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Last updated: Mon, Nov 4, 2024
The early years of the Social Security Disability Insurance program revealed that the role of pain in disability was by no means a settled question. The existence of the program meant that rules and procedures for determining disability were needed. Medical doctors were drawn into the problem, often unwillingly, and along with them lawyers and other newly-minted pain experts from fields such as psychology and sociology.
The case of Page v. Celebrezze in 1963 established the early legal standard regarding pain and disability under the SSDI program. Rosie Page was a Texas manufacturing worker who developed severe pain and accompanying "nervousness," and ultimately applied for disability benefits under the SSDI program. Her application was denied, appealed, denied, and finally taken to the courts. As today, medical experts were relied upon and had a range of disparate yet firmly-voiced opinions about Ms. Page.
Page's own osteopath diagnosed her as having significant rheumatiod arthritis in the fingers of both hands.
The disability examiners of the Department of Health, Education, and Welfare found that there was no objective evidence to support complaints of pain in areas other than the hands.
One physician, based on observing Page moving, was convinced that Page's claim was not fraudulent. Another reported that Page exhibited a severe anxiety state with conversion hysteria.
An orthopedic surgeon found no objective X-ray signs related to Page's alleged back pain and concluded that Page's symptoms were entirely psychological, further reporting a marked psychogenic overlay of her symptoms
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The case arrived at the bench of Judge John R. Brown. Judge Brown decided that if pain is real to the patient..., the disabilty entitles the person to the statutory benefits even though the cause of such pain cannot be demonstrated by 'objective clinical and laboratory findings....'2 This notion that pain must be endured, that pain, no matter how severe or overpowering, is not disabling unless it will 'substantially aggravate' a condition is 'contrary to the standard announced in' cases from this and other Circuits.
3 (Here Brown was referring to then-extant case law.) Cases alleging pain as a cause of disability increased over the remainder of the decade.
Others' pain became a matter of interest to the public. Journalists adopted the role of communicating the subject to the people at large, and, as today, included a large dose of anecdote in their accounts. Stories of stoic endurance taking place in distant places and times promoted the idea of cultural differences in pain tolerance.
This was a time of broad interest in the effects of culture and nurturance. Parents were advised to be concerned about the effects of "permissiveness" in child raising. The placebo effect was noted and discussed. A popular, "standard model" of pain developed that emphasized variability in pain perception based on differences among people.4
The expansion of disability programs was not the only nor even the major source of concern over pain during this period. The Medicare and Medicaid programs were adopted in 1965, further expanding the role of government in health care and the shared cost of same. This post-war period was a time of great expansion of the pharmaceuticals available for addressing problems of pain, stress, and anxiety. The debate over these drugs was not just about safety or efficacy, but extended to concerns that the use of the pharmaceuticals could mask or even worsen underlying problems.
This is also the period in which pain management clinics became common. Pain had become a public concern. Great personal and economic stakes were involved and there was little bona fide expertise available. Pain management clinicians, who at that time were self-selected, became involved not only in the medical concerns of their patients but in legal and public policy debates. Keith Wailoo sees this as an important fact about the pain management movement:
...it is important, therefore, that we see this field [pain management] not as a medical invention but as a social and political one. Pain management, broadly defined, would henceforth involve negotiating between these competing ideologies of relief and working with the interest groups--physicians, patients, soldiers, police, legislators, and so on--with their own stakes in relief.5
Pain clinicians, especially prominent ones such as Dr. John Bonica, were looked to as the experts on real vs. feigned pain, safe vs. unsafe drugs, and other contentious issues related to pain.
When looked at carefully, pain revealed itself as complex, variable, and mysterious, perhaps even apocryphal. The Wall/Melzack gate-control model arrived on the scene just at this time. (See The Gate-control Circuits (Descending Modulation).) When the model was first stated, it only stated that there is some influence arising from the brain that can increase or decrease the perception of pain. The model has since proven to be correct, although much simpler than our real pain systems. Much more is now known about the descending influence on pain perception, although our understanding is still far from complete.
The gate-control theory was flexible because of its vagaries. Such a flexible theory was in a sense a very good match with what was "needed" at the time--a theory open-ended enough to support what I've called the popular "standard model" of pain and explain variability in pain perception. Melzack in fact remarked in 1976 about the theory riding in on the Zeitgeist.
6 The gate-control theory has been successful not just in being verified by subsequent testing, but also by stimulating a broad range of related concepts and treatment approaches. Yet it does, I believe, have a shadow cultural existence as a quasi-scientific meme that embodies an ideology more than a model, and allows the willing to plug almost any conceivable factor into the descending modulatory system.
Pain treatment clinics were established in these post-war years. Despite hopeful beginnings, three of the most prominent pain specialists had by the 1970s come to the opinion that pain patients could become the victims of their treatment, which Dr. Stephen Brena christened "learned helplessness."7 Brena reported that the psychic "act" of "fixating" on pain leads to higher felt pain, and that patients with pending disability claims tended to report higher pain levels.8