psy 06_11 p416_421 pain jarrett 1_Layout 1 16/05/2011 16:11 Page 416

FEATURE

studies that we’ll hear about often focus

on either psychosocial or biological

Ouch! The different ways mechanisms, it’s worth remembering that

a person’s beliefs and cultural upbringing
can change the way their body and brain

people experience pain respond to pain. ‘It’s important that we

Christian Jarrett examines the psychology of pain perception
eadache, stubbed-toe, injection,
not fight it out as to who’s winning – the
psychologists or the biomedical folks,’
says Professor Roger Fillingim, a clinical
psychologist at the University of Florida
and a leading expert in the field. ‘We need
to integrate all of these factors to better
understand how they work together to
ultimately create the experience of pain.’
for others pain is a constant companion.

H broken bone – most of us have

suffered pain in one form or
another, but our experience of that pain
will have varied wildly. In the lab, the
same level of stimulation, from extreme
cold to electric shock, has been shown
to cause a yelp in some but a barely
discernible wince in others. Moreover,
whereas many people are lucky enough
to experience pain as a fleeting encounter,
bibliography
The sensitivity and tolerance people
show towards pain varies predictably
according to several factors, including
gender, ethnicity, personality and culture,
all interacting, overlapping and playing
out in the tissues and synapses of the
body. Indeed, the topic of individual
differences in pain is like a microcosm of
science – it’s where biology, psychology
and sociology all meet. So, although the
Gender
The question of whether men or women
have the greater pain threshold is
guaranteed to liven up the most soporific
of dinner parties. From a lay perspective,
evidence exists on both sides. There’s no
shortage of stories of feminine bravery –
for example, in the grip of prolonged
labour. On the other hand, it’s men who
have the greater reputation for a
warrior instinct and physical risk-
taking. Although some studies turn
up negative results, the research points
overwhelmingly in one direction.
Whether in the lab or in the clinic, men
demonstrate greater tolerance of and
less sensitivity to pain than women.
Women are also far more likely to be
diagnosed with chronic pain conditions
like fibromyalgia (see box).
Consider a 1998 paper, typical of
the field, in which Pamela Paulson and
colleagues scanned the brains of 10
women and 10 men while they
experienced a heat stimulus applied
to their forearm. The participants were
told the experiment was testing their
ability to discriminate temperatures
using a scale from 0 ‘no heat sensation’
to 10 ‘just barely tolerable pain’. Not
only did the female participants
consistently rate the higher 50oC
stimulus as more painful than the
male participants, but their brains also
showed a greater change in activation
in response to it, including in the

Applegate, K.L., Keefe, F.J., Siegler, I.C. et
al. (2005). Does personality at college
entry predict number of reported pain
conditions at mid-life? A longitudinal
study. The Journal of Pain, 6, 92–97.
Campbell, C.M., Edwards, R.R. &
Fillingim, R.B. (2005). Ethnic
differences in responses to multiple
experimental pain stimuli. Pain, 113,
20–26.
Campbell, C.M., France, C.R., Robinson,
M.E. et al. (2008). Ethnic differences
in the nociceptive flexion reflex (NFR).
Pain, 134, 91–96.
Campbell, C.M., France, C.R., Robinson,
M.E. et al. (2008). Ethnic differences
in diffuse noxious inhibitory controls.
The Journal of Pain, 8, 759–766.
Diller, A. (1980). Cross-cultural pain
semantics. Pain, 9, 9–26.
Conrad, R., Schilling, G., Bausch, C. et al.
(2007). Temperament and character
personality profiles and personality
disorders in chronic pain patients.
Pain, 133, 197-209.
Fitzgibbon, B.M., Giummarra, M.J.,
Georgiou-Karistianianis, N. et al.
(2010). Shared pain: From empathy to
synaesthesia. Neuroscience and
Biobehavioural Reviews, 34, 500–512.
Hobara, M. (2005). Beliefs about
appropriate pain behaviour: Cross-
cultural and sex differences between
Japanese and Euro-Americans.
European Journal of Pain, 9, 389–393.
Keefe, F.J., Lefebvre, J.C., Egert, J.R. et
al. (2000). The relationship of gender
to pain, pain behaviour, and disability
in osteoarthritis patients: The role of
catastrophising. Pain, 87, 325–334.
Levine, F.M. & De Simone, L.L. (1991).
The effects of experimenter gender
on pain report in male and female
subjects. Pain, 44, 69–72.

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psy 06_11 p416_421 pain jarrett 1_Layout 1 16/05/2011 16:11 Page 417
anterior cingulate cortex
(a region known to be
associated with the evaluation
of painful stimuli) and
posterior insula (which
regulates internal body
states).
These kinds of studies
are not without problems.
For socio-cultural reasons
men are less likely to want
to admit that they’ve found
a stimulation painful. The sex
of the experimenter can play
a role here. Several studies
have shown that men report
lower pain intensity ratings
and exhibit greater pain
tolerance when the
experimenter is a woman.
Fredric Levine and Laura Lee
De Simone in a 1991 study
even chose especially
attractive researchers to
amplify the effect. At least
one study has found that
women too report higher
pain tolerance when tested
by the opposite sex.
Other research has shown
that the degree to which
participants identify with
masculinity and femininity
influences their response to
pain. For example, Cynthia
Myers at the University of
Florida showed this in
relation to the widely used
cold-pressor task in which
participants are required to
hold their hand in icy water
for as long as they can. Male
and female participants who identified
more with masculinity tended to hold
their hand in the ice for longer.
Whilst findings like this highlight just
how important it is to consider gender-
role influences when investigating sex as
a factor, this doesn’t mean that there aren’t
also underlying physiological differences
in the way the sexes experience pain.
Myers, for example, found that sex still
Myers, C.D., Robinson, M.E., Riley, J.L. III
& Sheffield, D. (2001). Sex, gender
and blood pressure: Contributions to
experimental pain report.
Psychosomatic medicine, 63, 545–550.
Nayak, S., Shiflett, S.C., Eshun, S. &
Levin, F.M. (2000). Culture and gender
effects in pain beliefs and the
prediction of pain tolerance. Cross
Cultural Research, 34, 135–151.
Komiyama, O., Kawara, M. & De Laat, A.
read discuss contribute at www.thepsychologist.org.uk
special issue
Extremes of pain
According to the Chronic Pain Policy Coalition over seven million
people in the UK are affected by chronic pain and it’s the second
most common complaint cited by claimants for incapacity benefit
(www.paincoalition.org.uk). Chronic pain can be associated with
illnesses such as cancer or arthritis. However at other times, as
in the chronic pain syndrome of fibromyalgia, the cause is unclear.
Fibromyalgia, which is 10 times more common in women than in
men, is typically associated with all-over body pain, increased pain
sensitivity and also tenderness on specific parts of the body.
At the other extreme, people with chronic indifference to pain
(CIP) lead lives with no experience of pain whatever (Stieg Larsson
fans might recall that the unstoppable blond hulk Ronald
Niedermann had this diagnosis). CIP may sound like a blessing
but the tribulations of those with the condition – undetected
bumps, bruises, burns and shortened lifespans – are a reminder
of how pain in moderation can serve a useful role. In some cases
CIP has been traced to a mutation in a single gene that codes
for a protein involved in the sodium channel of nerve endings.
A different mutation of the same gene is associated with an
opposite condition whereby patients experience even mild touch
as excruciatingly painful.
Another form of extreme pain experience is so-called pain
synaesthesia. People with this condition have an exaggerated
empathy for the sight of other people’s pain. Few cases have
been documented so far, but the condition seems to manifest in
a person after they themselves have suffered a traumatic pain
experience. In a review published in 2010 Bernadette Fitzgibbon
cites the case of a man (now deceased) with hyperalgesia, who
experienced physical pain whenever his wife hurt herself. If she
knocked her finger, he would grasp his own finger in excruciating
pain. Fitzgibbon also describes phantom limb pain triggered in
amputees (most of whom had lost their limb in traumatic
circumstances) by the sight of other people’s painful experiences
or even merely by stories about those experiences.
predicted pain tolerance even after the intake of hormone replacement therapy
influence of gender identity was taken or the contraceptive pill. Hormones are
into account. likely to exert their effects via the
There’s no shortage of potential inflammatory response, but these
biological mechanisms that could pathways are still being worked out.
underlie women’s greater sensitivity to There’s also evidence that the body’s
pain than men. These include hormonal natural pain killer system – the
effects – for example, women’s response ‘endogenous opioids’ – works differently
to pain varies across the menstrual cycle, in women compared with men. For
during and after pregnancy, and with the example, in a 2002 study, Jon-Kar Zubieta
(2007). Ethnic differences regarding (2009). Exploring relationships for gender predict the response to
tactile and pain thresholds in the visceral and somatic pain with morphine. An experimental cold pain
trigeminal region. The Journal of Pain, autonomic control and personality. study. European Journal of Pain, 10,
8, 363–369. Pain, 144, 236–244. 103–112.
Paulson, P.E., Minoshima, S., Morrow, T.J. Palmer, B., Macfarlane, G., Afzal, C. et al. Rahim-Williams, F.B., Riley, J.L. III,
& Casey, K.L. (1998). Gender (2007). Acculturation and the Herrera, D. et al. (2007). Ethnic
differences in pain perception and prevalence of pain amongst South identity predicts experimental pain
patterns of cerebral activation during Asian minority ethnic groups in the sensitivity in African Americans and
noxious heat stimulation in humans. UK. Rheumatology, 46, 1009–1014. Hispanics, 129, 177–184.
Pain, 76, 223–229. Pud, D., Yarnitsky, D., Sprecher, E. et al. Sargent, C. (1984). Between death and
Paine, P., Kishor, J., Worthen, S.F. et al. (2006). Can personality traits and shame: Dimensions of pain in Bariba
417
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special issue
and colleagues used PET
and a deep-tissue pain
stimulation and found less
μ-opioid system activation
in the brains of female
compared with male
participants. Men and
women respond differently
to pain treatments too,
with women generally
showing more of a
response to opioid-based
analgesics, although this
research is patchy.
There are also cognitive
factors that could explain
gender differences in pain
response. One of these
concerns ‘catastrophising’ –
that is perceiving a pain as
particularly threatening
and believing that it is too
severe to cope with. Typical
items used to measure this
factor include: ‘it is terrible
and I feel it is never going
to get any better’ and ‘it is
awful and I feel it overwhelms me’.
Several studies have shown that women
tend to catastrophise about pain more
than men. In 2000, for example, when
Francis Keefe at the Duke University
Medical Centre and his team studied 168
patients with osteoarthritis of the knees,
they found that the female patients
reported more pain but that this gender
difference disappeared once levels of
catastrophising were taken into account.
Ethnicity
Alongside gender, substantial evidence has
also accumulated suggesting an association
between pain experience and ethnicity.
Generally, white Caucasian people are
found to be less sensitive to, and more
tolerant of, pain than individuals of
African or Asian descent.
Claudia Campbell and colleagues
in association with Fillingim’s Lab at
the University of Florida, for example,
culture. Social Science and Medicine,
19, 1299–1304.
Schmahl, C., Bohus, M., Esposito, F. et al.
(2006). Neural correlates of
antinociception in borderline
personality disorder. Archives of
General Psychiatry, 63, 659–667.
Schmahl, C., Greffrath, W., Baumgaertner,
U. et al. (2004). Differential nociceptive
deficit in patients with borderline
personality disorder and self-injurious
418
reported in 2005 that 62 African
American participants were on average
less tolerant of heat pain, cold pressor
pain and ischaemic pain than white
participants. Another study by the same
research team found that African
American participants exhibited the
nociceptive flexion reflex – an automatic
withdrawal movement – to an electrical
pain stimulus at a lower intensity than
did white participants. This paradigm has
the advantage of not requiring
participants to report the pain they’re
experiencing, so bypassing some of the
socio-cultural confounds that that entails.
Although most studies in this field
have compared African Americans and
white Americans, there are some
exceptions. Osamu Komiyama’s team at
the Nihon University School of Dentistry
at Matsudo, for example, compared white
Caucasian Belgian and Japanese
participants, finding that the latter were
more sensitive to needle-like stimuli
behaviour. Pain, 110, 470–479.
Vossen, H.G., van Os, J. & Lousberg, R.
(2006). Evidence that trait-anxiety and
trait-depression differentially moderate
cortical processing of pain. Clinical
Journal of Pain, 22, 725–729.
Zubieta, J-K., Smith, Y.R., Bueller, J.A. et
al. (2002). µ-Opioid receptor-mediated
antinociceptive responses differ in men
and women. The Journal of
Neuroscience, 22, 5100–5107.
applied to their cheek, gums
or tongue. Intriguingly, this
same study also found that,
despite their increased
sensitivity, the Japanese
participants gave the same
stimuli lower pain ratings.
The researchers said this likely
reflects the ‘Japanese cultural
emphasis on stoicism and the
desirability of concealing pain
and emotions’ (see ‘Cultural
differences’).
Besides the role played by
cultural influences, several
physiological and
psychological mechanisms
underlying ethnic differences
have also been identified. One
of these is the endogenous
pain control mechanism called
‘diffuse noxious inhibitory
controls’. This is the
physiological reality behind
the folk belief that one way
to alleviate an ache is to induce
pain somewhere else in the body.
Another study by Claudia Campbell and
colleagues in 2008 investigated this in
relation to an ischaemic pain, induced via
a tightened arm tourniquet, and a painful
electric zap to the leg. In the wake of the
arm pain, white participants showed
greater reductions in sensitivity to the
electric stimulation to their leg than did
African American participants.
As regards psychosocial factors,
a team led by F. Bridgett Rahim-Williams
in Roger Fillingim’s lab found that pain
sensitivity was greater among African
Americans and Hispanics who expressed
more identification with their ethnic
group – for example, they agreed with
statements like ‘I’ve spent time trying to
find out more about the history and
traditions of my ethnic group’. Consistent
with this, Ben Palmer and colleagues at
Manchester University Medical School
and the University of Aberdeen found
that reports of all-over body pain were
four times higher, on average, among
a sample of South Asian participants in
the UK compared with white Europeans,
and crucially, that such reports were
negatively correlated with participants’
degree of assimilation into British culture.
One possible explanation for these
effects of ethnic identification and
assimilation is that ethnic differences in
pain experience are largely cultural and so
people who identify more with their
ethnic group are more likely to be
susceptible to these cultural influences.
Again it’s important to remember that
cultural influences are also likely to have
neurobiological correlates, as a person’s
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Cultural differences
‘between death and shame, includes items such as ‘Men (or women) should be able to tolerate
death has the greater beauty’ pain in most circumstances’ or ‘It is acceptable for men (or women)
to cry when in pain’. Using this questionnaire in a 2005 study, Mieko
These lines come from a Bariba proverb quoted in a 1984 article by Hobara at the New York State Psychiatric Institute found that 32
the anthropologist Carolyn Sargent, now at Washington University in Japanese men and women consistently rated it as less appropriate
St Louis. The Bariba are an ethnic group located in Benin and Nigeria for people of either gender to express pain compared with 32 Euro-
in West Africa and whenever Sargent American men and women. Using
attempted to talk to them about pain, she the same scale in a 2000 study,
found that they turned the discussion to Sangeetha Nayak and colleagues
issues of honour and shame, many of them found that college students in India
citing the proverb above. The Bariba, at similarly rated expressions of pain
least at the time of Sargent’s study, believed as less acceptable than their
that expressions of pain were a shameful counterparts in the USA. In line with
sign of weakness. Boys were circumcised in their beliefs, the Indian participants
groups and taught not to show a flicker of also showed greater pain tolerance
pain (girls too were circumcised but were than the US sample.
allowed to cry). Women were expected to Other researchers have examined
deliver their own babies and any outward differences between cultures in their
signs of pain were considered taboo. Do linguistic terms for pain. Anthony
these behavioural mores have any influence Diller writing in 1980 noted that
on pain perception? Bariba women told some languages have one general
Sargent that there was pain in labour but term for pain which is then tailored
there was no point in crying – if you’re going with modifiers – for example, sharp
to die it won’t help, they said. Recalling her pain or stinging pain – whereas other
clitoridectomy as child (a practice that has languages, such as Thai, have
since been outlawed) another woman told several different words that refer
Sargent that no pain is as excruciating and The Bariba believed that expressions of pain were a directly to different types of pain. He
that after that experience no pain will ever shameful sign of weakness (Sargent, 1984) also notes that the Khamti language
overwhelm a person. of Assam in India has four different
Several psychologists investigating cross-cultural attitudes to words for itchy and that the Japanese have different terms for pain
pain have used the ‘Appropriate Pain Behaviour Questionnaire’, which depending on the status of the sufferer.

beliefs and upbringing can affect the way
their body responds to pain. ‘My
simplistic assumption is that the only
way culture can influence pain is via
some psychological mechanism, because
for me that’s the conduit through which
it’s manifested in the individual,’ says
Fillingim. ‘So if I grow up in a culture
that believes pain is noble and a sign of
a higher power, that would alter my
beliefs about pain, would alter my
cognitive appraisals of pain and then
those beliefs and appraisals would
influence my behavioural, biological and
physiological responses related to pain.’
Personality
Another major factor that’s associated with
the way a person experiences pain is
personality. Although research in this area
is hampered by the use of varied
personality measures, a consistent
finding is that people who score higher
on neuroticism or a neuroticism-like factor
tend to show greater sensitivity to pain
and reduced tolerance. Helen Vossen at
Maastricht University in a 2006 paper
showed this sensitivity is also reflected in
an exaggerated cortical response to pain
as measured by EEG in an electrical pain
paradigm. Aspects of personality also seem
to predict the way a person responds to
pain relief. Dorit Pud of the Pain Relief
Unit at the Rambam Medical Centre in
Israel found that men and women who
scored more highly on ‘harm avoidance’
(a trait resembling ‘neuroticism’ that’s
derived from Robert Cloninger’s
Tridimensional Personality Questionnaire)
showed a larger response to morphine in
terms of their subsequent performance on
the cold pressor task.
Personality isn’t only related to acute
pain sensitivity and tolerance, it’s also
predictive of chronic pain conditions
in later life, and people diagnosed with
a chronic pain condition tend to exhibit
a characteristic personality profile. For
instance, Katherine Applegate and
colleagues at Duke University Medical
Centre caught up with over 2000
university students after a 30-year gap
and found that those who’d scored highly
in their youth on the Minnesota
Multiphasic Personality Inventory
measures of ‘femininity’ (male
participants only), ‘paranoia’ (female
participants only), ‘hypochondriasis’, or
‘hysteria’ also tended to be more likely to
have a chronic pain condition in middle
age.
As for the typical character profile of
a chronic pain patient, Rupert Conrad at
the University of Bonn in a 2007 paper
compared 207 patients with 105 pain-free
controls, finding that the patients scored
higher on ‘harm avoidance’ and lower on
‘self-directedness’ (a mix of the Big Five
factors of Conscientiousness and
Extraversion) and ‘cooperativeness’ (akin
to the Big Five factor of Agreeableness).
The patients also tended to score higher
on depression and state anxiety, with 41
per cent meeting the psychiatric criteria
for a personality disorder (PD) – most
frequently paranoid or borderline PD.
It’s obviously sensible to take rest,
relax and take precautions after a painful
injury. However, Conrad says a person
who scores high in harm avoidance will

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special issue
continue to behave in this way even after
their injury has healed. He adds that a
related personality factor associated with
chronic pain is low self-efficacy: ‘That
means a feeling of helplessness and
a conviction of not being capable of
controlling a situation or being able
to overcome obstacles associated with
chronic pain.’
‘As a consequence,’
he explains, ‘chronic pain
treatment should aim at
psychological mechanisms
enhancing self-efficacy and
lessen avoidance (e.g.
cognitive behavioural therapy)
and at pharmacologic agents
improving supraspinal
modulation of pain. It is
important to note that
psychotherapeutic and
pharmacologic approaches
should be seen as
complementary treatments.’
Somewhat paradoxically,
whilst the prevalence of
borderline PD is elevated
among patients diagnosed with
a chronic pain condition, the
same diagnosis is also
associated with reduced pain
sensitivity on laboratory
measures. In one
representative study published
in 2004, Christian Schmahl at
Johannes Gutenberg-University used an
infrared laser as the painful stimulus and
found 10 women diagnosed with
borderline PD to have higher heat pain
thresholds and lower subject pain ratings
than 14 non-clinical controls. In 2006 the
same researcher and his team linked this
reduced pain sensitivity to reduced pain-
related activation in the anterior cingulate
gyrus and amygdala of patients with
borderline PD compared with controls.
Recently attention has turned to
identifying the physiological mechanisms,
not merely the neural correlates, that
might account for the link between
personality and pain perception. Two
years ago, in an unpleasant-sounding
experimental paradigm, Peter Paine and
colleagues at Hope Hospital in
Manchester identified a link between
personality, pain and autonomic nervous
system activity. They used a balloon
inflated in the oesophagus to simulate
visceral pain and found that this triggered
an increase in parasympathetic nervous
system activity, as identified through
heart-rate variability, in participants who
scored more highly in neuroticism,
whereas repetitions of
the same stimulus in those lower in
neuroticism led to reduced
420
parasympathetic activity. One possible
explanation is that increased
parasympathetic nervous system activity
corresponds to a ‘freeze’ response in the
participants higher in neuroticism,
although how this relates to pain
experience remains to be worked out.
Conrad says there’s evidence that the
personality factors underlying chronic
pain may be
associated with
decreased
activation of the
prefrontal cortex
– a key brain
region involved
in the top-down
modulation of
pain. ‘This
neuroanatomical
structure can be
activated by a
cognitive
anticipation of
the potential
controllability of
pain,’ he says. ‘A
personality-based
conviction of
uncontrollability
and helplessness
and an avoidance
of pain makes
activation of these
neuroanatomical
structures less likely and hampers top-
down modulation of pain.’
Applications and controversies
We’ve seen how factors like ethnicity and
personality are related to people’s experience
of pain, a key challenge now is to use this
information to improve people’s quality of
life. ‘The goal ultimately,’ says Fillingim
‘is to gather all the information we have
about an individual – their age, weight,
race, sex, genotype data, psychology
questionnaire results – put all that into
a computer and based on an abundance
of evidence that we already have, the
computer will tell us, for example, what
drug is going to work best for that person.’
And even more helpful, Fillingim says, is
that same information might help predict
who’s at risk for developing chronic pain.
For example, if it’s judged that a patient
has a high chance of developing a chronic
pain condition after surgery, it might be
better to pursue alternative treatment
options where they exist. ‘So, it’s not just
picking the right drug or dose,’ Fillingim
says, ‘it’s really understanding the risk for
the development of chronic pain because
chronic pain is what we really have trouble
helping people with.’
Conrad agrees, adding: ‘Future studies
addressing the issue of chronic pain have
to give an even deeper insight into the
complex interplay of personality factors,
psychological mechanisms and the
associated neurobiological mechanisms.
The identification of a risk factor such
as low self-efficacy by personality
questionnaires – for example,
temperament and character inventory –
may lead to an earlier identification of
populations at risk and may lead to an
earlier treatment, which may positively
affect outcome.’
How long until these kind of benefits
might be seen? ‘I’m sure we’ll get there
one day,’ Fillingim says, ‘but I’m not sure
how far away that is. The more we get
into these individual differences, be it
genetic, gender, ethnic group or whatever,
the more complicated everything looks!’
A particularly compelling justification
for continuing to study individual
differences in pain experience comes
from as yet unpublished research looking
at genetic influences on pain perception.
Fillingim and his colleagues have
identified a marker for a particular gene
that’s associated with increased pain
sensitivity in one ethnic group but
reduced pain sensitivity in another.
This means that if biomedical researchers
ignore factors like ethnicity and gender,
they risk forming conclusions about
genetic influences that are too general.
‘This just shows that we’ve got a lot
of work to do,’ says Fillingim, ‘but
hopefully it will be useful in the long
run.’
Inevitably perhaps, this field has
attracted criticism from those who fear
the findings will be used to bolster
stereotypes. Fillingim and others in the
field are sensitive to these concerns and
don’t want their results to be used in that
way. ‘To me the broader concern is with
health disparities such that ethnic groups
experience poorer health than white
people do – that’s obviously driven by
many factors including socio-economic
status but what we’re finding may imply
that there are individual characteristics
of people from different ethnic groups
making them more or less prone to
experiencing pain or disability associated
with pain, and unless we understand
what’s driving these differences, we’re
not going to be able to remove the health
disparities even if we fix all the system-
level problems. So I think the benefits
of this kind of research far outweigh the
concerns that people have.’
I Dr Christian Jarrett is The Psychologist’s
staff journalist. chrber@bps.org.uk
vol 24 no 6 june 2011