Elsevier

The Lancet

Volume 353, Issue 9171, 26 June 1999, Pages 2233-2237
The Lancet

Series
Suffering: the contributions of persistent pain

https://doi.org/10.1016/S0140-6736(99)01308-2Get rights and content

Summary

Pain is a perceived threat or damage to one's biological integrity. Suffering is the perception of serious threat or damage to the self, and it emerges when a discrepancy develops between what one expected of one's self and what one does or is. Some patients who experience sustained unrelieved pain suffer because pain changes who they are. At a physiological level, chronic pain promotes an extended and destructive stress response characterised by neuroendocrine dysregulation, fatigue, dysphoria, myalgia, and impaired mental and physical performance. This constellation of discomforts and functional limitations can foster negative thinking and create a vicious cycle of stress and disability. The idea that one's pain is uncontrollable in itself leads to stress. Patients suffer when this cycle renders them incapable of sustaining productive work, a normal family life, and supportive social interactions. Although patients suffer for many reasons, the physician can contribute substantially to the prevention or relief of suffering by controlling pain. Suffering is a nebulous concept for most physicians, and its relation to pain is unclear. This review offers a medically useful concept of suffering that distinguishes it from pain, accounts for the contributory relation of pain to suffering by describing pain as a stressor, and explores the implications of these ideas for the care of patients.

Section snippets

Basic definitions: pain and suffering

The standard definition for pain is that it is “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”.1 Viewed from an evolutionary perspective, pain is perceived threat or damage to one's biological integrity and has sensory and emotional features. The sensory awareness of tissue trauma represents information crucial for adaptation and survival. The emotional experience of tissue trauma represents the biological

How pain causes suffering

Many physicians think of pain as a purely subjective, private experience; this view is correct but incomplete. Tissue trauma generates noxious signals, and figure 1 shows how excitation of nociceptors15 and sometimes neuropathic conditions16 can generate nociceptive afferent volleys. Peripheral and central mechanisms can exacerbate noxious signalling through sensitisation. Tissue trauma may cause nociception, neuropathy with abnormal neural firing patterns, or both. Inflammation and repetitive

Implications for care

Our concept of suffering resonates with the lay use of the term-the perception of damage to the self and grief over a loss in self-esteem. Although unrelieved pain can create an overwhelming degree of personal discomfort, its contribution to suffering is more insidious. At a physiological level, chronic pain is a stressor that promotes an extended and destructive stress response that involves neuroendocrine dysregulation, fatigue, dysphoria, myalgia, and impaired mental and physical

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