Pain and Suffering

M. Brunner, M. Löffler, S. Kamping, S. Bustan, A. M. González-Roldán, F. Anton, and Herta Flor

Abstract. Although suffering is a central issue in pain, there is only little research on this topic. The aim of this study was to assess suffering in an experimental context using various stimulation methods and durations, and to examine which psychological or psychophysiological measures covary with pain-related suffering. Twenty-one healthy volunteers participated in two experiments in which we used tonic thermal and phasic electric stimuli with short and long stimulus durations. The participants rated pain intensity, unpleasantness, and pain-related suffering on separate visual analog scales (VAS) and completed the Pictorial Representation of Illness and Self Measure (PRISM), originally developed to assess suffering in chronic illness. We measured heart rate, skin conductance responses (SCRs), and the electromyogram (EMG) of the musculus corrugator supercilii. For both heat and electric pain, we obtained high ratings on the suffering scale confirming that suffering can be evoked in experimental pain conditions. Whereas pain intensity and unpleasantness were highly correlated, both scales were less highly related to suffering, indicating that suffering is distinct from pain intensity and unpleasantness. Higher suffering ratings were associated with more pronounced fear of pain and increased private self-consciousness. Pain-related suffering was also related to high resting heart rate, increased SCR, and decreased EMG during painful stimulation. These results offer an approach to the assessment of suffering in an experimental setting using thermal and electric pain stimulation and shed light on its psychological and psychophysiological correlates.
Keywords: pain-related suffering, pain intensity, pain unpleasantness, fear of pain, private self-consciousness, PRISM

http://econtent.hogrefe.com/doi/10.1027/2151-2604/a000279

Löffler, M., Kamping, S., Brunner, M., Bustan, S., Kleinböhl, D., Anton, F., & Flor, H.
Introduction: Chronic pain and pain-related suffering are major health problems. The lack of controllability of experienced pain seems to greatly contribute to the extent of suffering. This study examined how controllability affects the perception of pain and pain-related suffering, and the modulation of this effect by beliefs and emotions such as locus of control of reinforcement, pain catastrophizing, and fear of pain.

Methods: Twenty-six healthy subjects received painful electric stimulation in both controllable and uncontrollable conditions. Visual analogue scales and the “Pictorial Representation of Illness and Self Measure” were used to assess pain intensity, unpleasantness, pain-related suffering, and the level of perceived control. We also investigated nonverbal indicators of pain and suffering such as heart rate, skin conductance, and corrugator electromyogram.

Results: Controllability selectively reduced the experience of pain-related suffering, but did not affect pain intensity or pain unpleasantness. This effect was modulated by chance locus of control but was unrelated to fear of pain or catastrophizing. Physiological responses were not affected by controllability. In a second sample of 25 participants, we varied the instruction. The effect of controllability on pain-related suffering was only present when instructions focused on the person being able to stop the pain.

Discussion: Our data suggest that the additional measure of pain-related suffering may be important in the assessment of pain and may be more susceptible to the effects of perceived control than pain intensity and unpleasantness. We also show that this effect depends on personal involvement.

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A study was carried out to explore the effects of two variables on the amount of pain and suffering awards in a product liability litigation context. The first variable was the level of liability/responsibility allocated to the plaintiff and defendant for the accident and injury. The two levels were 100% and 60% assigned to the defendant, with the corresponding levels for the plaintiff at 0% and 40%. The second variable was the severity of the injury which was characterized as high or low. The two variables were manipulated between participants, resulting in a 2 x 2 design. Four separate accident/injury scenarios were employed, and each participant was presented with all four scenarios in one of the conditions. The scenarios described an automobile accident resulting in paralysis, a workplace accident resulting in chemical burns, a workplace accident resulting in brain damage, and an automobile accident resulting in the death of a small child. Following the presentation of each scenario, participants were asked to make a pain and suffering award. There were no constraints, small or large, on the size of the awards. Results indicated significant differences in pain and suffering allocations for the two levels of liability/responsibility (means in dollars were: defendant 100% = 4.0 million, defendant 60% = 1.2 million). While the means were in the expected direction for the high and low injury severity manipulation (high = 3.2 million, low = 2.0 million) the difference in pain and suffering allocations was not significant. The results suggest that liability or fault may play an important role in pain and suffering awards, a finding of significance in understanding jury decisions.

Studies of juror decisions regarding pain and suffering awards in product liability litigation tend to show substantial variability across participants. A possible explanation is that jurors do not have a useful metric for assessing pain and suffering. A study was conducted to explore effects of providing day-rate suggestions on such decisions. Day rate refers to giving information about remaining life expectancy in days and suggesting a value to assign per day. Four scenarios describing product-related accidents were presented to 134 participants. Seven day-rate conditions were employed for each scenario: a no day-rate control; five day rates consisting of $1, $50, $100, $200 and $1000; and a multiple day rate condition that described four alternative rates. Results showed a significant day-rate effect, with higher rates resulting in higher awards. Variability of awards was greater in the no day-rate condition than in day-rate conditions with similar award levels. This finding is consistent with the notion that jurors are susceptible to monetary award suggestions. Implications for "biases" in pain and suffering award decisions are discussed.

A study addressing jury decisions regarding punitive damages awards in civil litigation was carried out. Two issues explored were the fkct that jurors typically do not have a good metric for assigning a value to such damages and the concept of "leakage." The latter concept refers to decisions regarding compensatory damages and punitive damages influencing each other; in the law they are supposed to be independent. Forty-two participants were given three scenarios describing accidents, injuries, liability outcomes, and the amounts of economic and non-economic (pain and suffering) awards. Their task was to decide on punitive damages awards. Two variables manipulated in the scenarios were the presence or absence of defendant profit information and the amount (high or low) of the pain and suffering award. Results indicated the main effects of the two variables were not statistically significant. A significant interaction between the profit-information and pain-and-suffering-amount variables indicated that when profit information was available, low pain and suffering awards led to higher punitive damage awards. When profit information was not available, high pain and suffering awards led to higher punitive damage awards. The results indicate that decisions regarding compensatory and punitive damages are not independent as the law intends; an outcome that may be due, at least in part, to the uncertainty associated with these types of decisions. These findings have implications for judicial procedures, particularly jury instructions.