Clinicians and researchers are challenged to understand the dynamic interplay among biological, psychological, and social determinants of pain. The social communication model,2,8 (Fig. 1), provides an inclusive framework for organizing and considering these facets and their relationships. Understanding any episode of pain, acute or chronic, requires grasping the broad picture and details at biological, psychological, and social levels of analysis. The social communication model of pain specifies necessary domains to be attended to in the education of researchers and practitioners.1,16
- (1) A painful event chronology is provided: episodes of pain unfold over time, involving status of the individual before the event, perception of pain, personal expression, and the appraisal and actions of observers, with each phase responsive to preceding events. Reciprocal, recursive, and dynamic influences are acknowledged. Different colors are used to attract attention to the importance of each phase.
- (2) Social determinants of pain are explicitly acknowledged in human and nonhuman animals.10
- (3) A clear distinction is made between historical and current biological and social determinants:
- (a) Intrapersonal: people bring dispositions to react based on their biological, psychological, and social histories.
- (b) Current setting: the immediate social and physical environment within which pain is suffered has a powerful impact on both the person in pain and potential caregivers.
Timeline with illustrations of research
People are predisposed to react in variable ways when in pain, for example, through biological priming or adaptation, and trait-like dispositions, including fear of pain and catastrophising.15 Pain prevention or amelioration strategies are possible and important.
Biological substrates for the perception of pain have been a heavy focus for research and medical interventions. Life history has a potent impact. Socialization in unique familial/ethnic environments determines the meaning and affective understandings of pain.6,11
Although pain is inherently private, behavioral activity permits observer inferences.13–15 Some features of pain reactions are spontaneous and reflexive, whereas others reflect conscious deliberation.3 Expressions of pain are often modulated (eg, enhanced or suppressed) with considerable sensitivity to the audience and social milieu.3,12
Decoding pain expression
Displays of pain command the attention of observers, leading to spontaneous neurophysiological reactions,4 reflexive distress, reflective appraisal, and the potential for empathy and clinical judgment.7,9 Experience with pain, professional histories, and personal characteristics, including biases, influence dispositions to attend, recognize, and understand the experience of others.3,5
The appraisal of pain drives decisions to deliver care. Clinicians with personal commitments, indifferent bystanders, and enemies would be expected to react differently. Professional training and institutional best practices invariably constrain service delivery.
Social, economic, and physical ecological contexts of care delivery
The contexts of community caring, professional standards of practice, institutional structures and policies, health care delivery systems, the research enterprise, and political systems all have powerful influences on how people care for others in pain.
. Carr DB, Bradshaw YS. Time to flip the pain curriculum? Anesthesiology 2014;120:12–4.
. Craig KD. The social communication model of pain. Can Psychol 2009;50:22–32.
. Craig KD, Versloot J, Goubert L, Vervoort T, Crombez G. Perceiving others in pain: automatic and controlled mechanisms. J Pain 2010;11:101–8.
. Decety J, Jackson PL. The functional architecture of human empathy. Behav Cogn Neurosci Rev 2004;3:71–100.
. De Ruddere L, Goubert L, Stevens MAL, Deveugele M, Craig KD, Crombez G. Healthcare professional reactions to patient pain: impact of knowledge about medical evidence and psychosocial influences. J Pain 2014;15:262–9.
. Goubert L, Vlaeyen JWS, Crombez G, Craig KD. Learning about pain from others: an observational learning account. J Pain 2011;12:167–74.
. Hadjistavropoulos T, Craig KD. A theoretical framework for understanding self-report and observational measures of pain: a communications model. Behav Res Ther 2002;40:551–70.
[8. Hadjistavropoulos T, Craig KD, Duck S, Cano AM, Goubert L, Jackson P, Mogil J, Rainville P, Sullivan M, de C Williams A, Vervoort T, Dever Fitzgerald T. A biopsychosocial formulation of pain communication. Psychol Bull 2011;137:910–39.
. Hadjistavropoulos T, Herr K, Prkachin KM, Craig KD, Gibson SJ, Lukas A, Smith JH. Pain assessment in elderly adults with dementia. Lancet Neurol 2014;13:1216–27.
. Langford DJ, Bailey AL, Chanda ML, Clarke SE, Drummond TE, Echols S, Glick S, Ingrao J, Klassen-Ross T, LaCroix-Fralish ML, Matsumiya L, Sorge RE, Sotocinal SG, Tabaka JM, Wong D, van den Maagdenberg AMJM, Ferrari MD, Craig KD, Mogil JS. Coding of facial expressions of pain in the laboratory mouse. Nat Methods 2010;7:447–9.
. Lewandowski AS, Palermo TM, Stinson J, Handley S, Chambers CT. Systematic review of family functioning in families of children and adolescents with chronic pain. J Pain 2010;11:1027–38.
. Mogil JS. Social modulation of and by pain in humans and rodents. PAIN 2015;156:S35–41.
. Pillai Riddell R, Flora DB, Stevens SA, Stevens BJ, Cohen LL, Greenberg S, Garfield H. Variability in infant acute pain responding meaningfully obscured by averaging pain responses. PAIN 2013;154:714–21.
. Prkachin KM, Craig KD. Expressing pain: the communication and interpretation of facial pain signals. J Nonverbal Behav 1995;19:191–205.
. Schiavenato M, Craig KD. Pain assessment as a social transaction: beyond the “Gold Standard”. Clin J Pain 2010;26:667–76.
. von Baeyer CL, Stevens BJ, Chambers CT, Craig KD, Finley GA, Grunau RE, Johnston CC, Pillai Riddell R, Stinson JN, Dol J, Campbell-Yeo M, McGrath PJ. Training highly qualified health research personnel: the pain in child health consortium. Pain Res Manag 2014;19:267–74.