experienced so little pain that they did not want any analgesic. Later, civilians, who in major surgery had incisions similar to the wounds received by the soldiers, were asked whether they wanted morphine to alleviate their pain. In contrast with the wounded soldiers, four out of five claimed that they were in severe pain and needed morphine. Apparently no direct relationship between the wound per se and the pain experience existed (Murray, 1971).

Drew, Moriarty, and Shapiro (1968) observed that when surgical patients are informed of the nature of the postoperative pain they may experience and are instructed how they might attain relief by themselves, they use less supportive medication after operation than do patients who have not been so instructed. Barber (1959) reports that the mitigation of discomfort or suffering by prefrontal leucotomy, opiates, and hypnosis appears to be secondary to a more generalized effect on the person's personality caused by these procedures.

Prefrontal leucotomy, when successfully performed, causes personality changes generally described as apathy that involves a decreased responsiveness to all stimuli, including noxious stimuli. These people exhibit a flattened affect if not total apathy. They fail not only to complain about their spontaneous pain but also of their needs, such as personal nursing care, need of urine bottle, bedpan, or the adjustment of an uncomfortable dressing. When incontinent of feces they are indifferent to the odor it spreads about their persons or beds.

Prefrontal leucotomy changes the attitude of the individual toward his pain, but does not alter the perception of pain. It should be emphasized that the leucotomized patient is able to respond normally to noxious stimulation. Some of these patients, although ostensibly tranquil before being asked about their pain, over-reacted with a show of grimacing and fears when their attention was focused upon the pain by a direct question concerning its quality and intensity. When questioned, other leucotomized patients indicated that some pain was present when they thought about it.

Apparently, when the leucotomized patient is directly asked to report on his pain, he focuses his attention on it and thinks about the noxious stimulus in his body and then often shows discomfort or suffering and usually reports a sensation of pain. When the patient is not asked abut his pain he does not attend to it or think about it to the same extent as before the leucotomy, and when not thus reacting to it, does not appear to be in pain because he does not show discomfort.

Petrie (1967) has described two personality types that appear to be distinctly related to a person's perception of pain and his tolerance of pain. She labeled these two types as augmenters and reducers. Personalities between these two extremes she identified for convenience as moderates.

These kinds of people differ from one another in their ways of processing their experience of the sensory environment. The augmenter tends subjectively to increase what is perceived. The reducer tends to decrease what is perceived. The moderate tends neither to increase nor to decrease what is perceived. These perceptual types generally occupy adjoining positions on a continuous scale from extreme augmentation to extreme reduction of subjective perceptual experience. Petrie found through experimentation and observation that in general augmenters are intolerant of pain and reducers are tolerant of it.

In her model, pain is conceived of as a result of an excess of sensory stimulation, or as a sensory lack that also results in distress. She believes that at one end of a continuum suffering results from sensory excess and at the other end suffering results from sensory lack.

The variation in suffering appears to be dependent on at least three components: (1) the characteristic perceptual reactance of the individual--that is, his tendency to reduce or to augment or to leave unchanged what is received; (2) the alterations in his characteristic perceptual reactance that follow upon his ingestion of drugs, or his illness, etc., at a particular time; and (3) the conditions of his environment--that is, how much freedom of movement and other varied sensory input he is allowed. Suffering in this context includes that which may be experienced by a strong, healthy young man who, after a brief period in an iron lung, where his movements and sensations have been greatly restricted, comes out in a state of panic vowing that no amount of money will ever make him go inside again. Suffering also includes that experienced by an equally strong and healthy dental patient who feels that he could not have borne the very loud noise of the machine or the stimulation to his tooth for another second.

Petrie experimentally identifies the augmenters, moderates, and reducers very simply. It can be demonstrated that a person's experience of the size of an object held between the fingers gradually changes; the reducer feels as if the object has been reduced in size and the augmenter feels as if it has been augmented. The extent of this change in a few minutes is such that something the size of a spectacle case, for example, is experienced by the extreme reducer as though it were half its original size, and to the extreme augmenter as if it were half again as large.

Petrie has developed a standardized method of determining the augmenting or reducing tendency in a person by use of wooden blocks of various sizes and a tapered block for the person to indicate how wide the wooden blocks appear to be when he is blindfolded and can only feel the blocks.

Petrie has found significant relationships between the tolerance of pain as well as threshold of pain and the reduction or augmentation tendency. She has also found that an individual will vary from time to time in reduction or augmentation of perceived stimuli, and that pain tolerance varies directly with this tendency.

Using the methods and definitions of Petrie (1967), Morgan, Lezard, Prytulak, and Hilgard (1970) performed a study comparing augmenters and reducers in their ability to reduce their perception of pain under suggested hypnotic analgesia. The authors found that although the augmenters and reducers did not differ in their responsiveness to the pain of immersing a hand and forearm in circulating ice water or in their hypnotic susceptibility, the augmenters reduced their perceived pain significantly more under suggested hypnotic analgesia than the reducers. Measures of their personality revealed little except a tendency for augmenters to be more tolerant of ambiguity than reducers.

Many clinicians have reported lesser sensitivity to pain in mental hospital schizophrenic patients than in normal people. Kane, Nutter, and Weckowicz (1971) conducted an experiment to determine how warmth detection thresholds, pain thresholds, and pain tolerance to radiant heat differed between groups of process schizophrenics, reactive schizophrenics, nonschizophrenics, and normals. They found that nonschizophrenics and reactive schizophrenics had significantly lower pain thresholds and pain tolerance thresholds than process schizophrenics.

The authors combined the use of subjective reports from the subjects and the autonomic response of dilation of the eye pupil in evaluating pain perception in the subjects. They found that the autonomic component was not different between any of the groups, which seemed to indicate that there was a dissociation between autonomic and verbal responses of the process schizophrenics when they are receiving more than moderate levels of noxious stimulation. The data supported the idea that the alarm reaction to biologically harmful stimuli is smaller in process schizophrenics and greater in reactive schizophrenics than in other psychiatric patients.

The authors propose that process schizophrenics tend to under-react to a wide variety of physical, chemical, biological, and psychological stimuli. The authors believe that in the acute phase of schizophrenia the anxiety level is high, producing a low pain threshold and a high reactivity to noxious stimuli. In the chronic case, anxiety is inhibited and there is a shift in the opposite direction in the sensitivity to pain. They further believe that the acute phase is particularly marked in reactive schizophrenics and that in process schizophrenics the acute phase is less marked and sometimes completely absent, with the patients progressing directly into the chronic phase particularly when the onset is insidious.

The main implication from the study was that chronically institutionalized psychiatric patients display weaker reactions to potentially harmful stimuli, and this diminished reactiveness may lead to their failing to report pain-causing conditions that may be hazardous to their health.

In an evaluation of self-inflicted pain in schizophrenic children, Green (1968) examined the case histories of several children who inflicted injuries on themselves with the resulting pain that must have occurred. He found that periodic parental physical abuse occurred in their early childhood in a matrix of overall rejection and stimulus deprivation.

He hypothesized that the physically abusing contact of the parents, although painful to the child, may have compensated for the deficiency of tactile and kinesthetic stimulation. He felt that the painful part of the physical abuse was subordinated to a greater pleasure that came from the satisfaction of the craving for physical contact. The gratification then would act as a potent reinforcer for repetition of behavior on the part of the child which in the past has led to this gratification along with pain.

The child then may substitute self-attack if his provocative behavior fails to elicit abuse from his parents. This has the effect of satisfying his craving for physical contact and stimulation even in the absence of his parents.

Green believes that the same child who uses self-mutilation as a direct means of repeating the abusive pattern may use provocativeness and accident proneness as indirect methods for eliciting similar painful gratification. Since all these varieties of pain-dependent behavior, including self mutilation, have an adaptive function of supplying sensory stimulation, they are likely to be repeated as long as the basic needs for tactile stimulation and body contact are not satisfied in a more appropriate manner.

Green believes that painful stimulation of this sort that takes place during the first two years of life before completion of ego differentiation contributes to confusion about the source of attack. Green states that the child learns to repeat the painful stimulus according to the laws of operant conditioning, and it gradually becomes an integral part of his behavioral repertoire.

The mores and customs of a society define general standards for the individuals of that society for appropriate behavior in pain. In addition, they set specific rules according to the situation in which pain is experienced and according to its cause.

American Indians were supposed to be able to bear any kind of pain without overt expression of suffering, whereas in many primitive tribes men are expected to tolerate ritual pain silently but are allowed to moan and groan freely when their pain is caused by illness. Exclamations of pain that are expected in a hospital are out of place in a football game although the latter pain may be more intense.

The culture of a group defines for its members each type of correct behavior when in pain, and a well-trained, socialized individual knows the answers to the formula of who does what, where, when, and how (Zborowski, 1969, p. 33).

Zborowski states that the ability to respond correctly to pain according to cultural standards has nothing to do with sensitivity to pain; it is only a matter of tolerance. Sensitivity and tolerance are being confused when physicians speak of higher or lower thresholds of pain among different groups of patients. The sensitivity to pain among all patients is probably about the same, but the presence or absence of reactions to pain shows tolerance, which usually results from the norms of correct behavior in the social group to which the patient belongs.

According to Zborowski (1969, pp. 28-29), there is a conflict between the automatic reflex reactions to painful stimuli that are inherited as a part of the biological heritage of man and the cognitive responses to those same stimuli that are learned in the process of cultural development. The automatic reflex of withdrawal from the jab of a needle will be present regardless of whether the needle is used for harmful or therapeutic purposes, but the cultural association with the situation will determine whether the reflex reaction will be freely manifested or voluntarily suppressed. Whether a person controls or follows his reflexes he depends on his ability to evaluate the significance of a stimulus in terms of his cultural criteria and attitudes.

A major element in the conflict between reflex tendencies and actual responses is the person's preparedness for the experience. Certain life situations are always associated with pain, such as childbirth, surgery, war, or some athletic events. People confronted with these situations are rationally prepared for their painful implications and these pains are considered as normal or natural. The anticipation of pain allows a person to prepare himself to respond to it according to his attitudes of acceptance or rejection. When a dentist tells his patient that the operation will begin to hurt, the patient who accepts the pain associated with dental treatment will brace himself and get ready to suppress his tendencies to react to the pain. However, when pain is perceived suddenly and unexpectedly, the individual's behavior will be characterized by uninhibited manifestations of alarm and anxiety, and violent escape reactions will probably occur.

Craig and Weiss (l971) proposed that experimentally exposing subjects to models manifesting either high or low levels of tolerance for pain would influence the subjects in similar directions. They found that having a model ostensibly react to the identical stimulus intensity as the subject was receiving as if it were more or less painful than the subject's reported experience had a potent influence on the subject's subsequently reported experience of pain.

The findings of the study indicated that verbal reports of pain are not linearly related to intensity of the noxious stimulus, but represent complex reactions to physiological, experimental, and social cues. The subjects in this study followed closely the models' reactions to the stimulus, indicating that the social factor is an important one in the perception of pain.

Buss and Portnoy (1967) found that strong identification with a group increased the tolerance for pain. They administered electric shock through a finger electrode to their subjects. After the pain tolerance of each subject was determined, the subjects were given false norms of the pain that other groups could endure in the same experimental situation. Several comparison groups were used for different groups of subjects. Americans were told that Russians had a greater tolerance for pain; college men were told that women could stand more pain than men; college students were told that men from their rival college could stand more pain and other college students were told that men from another college that was not a rival college could stand more pain; a control group was given no instructions.

The authors found that the stronger the identification the more pain the subjects could stand beyond their established thresholds. The subjects given the false norms of Russians endured the greatest increase in pain. The control group endured the least amount of pain increase of all groups.

The authors also attributed competition as being a strong motivating force for inducing subjects to endure more pain. They offered this data as a partial explanation of the effects of initiation ceremonies for the armed forces in building group identification.

According to Zborowski (1969) people respond to pain not only as individuals, but also as members of ethnic groups. This introduces another dimension into the study of pain--the sociocultural dimension. This is distinct from the physiological and psychological interpretations of the pain experience.

Acceptance of pain does not mean that the feeling quality of the sensation has changed. Pain is unpleasant (except in some cases where a person can enjoy the unpleasantness, as in masochism), but the displeasure of pain is tolerated when cultural tradition calls for its acceptance and conversely it is not tolerated when cultural tradition allows the free expression of pain reactions. Because of this, the original cognitive response to pain is modified by the cultural meaning attached to it (Zborowski, 1969, p. 28).

Zborowski (1969) conducted a study on the cultural components in response to pain. The study extended over a three-year period and the clinical data for the study were collected from patients in a large Veterans Administration hospital in the New York City metropolitan area. This particular hospital was selected because the author felt that this was one place where the ethnic groups to be studied would most likely be assembled in one place and be subject to the experience of pain.

In the study, four groups of patients were selected for an intensive study of their responses to pain. The four groups were identified as being applicable for the study by an exploratory phase where research in literature, questionnaires to physicians, and other ethnographic material was examined to formulate a general goal of the study. The four groups of patients selected were described as Old American, Jewish, Italian, and Irish.

The Old Americans, who were people from American descent for several generations, were selected because their behavior patterns are those of the social and cultural majority in this country. They seem to represent the cultural ideal that serves as a model for the descendants of immigrants who tend to adopt the American way of life.

Jews and Italians were selected because of the similarity of their behavioral responses, despite the differences in their cultural traditions and folkways.

Patients of Irish origin were selected because, although their behavior was singled out by physicians as similar to that of the Old Americans, a number of comments were made by the physicians that suggested a peculiar attitude toward pain. The Irish tend to neglect painful symptoms and to endure them for exceptionally long periods of time without seeking medical help.

Data for the study were collected by direct observation of daily affairs of the hospital. The data were complemented by information secured in intensive interviews. The interviews offered the patient the opportunity to describe freely his attitudes, behavior, or feelings in association with the pain experience. Data collected in this manner were further complemented with specific information provided by physicians, nurses, or members of the family.

The study revealed characteristic ways of responding for each of the ethnic groups.

The behavioral response of the typical patient of the Old American background, as described by the patient himself and often by people who have been in contact with him during the pain experience, is usually nonexpressive. The patient tends to appear unemotional and calm and is not vocal about his pain. He tries not to show it or to complain, cry, or scream.

Only a very small number of the patients admitted crying or complaining about pain. When the Old American patient is in pain he tries to be rational and to control his behavior. He feels that his actions should be directed toward alleviating the condition and evaluated according to their effectiveness. Things that help are done; things that do not help are not done. The purposefulness of the activities is the ultimate criterion of the behavior. Screaming, crying, and complaining belong to the category of things that do not help and therefore should be avoided.

They are also concerned about showing behavior appropriate for an adult male. They also try to suppress tendencies to groan, moan, or cry in order not to trouble others. When patients of this group deviate from the ideal pattern under the impact of pain, they are aware of their fault and express feelings of shame and guilt. In these instances the patient is apologetic and tries to explain his incorrect behavior by insisting it was involuntary, or that he was unable to control it. Unnecessary complaining is frowned upon because it is seen as looking for sympathy, and is viewed as a selfish tendency to monopolize the attention of attending people at the expense of other patients who are entitled to their share of care.

The Old American, although believing that complaining about pain is wrong, does not deny pain when asked about it by competent people. He views this as cooperation with the professionals who are helping him in finding a correct diagnosis and in determining the course of treatment.

The author proposes that the explanation for the typical Old American's attitude toward pain and his own reaction to pain is derived from the belief in a purely biological function of pain. He sees pain as a warning signal that tells him something is wrong with his body. The functions of pain are to alarm the individual and to stimulate his activities in the direction of taking care of or fixing the source of pain. The Old American likes to see himself as a strong and healthy organism that is constantly threatened by the presence of hostile elements in the environment.

The patient of Jewish origin, when dressed in his hospital pajamas and lying in a bed or sitting in a wheel chair, is indistinguishable from any other patient. However, an analysis of the background information derived from interviews reveals a number of significant differences between Jewish patients and others.

In terms of socioeconomic status, more than half the Jewish subjects of the study belonged to the lower middle and middle class, whereas patients of Irish, Italian, and Old American background were predominately of the lower class. More than 50% of the Jews were engaged in nonphysical or intellectual work; the occupations of all other subjects were predominately physical or nonphysical with some physical effort. The Jewish patients also differed in educational background. Almost half of them had some college education which is more than twice the number of any of the other groups, who had some college.

In the interview setting, the Jewish patient stands out in his role as informant. They are the most verbal of the groups and their responses to questions abound in details that sometimes have only a distant relationship to the topic. They seem to enjoy having a listener for their descriptions of pain, illness, anxieties, and family relationships.

Members of the medical profession who expect a tendency in a patient to understate his feelings with the pain experience, tend to describe the Jewish patients as overemotional or as exaggerating their pains or illness. These patients use a dramatic vocabulary to describe their discomfort and anxieties to the fullest extent. They seem to be afraid that the physician may not fully grasp the impact of their situation.

To describe their pain, these patients use such adjectives as terrific, unbelievable, fantastic, unbearable, excruciating, and agonizing. As if to impress on the listener the intensity of his suffering, the Jewish patient will tell how he was rolling around on the floor, jumping around, or hitting his head against the wall. He tells the listener without inhibition or shame that he cannot stand pain, that he cannot tolerate it, and that he has a very low threshold of pain. He freely reports groaning, moaning, and complaining as part of the pain experience.

Not only do they complain freely, but they consider it wrong not to express their feelings. This expressive behavior appears to fulfill a definite function in the Jewish patient's pain experience. Unlike the Old American patient, he complains because he feels it helps to complain. When the Jewish patient is in pain or discomfort, crying is a natural reaction for him. However, it is not so much the sensation of pain that makes him cry; rather, it is the feeling of helplessness in a situation in which no help is available. The evidence of secondary gain is very evident in the Jewish patient's tendency to complain as is shown by one patient's statement:

My woman--my wife--she--I drove her almost nuts. You know, she couldn't stand the pain which I had. She feels them (the pains) as strongly as I do. She's up at the first groan I give. If I sit up in bed, she's up the next second. If it's severe, "What can I get for you--you want the pill now? Do you want the heat pad? Do you want the lamp? You want an ice pack?" Anything that she can possibly do. (Zborowski, 1959, p. 103.)

Everyone in the family and social environment of the Jewish person in pain is expected to be informed about the discomfort and be ready to offer sympathy and help. The suffering of a member of the family is the suffering of the entire family. Father, mother, wife, or children are expected to participate in the total pain experience, from its onset to the final relief.

Thus, the Jewish patient has a very definite and clear concept of complaining. It fulfills several important functions: it gives relief through catharsis; it is an effective medium of communication; it mobilizes the assistance of the environment; and it reaffirms the kind of family solidarity that is the basis of Jewish family organization. The behavior of the Jewish patient in pain and illness reflects a value system that has developed through the ages and has been transmitted from parents to children.

When hospital personnel speak about patients who are overemotional or who exaggerate their pain, they usually mention both the Jewish and the Italian patients. Like the Jewish patient, the Italian patient is often described as a person who makes no effort to control his emotional reaction to pain, who demands attention, and who freely expresses his pain by sound and gesture.

The behavior on the whole of the Italian patients is seen as nonconforming to the standards of the hospital that emphasizes restraint and self-control. The impressions of people who are in constant contact with the Italian patients are confirmed not only by direct observation but also by statements by the patients themselves. They readily speak about their tendency to be quite expressive and most of them feel that it is only natural to cry, moan, and complain under the impact of pain.

There is no shame or guilt associated with these types of behaviors. They frankly state that they cannot stand pain and these statements are borne out by observation of the low tolerance of pain they appear to manifest. These patients often realize that their tears and complaints do not perform any useful function in relieving pain, but they cry because they feel that crying is a natural part of the pain experience.

The younger Italian patients of the study knew that expressive behavior such as crying or screaming is viewed in American culture as childish and unmanly conduct. Because of this, some of them tried to restrain themselves from being too emotional, yet few were successful in their attempts.

The Italian patient appears to be quite aware of the effects his behavior has on his environment. They complain freely to physicians and nurses, but refrain from complaining to members of their family. The Italian patient does not complain to his wife because he does not want to worry her. He seems to take for granted that his wife sympathizes with his suffering to such an extent that it is unnecessary to complain to get the required attention.

The avoidance of complaining within the family circle is a pattern that can be traced to early childhood. As a small child, he is taught not to run to mother with complaints about pain, but at the same time he is aware of his mother's devotion to him and feels that she knows of her child's trouble without being told. The same motherly care is given to the patient in his adulthood by his wife, and he appreciates her sympathy.

The American's idea of self-reliance and independence is alien to the Italian patient and when he is in need of help, he feels he is entitled to get it. This probably explains why he complains so freely to the physician and nurses. They are the ones in the business of relieving his pain.

Tears, complaining, and moaning are not the only manifestations of suffering from the Italian patient. Some of them speak of feelings of deep depression or of loss of energy and vitality under the impact of pain. Only the Italians mention depression to describe the effects of pain on their state of mind. They view their pain as an evil, unnatural force that takes away from the benefits of life.

The Italian patient does not seem too concerned with the future, and he is equally unconcerned about finding out the reasons for his pain. His primary preoccupations are the immediate consequences of the experience and instant relief. The fear of pain is very strong in the Italian patient. A number of the Italian patients in the study said that they would rather accept the amputation of a leg or arm than suffer chronic pain.

From all the data collected on Italian patients in the study, Zborowski concluded that the strength of group ties, both family and ethnic, provides the patient with a security that is reflected in the way he reacts to critical situations such as pain. The awareness of love, solidarity, and acceptance that the Italian patient brings with him into the hospital allows him to view his experience without much fear and anxiety about its significance and to react mainly to its emotional quality.

The last of the groups studied by Zborowski consisted of patients of Irish background. As a group the Irish patients differed very little from the Old American patients. Their behaviors as patients and their observable responses to pain associated with illness were also similar to the Old American patients.

The Irish tended to appear calm and unemotional; their reactions to pain tended to be nonexpressive, nonvocal, and noncomplaining. Hospital personnel described the Irish patients as taking their pain well, not too emotional about it, and not making too much fuss. They behave as the average, good patient should behave in a hospital. Some physicians who were interviewed made the observation that the Irish patients seemed to take their pain exceptionally well, and that they did not pay enough attention to their pain, sometimes coming to the physician too late.

The Irishman is much more reluctant to talk about his pain than any of the other groups studied. Although the Irish patient may make a minor verbal response if the pain gets very bad, he would not moan and groan, and he definitely would not scream. He considers screaming to be definitely extreme, and he would not go that far. Even if he felt like screaming, he would do everything to control himself.

The word "suffering" which rarely appeared in interviews with other types of patients was frequently used by the Irish patient to describe his experience. Also, when he speaks about suffering he refuses to share his suffering with anyone else. Many of the patients interviewed were unable to offer a reason for their behavior in taking pain in silence and even seemed to be slightly annoyed by the question.

The Irish also tend to have a lack of communication within the family during stress situations. Typically, the Irish patients do not tell their troubles to their family. Thus the patterns of communication concerning stress within the Irish family foster the feeling that one is alone with his trouble and that one is not to share it with anyone, just as nobody will share theirs with him.

Where people do not talk about their difficulties, they also develop the feeling that there is no point in speaking about it because nobody will understand it anyway. The Irish patients in the study consistently showed an inability to communicate with the interviewer about their pain. The following excerpt from an interview demonstrates the difficulties a patient had in trying to describe his experience:

(Do you have pain?) No. Never have inclination to it. (No pain at all?) No pain at all. (Doesn't your condition cause pain?) Only the arthritis does. (Severe pain?) Well, I can't walk. (Can't walk?) No. I'm only on my feet now two days. Knocks me right out. (So, your legs hurt you?) Oh. And the pain when I touch them in different spots. Bottom of my feet and this time it was my knee. It ain't always in the joints, though. It's always traveling around. Wrists and elbow. It's around, around the joints. (Is it a sharp pain?) Well, I wouldn't know what to say, sharp or not. It's just pain. (How often do you have these pains?) Oh, I wouldn't be able to say. (Do you know when they started?) Five years ago. (When you came to the hospital, did you come because of the urine difficulties?) Well, I wouldn't be able to tell you.

In describing anxieties and worries associated with the condition that caused the hospitalization, the Irish patient stresses fears about his physical appearance or performance in direct relationship to his ability to work. The Irish feel that as long as they can work there is no reason to worry about pain. Anxiety begins to increase only when the pain interferes with work. Thus, the Irish patient seems to be concerned less with the discomfort associated with pain than its crippling and immobilizing effects. Activity is seen as the best remedy against pain.

In all the worries and anxieties about pain, however, there is a striking absence of a concern for the pathology that provoked the pain. To them, pain is not seen as a symptom of a disease; it is seen as an independent experience that is only loosely associated with illness.

Thus, the image of an Irishman as it emerges from this study seems to be that of a patient who suffers a great deal from his pain, who is greatly worried about the effects of his experience on his body and working abilities, and who is unable to relate his condition to a pathological cause. Even in the most anxiety-producing situation, the Irish patient stubbornly refuses to think in terms of pathology. Pain is not perceived as a symptom, but as a sensation with possible harmful implications for the body, Once the sensation of pain is relieved, the anxiety is also gone.

This attitude allows for long periods of suffering before he will consult a physician. Because not many conditions are associated with a constant pain, the patient may develop a cyclical pattern of pain onset, anxiety, disappearance of pain, relief of anxiety, etc., until he is finally hospitalized. The lack of pain being a warning signal of some pathology has caused many Irish patients to lose their lives as a result of waiting too long to consult a physician. The biological value of pain seems to be largely lost for them and they have only the suffering aspects of pain left.

Zborowski concluded that pain and illnesses are stress situations to which individuals respond as people, as humans equipped with intricate biological and psychological mechanisms that enable them to adapt to stress. However, stress is also a cultural experience in perception as well as in interpretation, and as such is responded to by behavior and attitudes learned within the culture in which the individual is brought up.

One thing stands out in this review of the experience of pain: the historical view of pain as a physiological event needs drastic modification. Current researchers and authors are becoming aware that pain is a psychological experience that may or may not have anything to do with the physiology of the person involved. There seems to be a range of physical stimuli that, when intense enough, can cause avoidance behavior to occur in their presence or in the mere presence of their threat. This type of avoidance response can be observed in all biological organisms from microbes to man, and the responses have value to the organism--they protect his physiological integrity.

The question arises, however, are these responses indicative of the subjective experience of pain? Obviously this question can never be adequately answered since the subjective experience of an organism is available only to him and cannot be observed by any other organism. Can we infer that a dog is experiencing pain when he yelps and withdraws from the quills of a porcupine? We can only assume that he is experiencing the same thing we would experience in the same situation; but we are not dogs. The subjective experiences may be entirely different.

The phenomenon of pain in humans has been thoroughly studied, but usually from a physiological point of view--of trying to locate the neural pathways or structures responsible for pain. Recently, however, more research is being conducted on the effects pain may have on personality and of the effects personality may have on pain. This appears to be a productive direction because not only does the pain experience include a protective function, but also it is an unpleasant, sometimes debilitating experience that serves no purpose other than making a person suffer. If the personality variables are better understood, not only will we have a new tool in the fight against pain, but we will have a better understanding of human behavior.