Commentary

Affective Dimensions of Pain

How Many and How Measured?
Richard H. Grace/y

W
‘bile many authors still refer only to a sin-
gle dimension of “pain,” the separation
of pain experience into sensory-inten-
sity and affective components is well es-
tablished. In their focus article, Price and Harkins di-
vide the affective component into two parts: primary
feelings of immediate unpleasantness and secondary
stages, such as despair, that result from intervening
thoughts such as concern for the future.
This focus on the affective component is needed.
Although well established, it is likely that the term
“affective” has been a source of confusion. “Affec-
tive” has an established psychological-psychiatric
usage, such as reference to an affective disorder, or
to observable behavior, such as in the phrase, “affect
is not appropriate to mood.” The fact that pain affect
is commonly described as the “emotional compo-
nent” reinforces a psychological-psychiatric inter-
pretation of a persistent change in emotional func-
tioning. Thus, there could be three levels of pain
affect.
These various terms can be organized into 3
general types. First are feelings associated with
the immediate pain sensation. Psychophysicists
have used the term unpleasantness, pain re-
searchers the terms affective, distress, and dis-
comfort, and animal scientists the terms aver-
sive and motivational. Second are feelings
associated with human thought, with the way in
which pain experiences are cognitively inte-
grated into a patient’s life. These thoughts can
be about the past (accumulated effect of
chronic suffering), the present (uncertainty), or
From the Neurobiology and Anesthesiology Branch, National Insti-
tute of Dental Research, National Institutes of Health, Bethesda,
Maryland.
Reprint requests: Richard H. Gracely, PhD, Building 10, Room 1 N-
103, NIH, Bethesda, MD 20992.
the future (uncertainty, fear, dread). Third,
chronic or severe pain can aversely affect psy-
chological health. Terms like the emotional or
affective component may refer to changes in
mood and personality such as depression, an-
hedonia, irritability and paranoia.4
Price and Harkins make a strong theoretical argu-
ment for both a primary and secondary affective com-
ponent and buttress their proposal with a body of
empirical evidence, much of which has been gener-
ated in their laboratory. Their central thesis is sup-
ported by the results of both psychophysical and psy-
chological investigations, many of which were not
included in this brief article. Indeed, a thorough cov-
erage of the relevant issues would require a book.
What follows are a few thoughts stimulated by their
article.
THE PRIMARY IMMEDIATE AFFECTIVE
COMPONENT: PAIN UNPLEASANTNESS
Pain hurts; there is no doubt that pain is unpleasant.
Pain motivates behaviors of escape and avoidance in
all animals, regardless of intelligence. This primary
unpleasant quality is very similar to other biological
unpleasantries such as hunger or thirst and feelings
of overheating or suffocation. These feelings can be
extremely powerful, motivating extreme behaviors.
The primary unpleasantness of pain is likely to be at
least as strong as other feelings that motivate preser-
vation of the organism.
Pain Unpleasantness Is Not an Emotional
Component
Probably a majority of articles discussing immediate
pain unpleasantness refer to “an emotional compo-
nent.” However, immediate pain unpleasantness is
no more an emotion than is hunger or thirst. This

APS Journal l(4): 243-247, 1992 243

244 COMMENTARYiGracely

component feels bad all on its own, it does not need
any help from cognitive appraisals. In fact, the term
“unpleasantness” was borrowed from psychophysi-
cal investigations of the feelings accompanying
taste, olfactory, and thermal stimuli.2,6 It was pur-
posefully applied to describe the similar primary
component of pain affect.
In their model, the primary component is com-
posed of both unpleasantness and (immediate) cog-
nitive appraisals. Their secondary component, asso-
ciated strongly with chronic pain, is composed of
more extensive cognitive appraisals. This classifica-
tion appears to be based on the difference between
acute and chronic pain rather than the distinction
between primary pain unpleasantness and second-
ary cognitively mediated affect. It may be more parsi-
monious to describe initial and long-term pain as
separate constructs, each of which may contain both
a primary component of pain unpleasantness, shared
by most life forms and independent of cognitions,
and a secondary component resulting from cognitive
appraisals.
The Magnitude of Pain Unpleasantness
Not Emphasized
The tendency to associate the secondary affective
component with chronic pain overlooks the contri-
bution of the primary component in protracted pain
syndromes. The pain and “state” of backache, head-
ache, and arthritis can certainly engender cognitively
mediated feelings. Chronicity can also lead to a high
degree of coping as patients become “experts”
about their own pain. Although they may experience
negative affect related to thoughts about their pain
and state, their most significant distress still may be
the nagging unpleasantness that will not go away.
Relation of Pain Unpleasantness to Pain
Intensity: Affective Gain Control
Price and Harkins identify several loci likely to be
involved in the processing of the affective compo-
nent and note that it is possible that affective pro-
cessing could occur both in series and in parallel
with sensory-discriminative processing. Figure 1
shows a simplified model that requires a parallel
stage of affective processing and does not exclude
prior series processing before the affective pathway
branches from a common input.5*8 It is useful to think
of the affective processor as an amplifier of sensory
input with a gain control. Manipulations that increase
Is pain affect, such as anxiety, would do so by increas-
ing the affective gain, resulting in more unpleasant-
ness for a given pain sensation. Manipulations that
decrease pain unpleasantness would likewise do so
by decreasing the gain. Note that unpleasantness

PAIN-UNRELATED
* SECONDARY AFFECT

PAIN-RELATED
THINKING * SECONDARY AFFECT
p-0

bUNPLEASANTNESS
-0.
AFFECTIVE GAIN
CONTROL

NOCICEPTIVE
-SENSORY INTENSlTY >
INPUT -

Figure 1. The affective pain components. Pain unpleasantness is derived from the output of an affective amplifier (bottom)
that receives input from the sensory-discriminative nociceptive system. Pain unpleasantness is related to this input, and
thus to sensory intensity, and also related to the gain of the affective amplifier, which is under central control and indepen-
dent of sensory intensity. Also shown is a secondary affective generator (middle) that receives input from thoughts associ-
ated with pain experience. A third affective generator (top) receives input from thoughts unrelated to pain, for example,
the knowledge of a life-threatening disease. The affective experience of a patient in pain may be composed of affect from
all three sources. Not shown are feedback loops connecting all components to all of the gain controls.

can also be altered by changing the input signal re-
lated to the intensity of the pain sensation. Thus, pain
unpleasantness does not originate from an indepen-
dent parallel affective generator. It is related to both
nociceptive input and to a variable affective gain that
can be altered independently of sensory input.
SECONDARY, COGNITIVE COMPONENTS
The core of cognitive therapy is the concept that
emotions and feeling are not evoked by events, but
rather by an intervening third variable, the thoughts,
interpretations, or “self-talk” about the event. Price
and Harkins’ examples of a bee sting (to persons with
and without an allergy) or of abdominal pain (with a
history of indigestion or a recent diagnosis of cancer)
clearly indicate how the feelings associated with sim-
ilar painful events can result, with the addition of
other information, in very different affective re-
sponses. The literature on pain cognition contains
many more examples and relevant findings.
The focus article states that these secondary com-
ponents can be found only in patients, since labora-
tory methods cannot duplicate the affective conse-
quences of clinical syndromes. This is only true
where ethics and morality prevail; unfortunately the
history of man continually provides deplorable exam-
ples of secondary affective pain states produced by
“laboratory” methods.
Feeling Pain, Feelings About Being in Pain,
or Feelings About Being in an Undesirable
State
Price and Harkins emphasize the difference between
pain unpleasantness, the immediate feelings of pain,
and the secondary affective component of feeling
about being in pain. They recognize that these differ-
ent components require different measurement tech-
niques and have developed specific scales for each
component.
It may be important to further distinguish between
two types of secondary affective responses (see Fig.
1). The first type would be pain-specific, resulting
from direct thoughts about pain, and a future without
relief. For example, there are those who may con-
sider themselves especially sensitive to bee stings
and anticipate a great deal of pain. The knowledge
of abdominal pain and a diagnosis of cancer may
result in dread of a future of increasing and unremit-
ting pain. The second type may not be pain-specific,
but may originate from general thoughts and feelings
about one’s predicament. An allergic recipient of a
bee sting and a cancer patient with abdominal pain
symptoms may be concerned predominantly with a
COMMENTARY/Gracely 245
premature end to their lives. Their negative affect
may be little related to their pain sensations. Similar
affect may be experienced in other life-threatening
acute or chronic conditions that are not painful. Un-
like either the primary component or the pain-rele-
vant secondary component, this component would
not be expected to be related to sensory intensity.
The only relevance of these “state” feelings to pain
may be via the primary component. Cognitive ap-
praisals, either pain-related or unrelated, may modu-
late the affective gain of the primary component, re-
sulting in increased pain unpleasantness.
Thus, in addition to two types of secondary com-
ponents, it is also useful to think of two types of affec-
tive modulation. First, information or other interven-
tions may directly alter thoughts about experienced
pain, resulting in a change in the magnitude of the
secondary affective component. Second, cognitive
appraisals of either being in pain or of any other un-
desirable condition may increase the gain of the sys-
tem mediating primary pain unpleasantness, while
other cognitive, pharmacological, etc. interventions
may decrease affective gain.
A TERTIARY PSYCHOLOGICAL-
PSYCHIATRIC AFFECTIVE COMPONENT?
The term “affective” connotes a change in personal-
ity and mood. It is well documented that chronic pain
is associated with a number of measurable changes,
such as increased somatization, hostility, irritability,
and depression. Price and Harkins include these af-
fective changes in an overall secondary factor. Al-
though there is considerable overlap, there is likely
to be a sufficient reason to label these changes as an
additional subset of secondary pain affect, or as a
separate tertiary factor. For example, following a pro-
cedure that essentially cures a chronic pain problem,
the primary and secondary affect associated with the
pain sensation should disappear along with the pain
sensation. The psychological changes acquired dur-
ing the period with chronic pain, however, will likely
persist for some time. The pain is gone but the pa-
tient’s affective state lingers on.
MEASUREMENT OF PAIN
UNPLEASANTNESS
The measurement of immediate unpleasantness, and
also pleasantness, is well established in psychophys-
ical evaluations of the sensory intensity and subjec-
tive feelings produced by thermal, taste, and olfac-
tory stimuli during various internal states. My own
early studies used these methods as a starting point
for the development and validation of separate scales
246 COMMENTARY/Gracely
of intensity and unpleasantness. Verbal descriptor
scales were chosen for several reasons, including an
assumption, supported by some empirical evi-
dence ls3 that they might facilitate the discrimination
of these two pain dimensions.6,7 Price and col-
leagues have used visual analog scales and careful
instructions to separately rate these dimensions.
Both methods satisfy the criterion of similar structure
for the sensory and unpleasantness scales.’ With
parallel scales, differences can be attributed to the
dimension, and not to a method variance associated
with a confound between dimensions and a different
type of scale.’
Regardless of scale type, the validity of differential
scales must be firmly established. Only then can one
be confident that similar effects measured by sensory
and affective scales indicate a lack of a differential
effect and not a lack of a differential scale.
Validity: Different Functions
Price and Harkins cite the two lines of evidence pro-
posed by Gracely et al.‘to support the validity of sep-
arate scales of the intensity and unpleasantness of
pain sensations. The first uses different psychophysi-
cal functions as evidence for the validity of the sen-
sory intensity and unpleasantness. While such differ-
ences are suggestive, it should be noted that this line
of evidence does not stand alone. For example, the
use of different labels for two visual analog scales of
sensory intensity also could result in different func-
tions. Different descriptor scales of sensory intensity
could also show different functions, although meth-
ods exist for quantifying the descriptors on the same
common scale.6s13 Thus, difference in psychophysi-
cal functions may indicate the assessment of differ-
ent dimensions, but it can also indicate distortions
of the same dimension. Conversely, it is also possible
that valid scales of sensory intensity and unpleasant-
ness could produce similar psychophysical func-
tions.
This caveat also applies to the identification of
neurons involved in affective processing. In addition,
the variance and nonlinear characteristics of neu-
ronal responses would probably prevent any mean-
ingful differential correlations with sensory or affec-
tive responses. As Price and Harkins note, stronger
support is provided by the second, empirical, line of
evidence.
Validity: Empirical Test
Price and Harkins describe in detail the most impor-
tant evidence for validity of affective scales: the se-
lective response to manipulations assumed to alter
pain affect. Selective affective responses were dem-
onstrated in the early psychophysical studies of the
thermal and chemical senses; hunger or satiety al-
tered ratings of the unpleasantness or pleasantness
of taste or olfactory stimuli without changing inten-
sity ratings.’ Likewise, raising or lowering body tem-
perature altered unpleasantness-pleasantness rat-
ings of thermal stimuli without altering intensity
ratings.’ As the focus article notes, this validation
method has been applied to both verbal descriptor
and visual analog scales. It provides a validation gold
standard both for new subjective scales and for in-
vestigations of the neural basis of pain affect.
Affective Ratios
In affective ratio models, both the primary and sec-
ondary affective components can be compared to
sensory intensity. It is useful to quantify an “affective
ratio” defined as the amount of unpleasantness or
secondary affect associated with a specific magni-
tude of pain sensation. This model was first devel-
oped with verbal descriptor scale responses of pain-
ful electrical stimuli’ and the ratio using verbal
descriptor responses varied over experimental elec-
trical tooth pulp stimulation (0.15) clinical stimula-
tion of exposed dentin with cold spray (0.72) and
chronic myofascial pain (0.82).l” The absolute value
of these ratios can vary with the type of scale; the
important relation is the relative ratio between condi-
tions obtained with a consistent scaling method.
The affective ratio, describing the affective gain
(both primary and secondary), is an extremely useful
concept that can be used to quantify an important
dimension of pain, or the characteristics of a patient
or a treatment. Its use also clarifies the relationship
between sensory-discriminative and affective com-
ponents. For example, the importance of the distinc-
tion between sensory intensity and unpleasantness
has been challenged because of a high correlation
between these dimensions.“*12 This high correlation
reflects the sensory input into the “affective ampli-
fier.” Flgure 1 shows that the true affective variable
is the affective gain, not the output of the affective
system. This gain is measured by the affective ratio
and should be relatively independent (and thus un-
correlated) with sensory intensity.5v8
MEASUREMENT OF OTHER AFFECTIVE
COMPONENTS
Price, Harkins, and colleagues have made a compel-
ling theoretical case for secondary components, and
they have derived and used scales to measure them.

They found an association between secondary com-
ponents and variables such as neuroticism and
depression that is not shared by either the sensory
dimensions or the primary unpleasantness compo-
nent. They have, in addition, described a strategy for
further identification of both of these psychological
constructs and the underlying neural structures in-
volved in affective responses. Their preliminary re-
sults are very promising. However, the surface has
just been scratched. For example, what is the role of
clinical scales such as the McGill Pain Questionnaire
in the evaluation of secondary affective attributes?
What is the relation of their secondary components
to the affective and evaluative components of this
instrument? How do visual analog scales compare to
more complex measures of pain cognition? What do
psychometric validation studies indicate about visual
analog scales of secondary pain affect? For example,
a pain-independent secondary component such as
fear of death may be related to psychological vari-
ables directly without an intermediary conduit of pain
sensation. Price and Harkins should be lauded for
asking the right questions. They must be good ones
because they lead to many more.
References
1. Duncan GH, Bushnell MC, Lavigne GJ: Comparison of
verbal and visual analogue scales for measuring the
intensity and unpleasantness of experimental pain.
Pain 37:295-303, 1989
2. Gracely RH: Pain psychophysics. Doctoral Disserta-
tion, Brown University, Providence, Rhode Island, 1977
3. Gracely RH: Psychophysical assessment of human
pain. pp. 805-824. In Bonica JJ, Liebeskind JC, Albe-
cOMMENTARY/Gracely 247
Fessard D (eds): Advances in pain research and ther-
apy. Vol. 3. Raven Press, New York, 1979
4. Gracely RH: Theoretical and practical issues in pain
assessment in central pain syndromes. pp. 85-101. In
Casey KL (ed): Pain and central nervous system dis-
ease. Raven Press, New York, 1991
5. Gracely RH: Evaluation of multidimensional pain
scales. Pain 48:297-300, 1992
6. Gracely RH, McGrath PA, Dubner R: Ratio scales of
sensory and affective verbal pain descriptors. Pain 5:
5-18,1978
7. Gracely RH, McGrath PA, Dubner R: Validity and sensi-
tivity of ratio scales of sensory and affective verbal pain
descriptors. Pain 5:9-29, 1978
8. Gracely RH, Smith WB: Psychological modification of
cranial nociception. In Schmidt RF, Olesen J (eds):
Proceedings of the International Symposium on the
Pathophysiological Mechanisms of Migraine, (in
press)
9. Gracely RH, Taylor F, Schilling RM, Wolskee PJ: The
effect of a simulated analgesic on verbal descriptor
and category responses to thermal pain. Pain Suppl2:
173, 1984
10. Heft MW, SharavY, Gracely RH: Assessment of chronic
pain using verbal descriptor scaling procedures. J
Dent Res 58 (Special issue A):216, 1979
11. Holroyd KA, Holm JE, Keefe FJ et al: A multi-center
evaluation of the McGill Pain Questionnaire: results
from more than 1700 chronic pain patients. Pain 48:
301-312, 1992
12. Turk DC, Rudy TE, Salovey P: The McGill Pain Ques-
tionnaire reconsidered: confirming the factor struc-
ture and examining appropriate uses. Pain 21:
385-397, 1985
13. Tursky B: The development of a pain perception pro-
file: a psychological approach. pp. 171-l 94. In Weise-
nberg M, Tursky B (eds): Pain: new perspectives in
therapy and research. Plenum Press, New York, 1976