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Comment

What constitutes pain?

Comment on “Facing the experience of pain: A neuropsychological
perspective” by Franco Fabbro and Cristiano Crescentini
Joshua A. Grant
Max Planck Institute for Human Cognitive and Brain Sciences, Germany
Received 10 June 2014; accepted 10 June 2014
Available online 23 June 2014
Communicated by L. Perlovsky

Keywords: Pain; Emotion; Unpleasantness; Salience; Meditation; Mindfulness

In their thought provoking perspective article, Fabbro and Crescentini [1] review the neuropsychological mech-
anisms of pain, encompassing physical and psychological pain. An underlying assumption of the article is that
experiences, ranging from physical pain to the feelings that accompany thoughts of one’s own death, can all be sub-
sumed under the banner of pain. While Fabbro and Crescentini are certainly not alone in amalgamating these diverse
experiences, I would argue that it is not pain that binds them, but rather suffering.
I don’t think anyone would argue that burning one’s arm and seeing a loved one burn their arm is different, and feel
different, even though both experiences may roughly be categorized as painful. Similarly, being socially excluded or
thinking of one’s own death can incite distressful unpleasant feelings. But should these feelings be considered pain?
There are several reasons one might include these feelings under the domain of pain. Colloquially the word pain is
used to refer to all sorts of disagreeable situations or feelings. Further, the actual definition used by the International
Association for the Study of Pain suggests pain has both sensory and affective components and does not require a
physical precipitating cause. Thus, one could conclude that the hurt of social exclusion is an instance of the affective
component of pain. However, the definition also suggests, to be considered pain, a feeling must have both, a sen-
sory and affective component. While there is potentially a physical sensation associated with exclusion, it bears no
resemblance to physical pain.
Another point of potential confusion is the affective component of pain itself and how much of that is considered
specific to pain. Donald Price has proposed that along with the sensory dimension, physical pain has primary and
secondary affective dimensions [2]. The primary affective dimension is stimulus-driven, bottom-up and that which
signals alarm. The secondary affect is composed of various independent emotions such as fear that tend to be focused
on long term implications of the event. I would argue that what physical pain shares with psychological pain is this
secondary affect, making the two phenomena similar but ultimately different.

DOI of original article: http://dx.doi.org/10.1016/j.plrev.2013.12.010.

http://dx.doi.org/10.1016/j.plrev.2014.06.015
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554 J.A. Grant / Physics of Life Reviews 11 (2014) 553–554

In response one could rightly offer up results of research studies showing overlap of brain regions such as the
anterior cingulate cortex (ACC) and anterior insula (aINS) for psychological and physical pain systems. However,
one must consider that even within the domain of physical pain research there are still many disagreements. Where
nociceptive afferent signals actually become the experience of pain is heavily debated, as is the question of whether it
is even possible to ‘see’ the neural representation of pain at all [3]. Commonly, activation of ACC/aINS is interpreted
as the ‘emotional aspect’ of pain, owing to the fact that activity often correlates with unpleasantness ratings. However,
ACC and INS also happen to be nodes of what’s been called the salience network [4], which can be driven, not only by
noxious stimulation, but also by non-painful stimuli (e.g. visual or auditory [5]). It is not inconceivable that conditions
involving psychological pain would be more salient than the respective control conditions. Taken to extremes one
could argue that ALL brain activation typically ascribed to pain, is in fact, salience. This point is not trivial as to study
pain one must deliver a stimulus (or ‘painful’ situation), which is perceived as painful, but, probably for evolutionarily
adaptive reasons, all painful stimuli (and situations) are salient.

References

[1] Fabbro F, Crescentini C. Facing the experience of pain: a neuropsychological perspective. Phys Life Rev 2014;11:540–52 [in this issue].
[2] Price DD. Central neural mechanisms that interrelate sensory and affective dimensions of pain. Mol Interv 2002;2:392–403, 339.
[3] Iannetti GD, Salomons TV, Moayedi M, Mouraux A, Davis KD. Beyond metaphor: contrasting mechanisms of social and physical pain. Trends
Cogn Sci 2013;17:371–8.
[4] Seeley WW, Menon V, Schatzberg AF, Keller J, Glover GH, Kenna H, et al. Dissociable intrinsic connectivity networks for salience processing
and executive control. J Neurosci 2007;27:2349–56.
[5] Downar J, Crawley AP, Mikulis DJ, Davis KD. A multimodal cortical network for the detection of changes in the sensory environment. Nat
Neurosci 2000;3:277–83.