# Issues in Interdisciplinarity 2020-21/Truth in Pain
## Introduction

Pain is a discomforting experience that involves sensory and emotional aspects, possibly attributed to tissue damage, informing the body of noxious stimuli or a problem with internal functioning. However, it is not fully understood in terms of its biological and psychological interaction.

## Biology

Biology takes a positivist approach to pain, arguing that the only way of knowing is through biological processes that offer an objective representation of reality and therefore hold the data from sensory encoding as empirical data. A stimulus is detected by nociceptors that respond to noxious stimuli, which leads to an action potential being fired. Once the pain threshold is passed, individuals will feel the pain, with the strength of pain corresponding to the frequency of action potentials.

### Neuroimaging

Neuroimaging techniques allow us to observe pain objectively through neural activity. An example of this is the use of functional magnetic resonance imaging (fMRIs) in the diagnosis of fibromyalgia, a condition which causes severe pain all over the body. Fibromyalgia patients have increased neural activity in the pain matrix - a group of brain structures activated during pain. In this case, neuroimaging is used to reach the truth of pain in an objective manner.

## Psychology and Philosophy

Psychology and Philosophy offer an interpretivist approach to pain, emphasizing how the experience varies significantly depending on individual interpretation and situational perception.

### Perception

In philosophy of perception, interpretivism suggests that human perception is not simply a reaction to external stimuli, it depends on the intention attached to it; different people react differently depending on their interpretation. An example of the importance of individual interpretation is masochism, characterised by sexual gratification derived from experiencing pain. While pain is usually synonymous with suffering, masochism demonstrates how this is not always true, as masochists contrarily derive pleasure from their pain.

### Scepticism

Philosophical scepticism questions the certainty of an objective reality; pyrrhonists established sets of arguments claiming that reality constitutes of experiences which vary based on circumstances and individual interpretation therefore, the experience of pain cannot be reduced solely to biology. Scepticism argues for the suspension of judgment, hence, despite the uncertain nature of an objective reality, the subjective experience of pain in humans is real and represents the truth of pain.
The placebo effect is an example of this; one study demonstrates this phenomenon using patients suffering from migraine attacks - the efficacies of the real drug "Maxalt" labelled as a placebo, and a placebo labelled as Maxalt were very similar in reducing pain in patients. Furthermore, when the patients were given the placebo labelled as "placebo", "Maxalt or placebo", then "Maxalt", the pain experienced decreased progressively, demonstrating that although they should physiologically and objectively experience pain, this is not the reality.

## Anthropology

Anthropology takes a social constructivist approach to pain, focusing on different cultures' attitudes in how pain is understood, and how the meaning and use of words vary across cultures.

### Differences in attitude

In some cultures, pain is not seen as an issue: a study in rural Nepal found that pain was common, yet no one ever sought help regardless of the severity; pain was perceived to be a normal part of aging, and not related to any health issue. Cultures such as those in American Indian, Asian, Black and Hispanic groups are stoic regarding pain and are reluctant to report it, seeing it as a weakness - whereas Arab and Iranian cultures encourage the emotive expression of pain. In China, pain is often seen as a test to improve their standing in life after death, therefore they encourage bravery and stoicism.

### Differences in language

Different cultures describe their pain differently - this was demonstrated in a study conducted using participants from Nepal and America that suffered from chronic pain. Descriptors such as "stabbing", "burning" and "sharp" were common across the samples to describe pain, but those unique to Nepalese participants were "catching" and "cloudy". Furthermore, 91.7% of the Nepalese participants used metaphors to describe their pain, which was much less common in the other sample. The results highlight how the meaning and use of words can vary across cultures, suggesting that language is not always a valid measure of pain, as the meaning of words may be misinterpreted by another culture.

## Tensions between Disciplines
### Critiques of Positivism

Positivism employed in biological fields may lead to reductionism and the personal account of the subjective experience being bypassed. For example, a patient who complains of pain may receive the wrong dosage of pain medication if the physician neglects the description of the pain severity by the patient and simply orders medical tests, such as an X-ray, blood test or CT scan, to be carried out to find material evidence of the pain. Such cases may be seen when pain is not reported yet there is physical evidence, such as when perception overrides physiology as seen in the placebo effect, or when pain is reported in the absence of physical evidence, such as pain in phantom limbs or tactile hallucinations.

### Critiques of Interpretivism

Interpretivism considers the personal account of pain to understand the patient's experience, however, social constructivists argue that the experience and account are influenced by different cultural attitudes and language use. Individuals from stoic cultures may deny experiencing pain, and cultures that view pain as a test or a normal part of ageing may not see pain as a threat to their health. The validity of the patient's account is also limited by differences in the use and meaning of words, as social constructivists argue language is a social construct, possibly leading to misinterpretation. This demonstrates how the interpretivist approach is perhaps too simplistic, as it may fail to recognise how individual experience and accounts are influenced by cultural differences.

### Critiques of Social Constructivism

Social constructivists argue that, due to cultural differences, accounts of pain vary so much that we cannot deduce the reality of pain. However, positivists state that the physiology of pain remains the same across all humans regardless of different cultural attitudes towards pain, therefore the assessment of cultural differences would be of no use. This is demonstrated in positivist methods of pain assessment, opposing techniques revolving around communication and language, where cultural background is relevant. Through a positivist perspective, pain is studied in a reliable, objective way, allowing inferences to be made by using data that is universally comparable between different individuals.

## Interdisciplinary Solutions

Recently there has been a shift towards research in Neurophenomenology; the discipline's combination of a positivist and interpretivist approach has been supported as a robust means of obtaining truth in pain.
The McGill Pain Questionnaire, designed with the intent of combining positivism and interpretivism, uses many pain categories such as "pressure", "tension", "temporal", "spatial", etc. combined with different pain dimensions such as "flashing", "throbbing", "pounding", etc., and compares these descriptors of sensation to descriptors of feeling, such as "exhausting", "suffocating", etc. The results are organised by summing values associated with descriptors to produce a number that represents pain quality in a positivist manner, based upon incorporating interpretivist principles.
Through these examples we can see real world implications that have a strong impact on people's lives, along with the necessity for including interdisciplinary approaches in the investigation of pain.

## Notes

* ↑ Srinivasa N. R. The revised International Association for the Study of Pain definition of pain: concepts, challenges, and compromises. The Journal of the International Association for the Study of Pain. 2020;161(9):1976–82.
* ↑ IASP Terminology - IASP [Internet]. Iasp-pain.org. 2017 [cited 9 December 2020]. Available from: https://www.iasp-pain.org/terminology?navItemNumber=576#Painthreshold
* ↑ Gracely RH, Ambrose KR. Neuroimaging of fibromyalgia. Best Pract Res Clin Rheumatol. 2011 Apr;25(2):271-84. doi: 10.1016/j.berh.2011.02.003.
* ↑ Kang, D. H., Son, J. H., & Kim, Y. C. Neuroimaging studies of chronic pain. The Korean Journal of Pain, 2010 [cited 2020Dec 1];23(3):159–165. https://doi.org/10.3344/kjp.2010.23.3.159
* ↑ Crane T, French C. The Problem of Perception (Stanford Encyclopedia of Philosophy) [Internet]. Plato.stanford.edu. 2005 [cited 30 November 2020]. Available from: https://plato.stanford.edu/entries/perception-problem/
* ↑ Rees-Thomas, W. Sadism and Masochism. Journal of Mental Science, 1921;67(276):12-17. doi:10.1192/bjp.67.276.12
* ↑ Vogt K. Ancient Skepticism (Stanford Encyclopedia of Philosophy) [Internet]. Plato.stanford.edu. 2010 [cited 1 December 2020]. Available from: https://plato.stanford.edu/entries/skepticism-ancient/
* ↑ Bett R. Pyrrho (Stanford Encyclopedia of Philosophy) [Internet]. Plato.stanford.edu. 2018 [cited 4 December 2020]. Available from: https://plato.stanford.edu/entries/pyrrho/
* ↑ Kam-Hansen S, Jakubowski M, Kelley JM, Kirsch I, Hoaglin DC, Kaptchuk TJ, Burstein R. Altered placebo and drug labeling changes the outcome of episodic migraine attacks. Sci Transl Med. 2014 Jan 8;6(218):218ra5. doi: 10.1126/scitranslmed.3006175.
* ↑ Anderson RT. An orthopedic ethnography in rural Nepal. Med Anthropol. 1984 Winter; 8(1):46-59
* ↑ Givler A, Bhatt H, Maani-Fogelman PA. The Importance Of Cultural Competence in Pain and Palliative Care. [Updated 2020 Jun 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan
* ↑ Ho AH, Chan CL, Leung PP, Chochinov HM, Neimeyer RA, Pang SM, Tse DM. Living and dying with dignity in Chinese society: perspectives of older palliative care patients in Hong Kong. Age Ageing. 2013 Jul;42(4):455-61.
* ↑ Saurab Sharma. The words people use to describe chronic pain: A cross-cultural comparison. Journal of Pain, 2016;17(4):S7 https://doi.org/10.1016/j.jpain.2016.01.028
* ↑ Scarry E. Introduction. In: The body in pain: the making and unmaking of the world. Oxford, New York: Oxford Univ. Press; 1985. p. 3–25.
* ↑ Giordano, J. The Neuroscience of Pain, and a Neuroethics of Pain Care. Neuroethics. 2010;3:89–94. https://doi.org/10.1007/s12152-009-9034-z
* ↑ Melzack R. The McGill Pain Questionnaire: major properties and scoring methods. Pain. 1975 Sep [cited 9 December 2020] ;1(3):277-99. doi: 10.1016/0304-3959(75)90044-5.