Understanding The Matrix Of Biology And Culture

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Human pain is always a biocultural condition - a com posite experience requiring a biology of brain states and of neural processes negotiated within a social space where individuals interact with the surrounding culture, including the culture of medicine. One major challenge is to understand how the biological processes associated with pain are influenced directly and indirectly by individual beliefs, social institutions, and cultural forces. We continue to learn about the neuroanatomy of the human pain system and its modulating pathways.69 It remains unclear, however, how this complex neuroanatomy is set in motion or modified by thoughts and emotions, which are influenced in turn by external and interpersonal for ces, such as medical systems, disability insurance, religious beliefs, and cultural attitudes. There is also a crucial role in human pain played by human consciousness. We know more about what disability insurance and religious beliefs contribute to pain than about the slippery contributions of human consciousness.

The importance of psychosocial factors in pain has been demonstrated recently in numerous articles and books. Psychologists Dennis Turk and Robert Gatchell contend that post-1960 attention to the cognitive and behavioral psychology of pain constitutes nothing less than a "revolution,'' and they argue for the continuing relevance of a clinical model that recognizes the mutual interdependence of biological and psychosocial pro-

cesses.70 One fascinating illustration of this mutual interdependence concerns the role of memory in pain. A patient's recollection of pain is most closely related to the intensity of pain during the inciting episode, and severe pain that persists for more than a few hours creates changes in the structure and function of somatosensory and pain pathways.71 The memory of severe pain thus differs from other, more casual memories, both at the cortical level and at the level of altered sensory neurons. Preemptive analgesia now commonly prescribed for postoperative patients not only prevents short-term discomfort, but also avoids long-term complications that can accompany the memory of pain.

Beliefs about pain illustrate a broader interdependence between biology and culture, i.e. human pain implies continuous processes of conscious and nonconscious interpretation.72, 73 (Nonconscious interpretation occurs, for example, when we process traffic signals without awareness.) Meaning helps to constitute pain, even if only in the nonconscious acknowledgment that a scratch is usually meaningless. We cannot name or discuss pain except by employing a language that exists only at a specific moment in its historical development and inevitably colors our understanding.74 Pain thus always comes already interpreted by the social world we inhabit. Meanings not only encompass articulate beliefs, such as the conviction that pain is a punishment, but in less obvious ways, they also interpenetrate our inarticulate attitudes, unexpressed emotions, habitual behavior, and even nonconscious knowledge. Pain-killing drugs may temporarily circumvent conscious meaning-making processes, but meaning does not therefore go away. A patient's knowledge of drugs - like the equally widespread fear of opioids - is not innate, but requires extensive, if largely nonconscious, cultural learning. In difficult cases of chronic pain, patients' beliefs and attitudes may impede, complicate, or entirely undermine treatment.

Recent research into pain beliefs challenges the entrenched opinion (still popular among patients) that pain is an electrochemical impulse triggered by tissue damage. Nociception is neither a necessary nor a sufficient condition for pain. Beliefs that help to shape the experience of pain include our convictions about cause, control, duration, outcome, and blame.75,76 Such beliefs affect not only chronic pain, but also acute and postoperative pain.67 Furthermore, emotion is an intrinsic part of the pain experience - saturated with and shaped by cognitive processes - rather than a mere reaction to pain.77,78 Many beliefs about pain are directly linked to strong emotions: anger toward a negligent employer, fear of catastrophe, hope for financial gain, love for a spouse. Specific pain beliefs can predict pain intensity.79 Beliefs also influence the ability to cope with pain. Researchers have found that patients function better when they believe they have some control over their pain, when they believe in the value of medical services, when they believe that family members care for them, and when they believe that they are not severely disabled.80 A study of 100 patients showed that specific pain beliefs correlate directly with treatment outcomes.81 Such research has clear implications for clinical practice, where the interdependence between culture and biology challenges us to consider new approaches to the ethics of pain and suffering.

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