dorsal horn. The inhibitory system utilizes several neurotransmitters including serotonin, enkephalin, norepinephrine gamma aminobutyric acid (GABA), and somatostatin. The periaqueductal grey receives neuronal fibers from cortex, hypothalamus, and the limbic system, probably explaining the interaction of cognitive and emotional elements with pain perception and inhibition. Given the same noxious stimuli, the pain perception between two people may vary according to the phenomenon of attention or inhibition, both of which are probably modulated by various descending neurons. Emotion, attention, and motivation may all influence pain perception, probably through a complex network of reticular, limbic, and cortical fibers.
From the patient's point of view, the pain complaint connotes distress and is a plea for assistance. The subjective experience includes an urge to escape from the cause or, if that is not possible, to obtain relief. It is the overwhelming desire to terminate it that gives pain its power. Pain can produce fear, and if it persists, depression, and ultimately it can take away the will to live.
It has become abundantly clear that no isomorphic relation exists between tissue damage and pain report. The more recent conceptualizations discussed view pain as a perceptual process resulting from the nociceptive input and modulation on a number of different levels in the CNS and not as directly proportional to nociceptive input.
Pain is a subjective, perceptual experience, and one characteristic differentiating it from pure sensation is its affective quality. Thus, pain appears to have two defining properties: bodily sensation and an aversive affect (Fernandez & Turk, 1992; Melzack & Casey, 1968). Quintessentially, pain is experienced at a physical levels and an affective level. As underscored by the International Association for the Study of Pain (Merskey, 1986), “it [pain] is unquestionably a sensation in a part or parts of the body but it is also always unpleasant and therefore also an emotional experience” (p. S217).
In this chapter, conceptual models were presented to explain the subjective experience of pain. Current state of knowledge suggests that pain must be viewed as a complex phenomenon that incorporates physical, psychosocial, and behavioral factors. Failure to incorporate each of these factors will lead to an incomplete understanding. The range of psychological variables that have been identified as being of central importance in pain along with current understanding of the physiological basis of pain were reviewed. Several integrative models were described that try to incorporate the available research and clinical information. Pain has become a vigorous research area and the virtual explosion of informan tion will surely lead to refinements in understanding of pain and advances in clinical management.
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