‘What Type of Pain is It? Dualisms and Thinking about Pain’ – a contribution to our special edition collection of pain in the medical humanities, by Dr Véronique Griffith
A woman breaks her arm slipping on the ice while going to get the post outside her house. When she goes to Accident and Emergency, an X-Ray of the upper arm reveals a broken bone. In the next several days, if she is to explain to others what is wrong, yes she will describe terrible arm pain.
The doctors will prescribe medication intended to relieve the pain. However, she will also describe how she has suddenly lost her independence. She can no longer drive, and since her home is far from public transportation, she can no longer leave the house alone. She has trouble buttoning her shirts by herself now, and she can no longer type properly. She loves to cook but also cannot do this at the moment. What bothers her most is that hugging her husband has become a chore. She realizes that the fracture has impacted her identity as a high-functioning wife and independent woman.
So what type of pain is she experiencing? She describes significant physical pain that affects her sleeping patterns and she also complains of feeling down. Yet the doctors only treat her physical pain symptoms.
There appears to be a certain duality to thinking about pain. It is something we apparently struggle to escape from. When thinking about pain we tend to ask ourselves: which type of pain are we talking about? We then proceed to list dualities: is it physical pain or mental/emotional pain? Chronic pain or acute pain? Pain that we can describe or pain that leaves us at a loss for words?
This dualism is thought to link back to Descartes and the Cartesian separation of mind and body, in which mind (a thinking thing) and body (a non-thinking entity) are considered distinct.
What does it mean to be in pain? The International Association for the Study of Pain (IASP) defines pain as ‘[a]n unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.’ (IASP) This definition attempts to limit the separation of pain into ‘physical’ and ‘mental’ or ‘emotional’ pain. But how does this definition, including the psychosocial dimensions of pain, translate into use in the biomedical system?
Practically, it appears that treatment and diagnosis of pain are first of all focussed on physical pain. Doctors are trained to ask questions such as ‘where is the pain?’ ‘How often does it come?’ ‘How strong is it?’ Or ‘is it a sharp pain or a dull pain?’ Mental pain, in contrast, appears to be largely separated out into something left to be treated by psychiatrists, psychologists or perhaps even nurses. In this way, emotional pain becomes something not to be investigated by blood tests or imaging techniques or treated by pain medication or surgery, for example. Therefore, despite a definition of pain which links or tries to reincorporate the mind/body dualism, the treatment and investigation of pain remains intrinsically separated into pain caused by either mind or body.
However, this distinction between physical and psychical pain remains complicated by the question of how you separate the two. Where does physical pain end and mental pain begin? As the IASP definition above reminds us, the difficulty stems from the fact that physical pain can cause emotional pain, and mental pain may exacerbate physical pain.
It has been well documented that patients with chronic pain search not only for a ‘cure’ but an understanding from the clinicians, and acceptance that they are in fact actually ‘ill’. This appropriation of the sick role positively affects pain in scores of patients. (See Good et al. 1992; Kleinman 1988)
But what happens when social stigma impacts our understandings of someone’s pain? Some research has shown that when women and men present with the same pain symptoms to the doctor, the man will be thought to have physical pain, while the woman has mental pain. (See Ballweg 1997) Suddenly, what was by definition physical pain (when in the male body) becomes intrinsically mental pain (while in the body of a woman). Are these dualisms gendered?
There may be a third option when a patient (often a woman) presents with pain to the doctor: only to be told her symptoms are ‘normal’. This possibility of seeking help only to be told the suffering she is experiencing is normal, is one often experienced by patients later found to have endometriosis. Where does this case fit into the mind-body dualism? While she believes she has pain, she is effectively told that she does not. So who determines whether the pain in fact exists? In this case, the patient has had her pain taken away from her. Her pain has been transformed to a suffering that now includes isolation, confusion and fear.
Asking whether we should move away from the mind-body dualism that is so entrenched in medicine and the Western world may be the wrong question (Morris, 1991). Perhaps, we need to go beyond treating not only the ‘physical’ symptoms of pain, the ‘mental’ ones as well, to a place where we also treat that suffering that has been socially sanctioned as normal.
We need to aim for a system that not only moves the role of doctor from someone who only cures pain to someone who additionally seeks to diminish the impact of pain on patients’ lives. This involves not only a doctor who seeks to understand the severity of the pain as well as its impact on the everyday life of the patient, but also seeks to accept that a patient is in fact suffering. However, in order to accomplish this, patient and doctor must work together in designing the treatment plan, which must have as the objective to alleviate pain and restore the patient’s functioning.
This guest contribution was written by Véronique Griffith, who completed her undergraduate degree at Harvard University in 2002 and her medical degree at the Yale School of Medicine in 2009. She is currently studying for her PhD in medical anthropology at Durham University in the Department of Anthropology. Her research focuses on endometriosis, illness narratives and doctor-patient interactions.
Correspondence to Véronique Griffith
Works cited
Ballweg, M.L. Blaming the victim. The psychologizing of endometriosis. Obstet Gynecol Clin North Am. 24: 441-453.
Good, M.D., Browdin, P.E., Good, B.J. 1992. Pain as human experience: an anthropological perspective. London: University of California Press.
Kleinman, A. The Illness Narratives: Suffering, Healing and the Human Condition. New York: Basic Books.
Morris, D.B. The Culture of Pain. London: University of California Press.