PS1102 - Perception of pain

Vicky McGowan (vm88@le.ac.uk)

A personal tale

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Learning outcomes
• Discuss why we experience pain
• Describe the pain system
• Discuss how the perception of pain is affected by cognitive factors,
and how this contributes to placebo and nocebo effects.
• Discuss how individual differences contribute to perception of pain.

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What we’ll cover today
• Why we experience pain
• Sensory aspects of pain perception
• Cognitive aspects of pain perception
• Placebo and nocebo effects
• Sex/gender differences in pain perception

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Reading
• Essential
• Goldstein, B.E., & Brockmole, J.r. (2017). Sensation and perception tenth
edition. Cengage Learning. Pages 351-358.

• Recommended
• Racine, M., Tousignant,-Laflamme, Y., Kloda, L.A., Dion, D., Dupois, G., &
Choiniere, M. (2012). A systematic literature review of 10 years of research on
sex/gender and pain perception – Part 2: Do biopsychosocial factors alter pain
sensitivity differently in women and men? Pain, 153, 619-635.

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Bonus content
• Additional content on blackboard
• Videos, patient experiences, activities
• Not essential, but will help you consolidate
your learning

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Why we experience pain

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Why do we experience pain?
• Warning signal to
avoid bodily harm
• Cognitive dimensions:
• Learning to avoid or
reduce pain

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Sensory aspects of pain
perception
Pain sensation
Nociceptive pain, sensed by nociceptors (pain receptors)
Inflammatory pain: damage to tissues or inflammation
Neuropathic pain: damage to nervous system (e.g. carpal tunnel
syndrome)

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Pain sensation
Important function of
avoiding damage to the
skin
Signals carried to sub-
cortical and cortical
areas through the
spinothalamic pathway

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Pain matrix
Pain matrix: cortical
and subcortical areas
activated by
nociceptors
Accounts for sensory
and affective aspects
of pain

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Pain pathway
• http://www.youtube.com/watch?v=uOaiaYDoUnA

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Cognitive aspects of pain
perception
Attention
“I remember being around five or six years old, and I was playing
Nintendo when my dog ran by and pulled the wire out of the game
system. When I got up to plug the wire back in I stumbled and banged
my forehead on the radiator underneath the living room window ... As I
resumed playing the game all of a sudden I felt liquid rolling down my
forehead, and reached my hand up to realize it was blood. ... All of a
sudden I screamed out, and the pain hit me.”

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Attention
• McCaul & Haugtevdt (1982)
- Participants had to put their hand in cold water
- Were instructed to pay close attention to the sensations that they were
feeling, or pay attention to slides on the wall (with questions about them
afterwards).
- Time taken until they felt pain: sensation – 20 seconds, distraction – 76
seconds
- Maximum time they could tolerate: sensation – 69 seconds, distraction – 99
seconds

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Attention

https://www.bbc.co.uk/news/uk-wale
s-49280154

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Emotional state
• De Wied & Verbaten (2001)
- Participants placed their hand in cold water
- Were shown either pleasant, neutral, or unpleasant
images
- Pain tolerance highest when viewing pleasant images
140
120
100
Pain tolerance
(seconds)

80
60
40
20
0
Pleasant Neutral Unpleasant
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Music
• Roy et al. (2008)
- Painful heat stimulation
- Subjects had to rate the intensity of the pain on a scale of 0 (“no pain”) to 100
(“extremely unpleasant”)
- Three conditions: (1) silence, (2) listening to “unpleasant” music (e.g. Sonic
Youth(!), pendulum music), (3) listening to “pleasant” music (e.g. Rossini,
William Tell Overture).

Condition Unpleasantness rating

Silence 60.0
Unpleasant music 60.1
Pleasant music 47.8

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Hypnosis
• Trance-like state with heightened focus and concentration

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Hypnosis
• Elkins et al. (2007)
• Review of hypnotherapy for the management of chronic pain
• Hypnosis interventions consistently produced significant decreases in pain

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Hypnosis
Low
• Freeman et al. (2000) hypnotizable
- Cold pressor pain
- Participants had a
“waking relaxation”
condition followed by
either distraction or
hypnosis. High
- Classified as a “low hypnotizable
hyonotizable” or “high
hypnotizable”

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Empathy
• Singer et al. (2004)
- Subjects received painful stimuli and also observed their real-life partner
receiving painful stimuli.
- Activation in the bilateral anterior insula, rostral anterior cingulate cortex,
brainstem and cerebellum both when receiving pain and when their partner
received pain.
- Activation in the insula/secondary somatosensory cortex, the sensorimotor
cortex, and the caudal anterior cingulate cortex only when receiving pain.
- Observing pain in others activated areas of the brain associated with
emotional responses to pain, but not sensory responses to pain.

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Placebo & nocebo effects
The placebo effect
• Placebo – Treatment that doesn’t contain any active substance that
will reduce pain
• Placebo effect – Beneficial response to a treatment that doesn’t
contain any active substance

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What affects the placebo effect?
• Type of pill
- Branded pills reduce pain more than generic pills (Branthwaite & Cooper,
1981)
• Colour
- Red, yellow, and orange are associated with a stimulant effect, blue and green
are associated with a tranquilising effect (De Craen et al., 1996)
• Who administers it
- Poorer pain relief when a machine automatically administers it than when a
doctor does it (Amanzio et al., 2001)

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What affects the placebo effect?
• Expectancy
- Price et al. (1999). Participants were given painful heat stimulation to their
arms.
- Were given a placebo cream and told that it was either a strong painkiller, a
weak painkiller, or a placebo.
- Pain was highest when participants were told it was a placebo, lowest when
they were told that it was a strong painkiller
- Expected pain levels accounted for much of the variance in pain ratings.

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The placebo effect
No treatment

• The placebo effect still happens even

Placebo labelled as
when you tell people it’s a placebo! placebo
• Kaptchuk et al. (2014).
- Patients with migraines received either a
placebo or pain relief. They were told that
their treatment was a placebo or was pain
relief.
- Reduction in pain scores even when they
were told that the placebo was a placebo.

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Expectation
• Bingel et al. (2011)
- Painful heat stimulation
- Pain rating of 0 (“no pain”) to 100 (“unbearable pain”)
- Four conditions – (1) baseline (saline solution), (2) no expectation (received
painkillers but were told that they were still receiving saline solution), (3)
positive expectation (received painkillers and were told that they were
receiving them), (4) negative expectation (received painkillers but were told
that they were no longer receiving painkillers).
- Pain ratings:
Condition Receiving painkillers? Pain rating
Baseline No 66
No expectation Yes 55
Positive expectation Yes 39
Negative expectation Yes 64
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The nocebo effect
• Negative side effect of a treatment that doesn’t contain any active
substance

 
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The nocebo effect
• Elsenbruch et al. (2012)
- Painful stimulation
- Subjects were told that an inert substance would either
relieve pain, increase pain, or were given neutral instructions
- Compared to the neutral condition, pain intensity was lower
when subjects were told that the substance would relieve
pain, higher when they were told it would increase pain.
• Schweiger & Parducci (1981)
- Subjects were told that a (non-existent) electrical current was
passing through their heads.
- Two thirds reported mild headaches

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Ethical issues
• Ethics of giving patients a placebo rather than a painkiller
• Deception
- May not even be necessary if placebo effects still occur if when patients are
informed that they’re receiving a placebo
• Nocebo effects – should patients be warned of side effects if that
makes them more likely to experience them?

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Sex/gender differences
Sex/gender differences
• Are there sex/gender
differences in pain
perception?

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Sex/gender differences
• Pain threshold – point at which pain begins to be felt
• Pain tolerance – maximum level of pain that someone can tolerate
• Pain intensity – how strong the pain is
• Pain unpleasantness – how unpleasant the pain is
• Various pain modalities – cold pain, heat pain, pressure pain, ischemic
pain (restriction in blood supply to tissues), muscle pain, electrical
pain, chemical pain, visceral pain (internal organ pain)

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Sex/gender differences
• Females have lower tolerance for pressure and thermal pain (cold and
heat) than males
• Most studies show no sex differences in pain intensity or pain
unpleasantness in any pain modality.

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Sex/gender differences
• What factors
contribute to
sex/gender
differences in pain
perception?

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Sex/gender differences
• Biological factors - Evidence for the roles of genetic, hormonal, and
physiological factors (e.g. blood pressure regulation) is either small,
inconsistent, or absent.
• Psychological factors – potential role of catastrophizing, adaptive
coping strategies, and personality traits
• Social factors – gender role expectations (e.g. willingness to report
pain)

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Sex/gender differences
• Fillingim et al. (2009) – critical review
- Consistent differences in clinical pain
- Prevalence of neuropathic pain, musculoskeletal pain, headaches, and
abdominal pain is greater in females than males.

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Summary
Summary
• Pain is necessary to protect ourselves from pain
• Sensory and affective aspects of pain perception
• Sensory – Nociceptors and pain matrix in the brain
• Affective – Distraction, attention, emotional state, etc.
• Placebo and nocebo effects reflect the cognitive mechanisms behind
pain perception
• Sex/gender differences – experimental studies are inconsistent, but
some show that females have lower tolerance for pressure and
thermal pain than males. Clinical studies consistently show that
females experience more pain than males.
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