they say passing a kidney stone is the worst pain you could ever have . i still feel it now , intense as ever , 10  years later . dan vento is talking about the time his daughter suffered a relapse of an uncommon form of cancer called osteosarcoma . but a year later , jennifer s left knee began to swell and hurt again , then her thigh , then her back . the cancer not only had returned but was now all over jennifer s body , and it had happened so quickly that even the doctors were caught off guard . metastatic tumors invaded jennifer s bones , obstructed her airways and destroyed her vision . overnight , their little girl had become unrecognizable , from the cancer and from the aggressive treatments  a swollen , lumpy mass with tubes and iv lines hooked up to beeping machines . they stood by , feeling as if the cancer were ripping through their bones too . it was almost a relief at first ; the ventos could nt bear watching their daughter suffer another day . but when they saw jennifer in the little coffin , when they saw the coffin lowered into the ground , when they saw the earth covering the coffin  from that day on , their pain would never end . i tried to be strong for my wife and kids ,  dan vento explained . if they saw me crumble , how would they be able to keep going ?  but despite the strong facade , vento was crumbling . i felt weak and lightheaded all the time , like i might pass out , and needed to grab onto something though not physically imposing  he was short and stocky  he was a self - made man from the bronx who owned a successful chain of grocery stores and always got whatever he wanted , at work and at home . when jennifer died , however , he did nt seem to want much anymore and found it increasingly difficult to concentrate . is what dan vento experienced  as he watched his daughter suffer , when he buried her , and now , 10  years later , still entangled in grief  pain ? he certainly thinks so and uses the word just as he did when he spent an agonizing night in the er with kidney stones . so do many other people who undergo similar trauma , as well as those who suffer  pain  in psychiatric illnesses like depression and schizophrenia . scientists who study pain and doctors who treat pain consider the experience a strictly physical phenomenon , in the sense that it can only be caused by injury to the body . pain occurs when receptors on nerve cells in the skin and internal organs detect potentially damaging stimuli , a pinrick , for example , or high temperatures ( melzack and wall 1983 , pp . the nociceptors ( from the latin nocere , to injure ) then signal the brain , which assesses the threat and coordinates a series of protective responses . this highly effective biological warning system that prevents further damage and aids in healing is something we ca nt live very well without . just think of patients who are unable to feel pain , those with genetic defects and those with diseases that affect nerve transmission like diabetes and leprosy ; the benefits of life without pain are easily outweighed by the negatives of progressive injury to the body and premature death ( see brand and yancey 1997 ) . dan vento has suffered no physical injury . nor have patients who experience the psychic pain that accompanies acute depression . nor have cancer patients ( and their parents ) who experience the overwhelming fear and anxiety and isolation that accompany the physical symptoms of their illnesses . their nociceptors , at least with respect to these particular feelings , remain silent , sending no distress signal to the brain . therefore , their feelings are not really pain but something categorically different , what the professionals prefer to call suffering or anguish ( cassell 1991 , pp . 3046 ) . and therefore , one will find no mention of grief or depression in medical classification schemes of pain . even psychiatrists are wary of speaking about pain in their patients , reserving it only for those rare and strange cases of psychogenic pain or somatoform pain disorder  that is , physical - like pain localized to a part of the body that has not been injured , the modern - day equivalent to what freud termed hysteria or conversion reaction ( dsm 3 , rev . ; american psychiatric association 1987 ) . the bottom line is that the psychological pain experienced by dan vento and millions of patients with acute depression is an oxymoron or , at best , a metaphor . how can there be such a gulf between the layperson and the expert , especially with regard to such a common part of life ? and if the experts are right , how could ordinary people like dan vento as well as our language professionals  celebrated writers like william styron and joan didion , for example , who wrote so eloquently about pain in depression ( darkness visible ) and grief ( the year of magical thinking)have gotten things so wrong ? unless of course they havent . unless it s not the layperson but the expert who is confused . perhaps one s instinctive tendency to see pain more broadly , as a category that incorporates both physical and psychological varieties , may be more enlightened than the expert s narrower conception . perhaps there are good reasons for speaking of pain in the setting of grief or depression or schizophrenia or divorce or the nonphysical suffering that accompanies illness . in the first place , there is a wealth of subjective evidence  what people feel and think and then convey to others through language . when we ask people about certain aversive emotional experiences and listen to their words , we find that they not only use the generic word  pain  to label these experiences , but also describe them in the same ways they describe physical pain . now pain of any kind is notoriously difficult to express . there are problems conceptualizing the experience because it is perceptually inaccessible ( we ca nt see or touch pain ) and because , unlike other inner states , it is not always linked to external objects that we can see or touch ( like the person who makes us angry or the dog that makes us scared ) ( scarry 1985 , pp . one is forced to think about pain indirectly , through metaphor : we imagine a more knowable object linked to the pain and then speak of the experience in terms of that object . by far the most common metaphor used to describe physical pain is the weapon ( scarry 1985 , pp . lengthy lists of similar adjectives can be found on the mcgill pain questionnaire , created in the 1970s to help patients communicate their feelings to doctors . pain can be described as piercing , drilling , burning , grinding , throbbing , stinging , squeezing , and so on . each of the descriptors implies the presence of a weapon or weapon - like object that can injure the body  the drill that drills , the fire that burns . and since most patients have never been stabbed or shot or are not being stabbed or shot at the moment of pain , they are using these terms figuratively to objectify what would otherwise be difficult to pin down and represent ; now they could see pain and describe how it feels by talking about knives and guns and the damage they can do the body . dan vento , silenced for so long by the incapacitating pain of loss , will eventually open up to a psychiatrist . it felt like a bomb , he explained , that exploded inside of him , obliterating everything in his body . at other times , he felt the damage was occurring more slowly and methodically , as if there were a swarm of parasites eating away at his organs . but either way , the result was the same for vento : he was being emptied out from the insidegutted  was the word he used  until all that was left was a big , raw gaping wound . when her husband died and she was flooded with grief , joan didion saw giant waves . in her memoir , she writes that she felt as if she were being battered by destructive waves , paroxysms , sudden apprehensions that weaken the knees and blind the eyes and obliterate the dailiness of life  ( didion 2005 , pp . 2728 ) . for kay redfield jamison , a psychiatrist who suffers from manic depression , it spins around her mind faster and faster , out of control , until it explodes , splattering blood everywhere ( jamison 1996 , p. 80 ) . listening to the language of pain of all kinds , we discover a shared felt structure that the weapon metaphor effectively captures ( biro 2010 , pp . whether triggered by grief and depression or kidney stones and spinal injury , pain reads like a story in three parts:\documentclass[12pt]{minimal } 
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				 \begin{document}$$ { \text{weapon } } \to { \text { injury } } \to { \text { withdrawal}}. $ $ \end{document } in pain we feel as if there must be some weapon - like object ( bomb , swarm of parasites , giant wave , centrifuge ) that is moving toward and threatening us ; that when it strikes , it will injure , possibly even destroy us ; and that we must get away from it or shield ourselves at all costs . even when there is nothing coming at us , when there is no injury , when we remain motionless , we feel the movement , the injury and the desire to run . whatever happens that makes us feel these things  the loss of a loved one or the physical destruction of cancer  we experience pain . the subjective evidence for the existence of emotional pain is compelling , especially since there is no objective way to verify and characterize someone else s pain . although we can attach a person to a functional magnetic resonance imaging ( fmri ) device , observe the blood flow to pain centers in the brain and then infer its presence , the only definitive test is a person s word : i feel pain or i do nt . actually , most experts grudgingly acknowledge the inescapably subjective nature of pain . in an addendum to their universally accepted definition of painan unpleasant sensory and emotional experience associated with actual or potential tissue damagethe international association for the study of pain ( iasp 2007 ) concedes that people do report pain for strictly psychological reasons and that , since such reports ca nt be distinguished from instances where there is a physical cause , they should be taken at face value :  if people regard their experience as pain and if they report it in the same ways as pain caused by tissue damage , it should be accepted as pain .  but despite the concession , the iasp does not make room for the pain experienced by dan vento , joan didion , or kay redfield jamison on their extensive classification schemes of pain disorders . while complex regional pain  which affects somewhere of the order of 626 people in 100,000 ( de mos et al . 2007)appears on the list , the vastly more common pain occurring in grief or depression does not . for physicians and scientists that will only pay lip service to the subjective argument , however , there is now mounting objective evidence for broadening our notion of pain . since the introduction of gate control theory in the 1960s , the link between tissue damage and pain has progressively weakened . we now have a better understanding why there can be severe injury and no pain ( wounded soldiers in battle ) and , conversely , no injury and severe pain ( migraine , fibromyalgia ) . this happens , as prominent pain scientists ronald melzack and patrick wall have explained , because there are psychological factors one s culture and past experiences , our emotional and cognitive states , the context of pain  that can intensify or dampen the nociceptor signal before it registers in higher brain centers ( melzack and wall 1983 , pp . moreover , many cases of chronic pain seem to occur without any direct nociceptor stimulation at all . neuropathic pain results when a dysfunctional nervous system fires spontaneously or misinterprets ordinary sensory stimuli as noxious ( woolf and mannion 1998 ) . in tic dolouroux , for example , the movement of a feather across the face can trigger spasms of intense pain . a second strand of evidence comes from our growing understanding of how the brain processes pain . most important for this discussion , there are distinct areas in the brain that process the sensation of pain ( its quality , location , intensity ) and our feelings about the sensation ( the narrative of its aversiveness ) ( price 2000 ) . further , the sensory center ( in the somatosensory cortex ) and the affective center ( in the anterior cingulate and insula cortices ) are not only spatially apart but dissociable : that is , a person can have the sensation of pain but not feel pain ( grahek 2007 , pp . we can observe this in patients undergoing minor surgery with medication that makes them indifferent to being cut with a scalpel . even more dramatic is a rare group of patients whose affective pain centers ( or the connections to those centers ) have been destroyed . in the case of pain asymbolia , patients can still sense a needle prick ( because the nociceptor signal registers in the somatosensory cortex ) but will laugh at its insignificance ( because the signal is not processed by the anterior cingulate cortex ) . these instances of disconnect between the sensation and the feeling of pain tell us that despite the complexity of pain  which involves sensations and behavior , feeling , cognition and memory  the critical component is feeling . if we do nt have the feelings that dan vento had when the kidney stone was passing through his ureter  that something bad was happening to him , that that something was damaging his body , and that he must do whatever he could to avoid further damage  then pain loses its biological value . because they laugh at pain rather than run from it , pain asymbolia patients will likely fare no better than patients with congenital or acquired pain insensitivity . in fact , i would argue that if we do nt feel pain , there s no point using the term at all . leprosy patients , soldiers on the battlefield , sedated patients undergoing surgery , pain asymbolia patients  they may experience unpleasant sensations but they do nt feel pain and do nt take protective measures . everything is contingent on the feeling of pain . if tissue damage is not necessary to feeling pain and if there is a special affective center in the brain devoted to such feeling , why ca nt that center be activated by means other than the nociceptor pathway ? why is nt it possible that noxious psychological stimuli  stimuli that threaten the emotional well - being of a person , like the loss of a child or the pain of depression or the suffering of cancer patients  find their way to the anterior cingulate gyrus , making us feel the same way we do when we experience physical pain ? naomi eisenberger and her colleagues at ucla have recently developed a clever model of psychological pain that can be studied objectively ( eisenberger et al . normal subjects played a video ball - tossing game while their brains were monitored by fmri . when the subjects were excluded from the virtual game , they experienced distress that correlated with increased blood flow to the anterior cingular and insular cortices , exactly the same pattern that would have occurred had they been stuck by a needle . the greater the social distress generated , the more active these affective pain centers became . studies done on saddened and grieving subjects produced similar results ( gundel et al . 2003 ) . it appears that the layperson s intuition about pain is being borne out by science ; psychological pain seems to run on the same neural tracks as physical pain . and why should nt it ? just as physical stimuli that can damage our bodies prompt certain feelings and responses , so too should psychological stimuli that can damage our psyche like the loss of a child or the intrinsic symptoms of depression . just as we need to rest the body to protect ourselves from further harm , so too should we protect the mind . is this just a semantic issue , a disagreement between two sets of language users that , in the end , does nt have any adverse consequences ? it matters because the disagreement reflects a much larger issue : the rigid mindset of the scientific community , which sees the world in a certain way and wo nt allow for deviation , even from dissenters within its own ranks . science focuses its spotlight exclusively on the objective world , what can be studied , quantified , and explained . because it seems resistant to such inquiry , the subjective realm has been traditionally off limits , something that can only be appreciated on much looser terms by the humanities and the because of their position in the intellectual hierarchy , there is a trickle - down effect , which carries over to the practical science of medicine and to the culture at large . in the case of pain , there is only one kind , the real or physical kind that can be objectively verified by observing nociceptor activity or finding lesions on a cat scan . other experiences that may feel like pain but can not be linked to tissue damage are not pain . much more subjective and less transparently material , they are therefore derivative , less important , and better labeled something else ( suffering or anguish ) . while psychological pain may be unpleasant , the fact remains that it is  in our heads ,  not our bodies . as we continue to unfold the logic of the objectivist ( and dualistic ) paradigm which has now thoroughly permeated our cultural consciousness  those who suffer without any physical corroboration to show for it inevitably begin to appear suspect . they are either crazy ( mentally ill ) , deceitful ( because there is no real pain ) or weak ( everything is painful to such people ) . they do nt need pain doctors or pain medication , but psychiatrists and priests . disregarding for a moment that that all pain is  in the headeven dan vento s kidney stone pain , which he localized to the right side of his pelvis  the truth is that psychological pain is often more intense and dangerous than the  real thing .  for dan vento , his bout with kidney stones , among the most painful of all medical conditions , was nothing compared to the pain of grief . similarly , lucy grealy tells us in her memoir , autobiography of a face ( 1995 ) , that she would much rather face the pain of cancer and its treatments than the far worse pain of feeling deformed and lonely ( pp . 7 , 170 , 186 ) . in fact , many such sufferers welcome , even court , physical pain , feeling that it actually alleviates their emotional pain to a degree . and when , unalleviated , the pain becomes too much to bear , some will choose to end it by ending life . suicide rates are significantly higher in the setting of grief and depression than they are in the setting of physical pain ( schneidman 1998 ) . in addition to relegating psychological sufferers to second - class status , sufferers of chronic pain conditions like migraine , lower back pain , and fibromyalgia find themselves somewhere in limbo between real pain and the derivative , mental kind . on the one hand , their pain seems physical ( because it is localized to a part of the body ) , but on the other , it has more in more in common with psychological distress ( because there is no detectable injury ) . for a long time , medicine had no idea what to do with these patients , and so they drifted from doctor to doctor without finding relief . although their lives have improved with the introduction of pain specialists and pain clinics , chronic pain patients are still often tormented by the insidious logic of the objectivist perspective ( see heshusius 2009 , pp . some , in fact , resort to self - mutilation to legitimize their pain in the face of ongoing skepticism from family members and doctors :  you see now , they will say , pointing to their slashed arms ,  the pain is not in my head , it s real ( see padfield 2003 , pp . i bring up the seriousness of psychological pain and the limbo - like situation of chronic pain conditions because , like the work of a growing number of scientists , it goes against the grain of the prevailing mindset . perhaps , then , we should change this mindset and broaden our outlook . instead of privileging one type of pain over another , let s approach them in a more inclusive , democratic spirit , in which all pains are created equal . or better yet , let s view pain as occurring on a continuum or spectrum that runs from one ideal ( pain linked solely to physical injury ) to another ( pain linked solely to psychological injury ) . it accommodates our belief that the feeling of pain can arise from injury to the body as well as injury to the mind . it also accommodates our experience of the considerable overlap between the two varieties , that there is never pure physical or pure psychological pain but always combinations . those suffering from grief and mental illness often have somatic complaints : dan vento felt the loss of his daughter in his gut ; william styron s descent into depression was accompanied by sleeping and breathing problems ( styron 1992 , pp . at the same time , patients in physical pain inevitably suffer emotionally ; cancer patients routinely feel terrified , helpless and lonely ( cherney et al . moreover , the benefits of adopting a broader perspective go beyond validating and valuing our lived experiences . there are practical implications . for science , it would mean more support for the transformative work of researchers like joseph ledoux and antonio damasio into the subjective realm of feelings and emotions ( ledoux 1996 ; damasio 1999 ) after all , these experiences are as material as the beating of the heart and the dna molecule , even though at the moment we do nt precisely know how to translate neural activity ( brain language ) into mental states ( mind language ) . now that we know it shares neurological substrates with physical pain , scientists will no doubt look to extend the work of eisenberger by finding the  nociceptor pathways  of psychological injury : how are feelings of grief or depression detected and transmitted to the anterior cingular cortex ? and how could the signals be modifed ? dan vento s prolonged grief  what psychiatrists classify as complicated grief  has much in common with certain chronic pain states . in both instances , the injury has long past and yet the reverberating pain circuit , no longer serving any biological purpose , continues . are there similar mechanisms at work here , and might they be manipulated to help vento escape from his self - destructive rut ? there would also be changes in the clinical realm , improving the way doctors treat pain . some patients may require more attention to the body ; others , to the mind ; the majority , to both . here take , for example , the placebo effect in clinical trials , in which a fake pill has been shown to relieve pain on the order of 1530% of cases . most investigators view the phenomenon as a contaminant that must be eliminated to assess the efficacy of the  real  drug . but why not switch frames , as benedetti ( 2009 ) has urged , and focus just as diligently on the reality of the psychological factors that are equally effective , in some cases even more so ( pp . 6 , 30 ) ? why not try to harness and enhance these factors to help patients ? this same novel way of thinking led dewall et al . ( 2010 ) to administer physical pain medication ( acetaminophen ) to people suffering from psychological hurt , and not unsurprisingly , it seemed to work . one of the greatest twentieth - century thinkers , ludwig wittgenstein , showed that paying attention to ordinary language can help advance philosophy . he also showed that clinging dogmatically to a certain picture can lead to conceptual illness ( wittgenstein 1958 , sect . 115 ) . if we can thoroughly break with our unhealthy ( and inaccurate ) dualistic legacy and truly see that mind and body are inextricably connected , then we must agree with dan vento , joan didion , and many other sufferers that psychological pain exists and is just as important and worthy of our attention as physical pain . they are two sides of the same coin and should be spoken of and treated as such .
medicine regards pain as a signal of physical injury to the body despite evidence contradicting the linkage and despite the exclusion of vast numbers of sufferers who experience psychological pain . by broadening our concept of pain and making it more inclusive 
 , we would not only better accommodate the basic science of pain but also would recognize what is already appreciated by the layperson  that pain from diverse sources , physical and psychological , share an underlying felt structure .