Pain Suffering and Illness Behavior

Nociception, or the process by which the nervous system detects tissue damage, is not synonymous with pain; increased afferent signaling to the CNS by itself does not always make a patient with chronic pain seek medical attention. However, nociception can, and often does, lead to suffering, a negative response to the perceived threat to the physical and psychological integrity of the individual and made up of a combination of cognitive and emotional factors such as anxiety, fear and stress. This in turn can lead to certain patterns of illness behavior, which in turn determines the clinical presentation. Such behavior is a complex mixture of physiologic (eg, pain intensity/severity or associated features), psychological (mental state, stress, mood, coping style, prior memories or experiences with pain, etc), and social factors (concurrent negative life events, attitudes, and behavior of family and friends, perceived benefits such as avoidance of unpleasant duties, etc). Thus individual attitudes, beliefs, and personalities, as well as the social and cultural environment, strongly affect the pain experience. Although the biological basis of these interactions is poorly understood, it is important to understand that the clinical presentation of chronic pain represents a dysfunction of a system that is formed by the convergence of biological, social, and psychological factors (the so-called biopsychosocial continuum). These factors not only modulate each other but also together are responsible for an individual's sense of well being. In a given patient or at a given time in the same patient, the primary disturbance may disproportionately affect one component of the spectrum. An example would include intense nociceptive activity associated with an inflammatory flare-up in a patient with chronic pancreatitis; this is expected to dominate the clinical picture while the episode lasts and the physician should concentrate on suppressing pain with strong analgesics. In between such episodes, when nociceptive activity is low, the spectrum may shift towards the psychosocial end and the wise physician may focus more on counseling and behavior modification. However, in either case, the patients' suffering is equally valid.

Indeed, most patients with chronic pain, regardless of etiology (somatic or visceral, "organic" or " functional") frequently suffer from depression, anxiety, sleep disturbances, withdrawal, decreased activity, fatigue, loss of libido, and morbid preoccupation with their symptoms, suggesting that these features may actually be secondary to the pain and not the other way around.

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