About two weeks ago, I started to be plagued with an inflammation of the membrane that encases the knee joint, called bursitis. The membrane secretes extra synovial fluid, and the pressure was indeed painful. I was struck by the amount of sympathy that this particular affliction elicited from my family and friends. (Thanks!). Since it keeps flaring up, an infiltration of cortisone into the joint this afternoon may calm things down for up to a month.

However, my expressions of pain in form of complaint are not really proportional to the pain itself. My complaints are verbal outlets to reduce the mental pressure that results from the frustration engendered by the pain. But the best way to describe pain itself is to elicit an empathetic reaction in the listener, by which they draw parallels with their own painful experiences and use their imagination to extrapolate.

Having tried a number of hands-on methods to learn about pain, all I can say is that the kind of pain induced really differs, but not how. It’s strange not to have the words to describe the the quality of feeling between them, but I can class them in order of least to most disagreeable ¹. When I look at the list, factors in the pain felt seem to be:

• Actual damage caused

• Novelty

• Chronicity

The British Pain Society among others has published a series of standard language translations of pain measurement scales for cognitively unimpaired adults.

The criteria being assessed are:

• Intensity (over time or not)

• Distress

• Relief upon treatment

A variety of other methods for assessing the same criteria in people who have problems using language are presented on a consecrated website called pain.com by Dr. Feldt.

As she points out, “Persons with dementia may not initiate conversations about pain or seek relief for pain because they have forgotten where they are, whom they should tell, or what event initially caused the pain.”

But they feel pain, and can be relieved from it with treatment. So verbal representation of pain and the attendant surprise or shock, is already distinct from the state itself.

A Checklist of Nonverbal Pain Behaviors (CNPI) is available here, and Dr. Feldt’s article from which it is derived is here

I wonder if, like for children, elderly people with dementia would actually find pain more distressing, and therefore more painful, when they can not draw on their memories of previous experiences of that particular kind of pain (eg. damage to the skin, or visceral pains of different sorts)? In addition, since they can express their feelings less well, they clearly don’t always get the reassurance and treatment they need.

A paper from the appropriately named journal, Pain, cites and presents additional evidence that the experience of pain can be somewhat analgesic for new encounters with pain: “Evaluation of pain severity depends on the context in which pain occurs.” One of the authors, Dan Ariely, has also written a very personal pamphlet describing his experience with burn pain and his subsequent step(s) back and analysis of its perception.

Ariely notes a number of interesting observations.

First, the altered perception of time, like for the pain itself, has to do with the level of shock – it’s a coping mechanism. Good for getting away from whatever caused the pain, but bad for the perception of how painful it was. What I called novelty, above.

Second, “pain that worsens over time is perceived to be more painful than pain that improves, or one that remains at the same level.” (cf citations therein). Related to what I called chronicity, and what the BPS termed “relief upon treatment”. Again, if the overall memory of the pain is something that gets progressively worse over time until the last experience of it, then one’s tolerance is reduced, the next time it happens. This makes me think somewhat of childbirth ². The fear of the pain is certainly part of the pain, and I came to that conclusion before I read any of Dr. Grantly Dick-Read ’s work. My first birth experience was already not horrific (although a touch of morphine when the forceps went in was welcome),so I was not dissuaged by the pain for a second delivery with really no painkillers. As it went better and faster than the first, I’d face another with even less anxiety (this does not suggest it’s underway, nor that I am dogmatic about avoiding painkillers for childbirth!). This willingness to face another delivery is contrary to some, but luckily, not most.

For the memory-impaired elderly person, perhaps the lost analgesic effect from not being able to draw on earlier painful experiences ³, is somewhat offset by not remembering that a chronic pain is objectively worse than a day earlier, or a month earlier? Or is there really such a thing as objective pain? Probably not. I’d have to experience renal colic to know if it is more or less painful than peritonitis. Pain is relative, and it’s really in the mind.

For children, I can attest from personal experience that their memory of an earlier painful event that did not improve, conditions their anxiety and therefore their perception of the next. My daughter had a number of skin reconstruction surgeries, and it was bandage-changing in the first couple weeks after each that was the most stressful and, presumably, painful. Like Ariely, she had to have iodine bath/shower sessions to unstick the first bandages, wash away the accumulated necrotic crud, and apply new ones. In later weeks, the glue from the bandages usually took off a superficial layer of the surrounding epidermis, to add injury to injury.

Nearly a decade later, when I came across one of the nurses who had participated in these sessions, she clearly remembered my daughter, her reactions, and my earnest efforts to make the bandage-changing as anxiety-free as possible. Also like Ariely, there were the nurses who allowed my daughter and myself “to have breaks and even, from time to time, remove some of (her) own bandages” and, especially early on, the ones who “gave [us] no control over the treatment process”. For the operations in the first year, letting her remove her own bandages was clearly not ideal. But quickly, I stepped in, realizing that if I could communicate any sense of control and expectation to my daughter, it was a comfort to both of us.

I should also add that my son is quite frightened of the pain of needles, to the point of tensing up so much that he’ll squeeze out blood upon an intramuscular injection ⁴.

Working at a children’s hospital, and frequenting collaborators at another specialized in cancer treatments, has shown me many examples of children who bear what seem to be excruciating conditions with a phenomenal amount of forebearance, because they are reassured. In this respect, not having a past reference point can be a boon.

So, to sum up all this, anxiety and the relationship of the ongoing experience to previous ones (based on memory), seem to be major factors in pain perception.

Footnotes

¹ Here are the owies that come to mind. There are probably a couple other minor ones.
- Epilation
- Superficial cuts and skin fissures
- Sunburn (I never let it get bad)
- Breast compression in mammograms
- Muscular fatigue from exercise
- Over-stretching
- Muscle aches from fever or lack of sleep
- Perineural fibrosis aka Morton’s neuroma
- Violent contusion (eg. falling, bike accident)
- Slamming a nailbed in a heavy metal frame of some sort or another
- Abscesses such as in the jaw, skin or breast
- Migraine
- Sciatica
- Burn (second degree)
- Sprains or cartilage issues (ripped meniscus or intervertebral disk issues, arthritis)
- Visceral pain such as childbirth, kidney infection, appendicitis
- Peritonitis (a whole other category despite being visceral)

² Childbirth, with its attendant possibilities of medical problems, is often brandished as an example of severe pain.

³ Older patients with visceral disease are more likely to present without pain

⁴ More recently, we’ve used topical analgesic like 1% lidocaine an hour ahead, under an occluding bandage, to great effect. A hint to other parents who find that the massively proven benefits of vaccinating their children outweigh the unsubstantiated inconvenients. But apparently, getting rid of the anxiety may be even better in eradicating pain than getting rid of the nerve transmission, though the assurance that the latter is effective may also reduce anxiety in a kind of positive feedback loop. A little harder to get rid of other kinds of anxiety.