Defining Pain: Natural Semantic Metalanguage Meets IASP: A Comment on Wierzbicka’s “Is Pain a Human Universal? A Cross-Linguistic and Cross-Cultural Perspective on Pain”

Pain Defined Scientifically (PDS)

In evaluating the universality of “pain,” Anna Wierzbicka appropriately references the International Association for the Study of Pain (IASP). It defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” (Merskey & Bogduk, 1994, p. 210).

Wierzbicka takes issue with several elements of the IASP definition. She views the characterization of pain as “unpleasant” as an understatement. Actually, “unpleasant” simply means any negatively valenced emotion or negative affect. It can range in magnitude from mild to extreme and it can assume any affective quality, be it fear, sadness, irritability, etcetera. But fundamentally, pain is an aversive experience. Wierzbicka correctly points out that tissue damage (TD) is not always present in pain. That is the very reason for the IASP caveat that pain is “associated” with TD. In other words, TD is probable but not essential for pain; it can also mean that whether there is a basis or not, people (cognitively) associate their pain with TD. Without such an attribution, an unpleasant sensation remains ambiguous. Nausea is an unpleasant sensation; so is vertigo. These sensations do not signal injury and are not grouped with pains. Later in the paper, Wierzbicka states that pain involves concurrent tissue damage and unpleasant feeling, and any temporal separation of the two is immaterial from a naïve point of view. This overlooks many instances in which tissue damage and its negative affect are separated in time. The primary noxious sensation from an ant bite or bee sting comes well after the stimulus, so much so that neuroscientists distinguish between first and second pains. In cancer, tissue damage often occurs well before the unpleasant feeling arises.

A more serious criticism stems from the increasingly popular notion of psychological pain or social pain. The IASP places this outside the boundary of its definition of pain. To speak of the “pain” of experiencing failure, abandonment, or longing is to speak in metaphor. These psychosocial experiences are forms of suffering—no less real and no less subjective than the suffering of pain, but what is critically absent is the physical sensation located in/on the body in association with tissue damage.

The McGill Pain Questionnaire

As the most widely used inventory of pain descriptors, the McGill Pain Questionnaire (MPQ; Melzack, 1975) receives due attention from Wierzbicka. Her criticisms echo some of the reports from psychometric studies of the MPQ. However, the methodology pioneered by Melzack has been refined to produce a more parsimonious pain descriptor system (Fernandez, Krusz, & Hall, 2011). Wierzbicka is correct that MPQ questions about the temporal pattern of pain may befuddle children, and this calls for simplified language. Wierzbicka proposes “semantic molecules” for “sharp” and “burning,” but it is unclear if this approach can be extended to communicate the varied qualities of pain sensation and affective reaction to pain.

Natural Semantic Metalanguage

Natural semantic metalanguage (NSM; Wierzbicka, 1996) has 64 semantic primes such as “body”. If these represent not only the core of all languages but also universal human concepts, one would expect some equivalent of “pain” to be on the list, but it is not. Pain aside, some correspondence with Jungian archetypes would be expected. Yet conspicuously missing from these primes are the archetypal images/forms of “birth,” “mother,” “father,” and “child.”

Wierzbicka’s decision to substitute “pain” with the verb “to hurt” raises as many problems as it attempts to solve. First, “hurt” is not one of the 64 semantic primes in NSM. Second, the substitution introduces circularity and it hints at tissue injury, the point of contention earlier. Wierzbicka insists that “hurt refers to a localized bodily occurrence, whereas pain (even physical pain) can be global” (2012, p. xxx). Yet, clinically, conditions such as fibromyalgia are associated with diffuse pain and people who have engaged in prolonged and strenuous exercise have been known to say “my whole body is in pain” or “I hurt all over.”

Wierzbicka’s suggestion to ask “When it hurts what is it like?” has an inviting, open-ended property. However, clinical experience tells us that many patients find it easier to select from an inventory of words than to generate words on their own, because the former strategy relies on recognition as opposed to retrieval of information. Generally, the inventory is just a checklist rather than a forced choice question. To say that “patients should not be told how they feel” (2012, p. xxx), and that one should not “shower the patient with obscure and mystifying prompts such as pulsing, pumping or lacerating” (2012, p. xxx), is a little misleading. First of all, the word “pumping” is not found in the MPQ or other pain inventories, and second, it is atypical of pain clinicians to tell patients how they feel.

The NSM definition of pain has three components: “feeling something bad in part of one’s body, thinking that something bad is happening to that part, and wanting it not to be like this” (Wierzbicka, 2012, pp. xxx, xxx). According to this, nausea and vertigo would be included. On the other hand, the pain of fibromyalgia would be excluded because it is not localized. The word “bad” has such breadth of meaning that it extends to anything from “sprouting a pimple,” to “losing hair,” or “developing a paunch.”

Conclusion

The search for universal semantic primes is laudable, but the yield is somewhat elusive. NSM has only 64 words, many of which do not mirror universal concepts. Absent in NSM, the word “pain” would need to be communicated using primes such as “body,” “bad,” and “don’t want.” This leaves open a host of bodily sensations that are unpleasant. And it says little about the many sensory qualities of pain and the variety of affective reactions to pain.