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IN CONCLUSION | MOSKOVITZ
even think it can be mortal. Fear, particularly in association
with an event or object that is only vaguely in awareness (as
with anxiety), causes terrible suffering. Who has not used the
expression “I was frightened to death”? Our attitudes toward
suffering, and therefore toward pain, come, in part, from the
observation that pain is often associated with grief and fear,
which are not “objective” physical impairments.
Complex Regional Pain Syndrome (CRPS) is characterized
by pain that is out of proportion to the inciting injury or tissue
damage and thus represents the quintessential maldynic (1, 2)
pain disorder. CRPS commonly begins with a physical impairment,
and although the injury sometimes appears to be trivial,
the subsequent pain and disability of CRPS are severe.
Although often confused, “disability” and “physical impairment”
are independent, and this confusion has harmful effects.
For example, both doctor and patient may wrongly assume that
when the physical impairment (disease) is treated, the disability
(illness) will cease. Furthermore, many physicians harbor a
judgmental disdain (only thinly veiled) for “non-organic” pain
and illness behavior, and nowhere is this failing more evident
than in the care of patients with CRPS. In addition, and in
spite of advancing science, a segment of the medical profession
still thinks that CRPS does not exist at all, that there is a “dystrophic
personality,” or that patients with CRPS are emotionally
disturbed or malingering. The suffering of people with
CRPS is further compounded when the legal system, compensation
agencies, and the medical profession treat the experience
of suffering itself with both passive and active disregard.
There Is No Suffering Without Fear or Grief
Our understanding of suffering has traditionally been more
metaphysical than neurobiological. Eric Cassell described in
detail how pain and disease threaten the integrity of the “facets
of personhood,” a composite of qualities that Antonio Damasio
referred to as “the autobiographical self” (3, 4). In my own
practice, I have seen patients who descend relentlessly from an
acute lumbar injury into chronic pain and disability under such
a threat. The most memorable have been laborers whose identity
as strong providers for their families, in part a culturally
defined role, was threatened by physical impairment. “Independent”
evaluators saw the increased disability as a vaguely inauthentic
secondary gain. The disc impairment was authentic;
however, the pain was suspect because the suffering that
increased the perception of pain—the loss of self-regard and
self-respect, loss of income, loss of customary role behavior, loss
of sexual capacity and identity, the stress of the medico-legal
conflict—was not “legitimate.”
Cassell defined and illustrated over a dozen “existential
domains of the person,” as reframed within a phenomenological
context by Giordano (1). For each of the facets of personhood,
as discussed by Cassell, the threat to the integrity of the individual
resulted in fear, loss, and the fear of loss of any of the
“facets of personhood.” When lost, these facets—cultural background,
habitual and accustomed behaviors, life experiences,
expectations, attachments to family and friends, secret relationships,
thoughts, aspirations, and bodily function—become
objects of grief. The fear of losing them is painful. Such is the
suffering of chronic pain and illness (5). Suffering increases the
noxious perception of disease and recalls associations between
suffering and diverse antecedents and causes of injury, disease,
and suffering long past. Suffering is not simply the affective
experience of pain, for suffering does not exist without the
emotions of fear and grief.
PREMISE 1
Fear and grief evoke bodily disturbances,
the experience of which is suffering.
I PROPOSE THAT PERSISTENT GRIEF AND FEAR evoke distinct
bodily disturbances that are experienced as suffering. The
somatic and visceral effects of grief and fear on the body proper
produce a characteristic perception of the maps in the brain’s
body-sensing regions. I propose that the feelings of fear and
grief are experienced as suffering. A definition of suffering, like
this one, that invokes the “somatic marker” hypothesis of neurologist
and humanist Antonio Damasio, implies a neural substrate
for the experience of suffering (4, 6, 7). And that is what
I intend to propose. Damasio’s language and theories of consciousness
inform much of my thinking.
A Classification of Emotions
SUFFERING IS NOT AN EMOTION; it is the awareness or feeling
of the bodily effects of the emotions of fear and grief. Fear and
grief are two of the six primary emotions, which also include,
according to Paul Ekman’s classification, joy, surprise, disgust,
and anger (8). The fact that Damasio, in his recent work,
accepts this classification gives it greater cogency (9). Each of
the primary emotions has unique facial expressions and, to a
lesser degree, vocal tone and body posture or movement. The
facial expressions of primary emotions are recognizable across
cultural boundaries (where display rules differ) (10), and are, to
some extent, recognizable across species. 1
I am persuaded to think, with arguable economy, that social
and other secondary emotions are combinations of primary
emotions that are superimposed on appetites or drive states, 2
1 Primatologists and dog lovers need no convincing from me.
2 I am not aware of a comprehensive, biologically based classification of
appetites and drives. For the sake of argument, here are ten: thirst, hunger,
oxygenation, elimination, thermal regulation, rest, lust, curiosity,
mastery/dominance, and attachment.
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