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The Ways We Talk About Pain


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Excerpts from the Personal Journal of Krystal D’Costa [i]

Tuesday:

I fell. Again. This time it was while getting out of the car. I’m not sure how I managed it. I got my foot caught on the door jamb and tumbled forward. I hit my shin—hard—against the door jamb and I think I tweaked my ankle in the process. S hurried around to my side of the car to help me up. He pulled me to my feet and asked, “Are you okay?” I’m not—but the truth is I feel like a total fool. Who falls getting out of the car? I told him I was fine and I hobbled into the house.

I’m going to bed.

Wednesday:

Morning – I woke up with some soreness, and there’s a large bruise on my shin, but I think I can hide that with some concealer. The ankle feels okay, but I think I’ll pass on the heels today. I still feel pretty silly about how I fell—glad I won’t have to tell this story to anyone.

Afternoon – My shin hurts, and I think the ankle is swelling. Will take a closer look when I get home.

Evening – I walked home from the train this evening. Boy, was that a brilliant move: my ankle is four times its normal size. What did I do to myself?

I sent S a text message with a picture of the ankle. I made an ice pack using a Ziploc bag, crushed ice, and one of his old socks (to hold the thing in place). And now I’m sitting here with it on the coffee table. The shin hurts too.

Thursday:

Afternoon – I wrapped the ankle and went to work. I felt silly explaining to people how I hurt it. But I think there’s something wrong with the shin—the bruise is growing, and it hurts like hell. Maybe I should see a doctor?

Evening – MRI reveals I have a bone bruise! Apparently, I was lucky not to break my tibia—did I really hit the bone that hard? Anyway, a bone bruise is a step below a fracture, and there’s nothing to do but RICE it. Hopefully, I’ll be able to walk on Saturday—though the doctor told me I have to take it easy. Right. He actually said, “You’re moving faster than your body can. Slow down. Let your feet catch up to your brain.”

Friday:
Thank goodness for casual Friday—saved me from having to explain why the shin is wrapped now instead of the ankle. Though I told a few people—the ones least likely to laugh, the ones who’ve noticed the limp.

Sunday:

Holy hell. What was I thinking yesterday? I can’t move today. My shin hurts like nothing I’ve ever felt.

Monday:

Home from work today. Probably for the best. But at least the time isn’t wasted—I have writing to do.

Tuesday:

Back to work today. Hid the bandages under tights, but this won’t work tomorrow; it’s just too warm. Getting ready to explain the new bandages. Gosh, I feel foolish. When are these bruises going to fade?

Friday:

It’s raining today—been raining all week, and my leg hurts like crazy. It’s probably the weather so I’m trying not to complain too much. I’ve kept up the RICE regimen and the bone itself feels better. There’s new swelling though, so I might need to have it looked at again.

Monday:

New diagnosis—hematoma near the shin. FML. Mandatory slow down – will need to be off of my feet until further notice. Well, at least it’ll have time to heal.

On the Mend

Anatomy of the shin, captured from BodyBrowser.

Bone bruises can take a really long time to heal. The tibia is the strongest bone in the body—which is apparently fortunate for me, but it’s also the least protected by surrounding muscle and tissue. I’m pleased to say I’m definitely on the mend: the pain in my shin is there, but it’s not off the charts (I can get by with ibuprofen when I need it) and the bruises are fading. The ankle is still a bit swollen, but I’ve been resting it as much as I can, and my regimen of RICE (rest, ice, compression, elevate) is pretty well set. The complication of the hematoma means I have to be off of my feet for a bit, but it could be worse. The leg, after all, is not fractured or too worse for the wear because I felt like a fool and pretended it was okay.

The experience forced me to think about our relationship to pain—not chronic pain, but acute experiences: how much of it we think we’re allowed to feel, how much of it that we express, and how we’re supposed to respond when we’re hurt. None of us are immune to physical pain. At the very least, we’ve all likely stubbed a toe or scraped a knee at some point. Some of us have broken bones. And we’ve probably had some degree of headache. However, for each of these scenarios there is a particular response. If you stub your toe, for example, and behave as though you’ve broken your leg, you’ll likely be met with skepticism about the magnitude of pain you claim to feel. And if you persistently do this, your reputation may lead toward dramatic or hyperbole.

  • How do we learn these measured responses?
  • How do we learn to talk about and share experiences of physical pain?
  • Why might we be reluctant to share that we’re hurt?

Establishing a Standard

Medical professionals use a numbered scale of zero to ten to help patients express the degree of pain they are experiencing. Zero is a pain-free state, and 10 represents the most excruciating pain imaginable. One, two, and three are “bearable”; four, five, and six are “moderate”; seven, eight, or nine are “severe” levels; and ten is unbearable. Within each group, there are higher and lower ends of the spectrum. But it’s entirely possible for one person’s bearable to be another’s moderate or even severe. How are these quantitative measures defined? And do they account for the emotional elements of pain?

The Diagnostic and Statistical Manual of Mental Disorders, which helps mental health professionals apply a standard diagnosis to patients, identifies the following criteria for pain disorder as follows:

  • Pain in one or more anatomical sites is the predominant focus of the clinical presentation and is of sufficient severity to warrant clinical attention.
  • The pain causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  • Psychological factors are judged to have an important role in the onset, severity, exacerbation, or maintenance of the pain.
  • The symptom or deficit is not intentionally produced or feigned.
  • The pain is not better accounted for by a mood, anxiety, or psychotic disorder and does not meet criteria for dyspareunia.

Pain disorders are chronic and the pain associated with them must be severe. The criteria for diagnosis can help us understand views concerning pain, and how the patient might report incidences of pain. Note that for pain to be considered severe it must cause distress and impairment, and it is falls to the patient to demonstrate that the pain is not fictionalized—which is particularly important as pain sometimes does not have a physical counterpart. The injured must be sufficiently convincing. How do we learn how to share this information?

It’s Okay to Cry—If You Aren’t Tall Enough to Ride the Rollercoaster

Alternative playground surfaces are meant to reduce chances of serious injury.

The ways children come to understand concepts of illness can shed light on how children come to understand and measure pain. Pain exists—I’m not suggesting that children have to learn to create notions of pain, but that they learn appropriate responses via their interactions with others, who help them identify sensations that are out of the ordinary and require attention.[ii] For example, when a child falls down, after assessing the situation adults may tell the child “You’re okay.” This reassures the child that the experience is minor and the bump or bruise can be tolerated—no additional extra care is necessary. Over time, children learn that some sensations of discomfort are part of our normal everyday existence.[iii]

But not all discomfort should be tolerated. Pain, after all, alerts us that something is wrong. Adults teach children when it is appropriate to express larger displays of pain by what behaviors they allow depending on the context. A child who fusses over a bump may be told repeatedly that he is okay, and his complaints may be ignored or told he is exaggerating. Adults have a sense for <i>how much</i> the bump should hurt and work to transfer this reference to their children. The amount of care an injury requires relays the significance of that injury. There comes a time when you can’t cry because you aren’t tall enough to ride the roller coaster—you have to accept it as a part of the reality at the moment and move on.

The Body as Object

The learning process also places distance between the experience and isolates the discomforting sensation. Distance and isolation help pain become a part of the “everyday”—remember, we aren’t discussing chronic pain here, but acute experiences that don’t create long-term impairments. However, when the pain is more extreme and requires more care, distance and isolation help focus attention to the location of the discomfort. Children will talk about pain in terms of the whole experience. For example, if you ask a young child “Where have you hurt yourself?”, the child is likely to place the pain in context. The response might be “On the swing” or “In the sandbox,” rather than by identifying an elbow or a knee that is injured.[iv]

The injury becomes a social event. Children view themselves as subjects integrated into the world at large—they can be acted upon by their environment. Adults tend to objectify the body by emphasizing the somatic experience rather than the context of the event. Medical anthropologist Arthur Kleinman suggests the former is more in keeping with how we experience pain:

However complicated to articulate and difficult to interpret, the patient’s experience of pain is lived as a whole. Perception, experience, and coping run into each other and are lived as a unified experience. When reconstituted as a medical problem, however, the experience is fragmented into a series of dichotomies that represent the deep cultural logic of biomedicine. Physiological, psychological; body, soul; mind, body; subjective, objective; real, unreal; natural, artificial – these dichotomies, so deeply rooted in the Western world and its profession of medicine, are at the heart of the struggle between chronic pain patients and their care givers over the definition of the problem and the search for effective treatment.[v]

Effective treatment is one of the reasons we have to learn how to categorize pain so that others can understand it. Children may not accurately report the nature or extent of what they feel. If they view the incident as part of the everyday, they might not report it at all, which impacts treatment and care. But part of the way we categorize pain is via the physical manifestation of the injury.[vi] With this foundation, a sprained ankle later in life that does not display extreme bruising may not be regarded as severe by the injured individual or his friends and family—though that might not be the case. The physical appearance of the injury may cause the injured to delay treatment because he has been taught that there is a particular response to this scenario.

Social Survival

Note: My leg isn't broken--though it's sort of neat that the name on the cast is Krystal.

Reporting an injury and expressing pain becomes a complex social endeavor. The injured has to be sure she is accurately representing the experience—and in my case, since I tend to fall fairly often, there’s another layer that I need to consider. Pain is not limited to the individual—it affects everyone around the afflicted, from family to friends to coworkers to strangers who might feel compelled to offer a seat in the face of a visible injury. When I’m injured, greater burdens are placed on people around me, who will all work to help me manage my pain whether that means that S is doing more around the house so that I can stay off of my feet or altering his schedule to take me to the doctor or that friends have to walk more slowly when we’re together—these are all ways that my pain becomes a social, shared experience.

This creates another reason to suspect reports of pain: pain can be used to manipulate social situations. Kleinman refers to this as “pain games:” it can be leveraged to control others, justify dependency, avoid work and social obligations, gain attention, punish others, and avoid relationships others.[vii] If I’m not really hurt and I’m faking it, then the others are making unnecessary accommodations—and even if I’m not faking, repeated instances of being injured can be tiresome to even the most amiable caregiver. There’s pressure to heal and be an active, productive member of society—which might also translate into pressure to feign normalcy and minimize pain.

Survival of the Fittest?

I’ve gotten over feeling like a fool about falling—it happens. I didn’t hurl myself out of the car intent on getting a bone bruise. What I do feel foolish about is delaying treatment for as long as I did because I probably extended the recovery period by not getting help. But I also felt that I had to minimize the injury because I’ve been hurt badly before, requiring extended and extensive care from my network.

Sharing my experience with some friends recently, they seemed to understand my reluctance—in the wild, they reminded me[viii], the weaker animals get picked off by predators or abandoned by the herd in many cases. While, exaggerations of acute experiences may eventually lead to isolation, we shouldn’t hesitate to get the help we need. New advances in medicine may minimize the doubt of the subjective experience. A recent PLoS paper discusses the ways neuroimaging may help physicians understand patients’ experiences of pain.[ix]

As for me, I’ll be off of my feet for a few days, but there are no lions in the neighborhood, so I should be safe.

Thanks due to Kyle West for reference suggestions.


Notes:

[i] These events are true—though I don’t actually keep a journal. | [ii] , [iii] Christensen 1999: 41. | [iv] Christensen 1999: 49. | [v] Kleinman et. al. 1984: 8. | [vi] Kleinman et. al. 1984: 50. | [vii] Kleinman et. al. 1984: 11. | [viii] Dave Mosher, Kendra Snyder, and Hannah Waters get credit for the “life in the wild” example. | [ix] Brown et. al. 2011.

 

References:

Brown JE,, Chatterjee N,, Younger J,, & Mackey S. (2011). Towards a physiology-based measure of pain: patterns of human brain activity distinguish painful from non-painful thermal stimulation. PLoS one, 6 (9) PMID: 21931652

Pain as a Human Experience: An Anthropological Perspective. Mary-Jo DelVecchio Good, Paul E. Brodwin, Byron J. Good, Arthur Kleinman, eds. (1994). California: University Press.

Pia Haudrup Christensen (1999). “It Hurts”: Children’s Cultural Learning About Everyday Illness Stichting Ethnofoor, 12 (1), 39-52

 

Photo credits: Lead image: Fracture, Earl Robert, Creative Commons | Playground, Eve Mosher, Creative Commons | Cast, SoccerKrys, Creative Commons

Krystal D'Costa About the Author: Krystal D'Costa is an anthropologist working in digital media in New York City. You can follow AiP on Facebook. Follow on Twitter @krystaldcosta.

The views expressed are those of the author and are not necessarily those of Scientific American.





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  1. 1. Hasufin 9:34 pm 09/27/2011

    I’m gonna leave this here: http://xkcd.com/883/

    Now, let me share a few stories of pain, for perspective purposes

    First, let me tell you how I injured my wrist. I like swordfighting – fencing, SCA-style, shortswords, you name it. About ten years ago, I was going to a regular weekend group which engaged in SCA-style swordfighting at a local park. I had started to feel some strain in my wrist, and so decided it was a good idea to take a break. While resting, a newbie approached me with a “genius” idea for why what he’d seen the more experience folks doing was totally wrong, and he wanted to show me. So, I figured, sure, I wouldn’t break a sweat showing him why he was wrong. I picked up my weapon again and we went at it. I was right in my assessment of skill levels – but I made a very wrong decision that day. The slight strain became a burning feeling that didn’t go away. The next day, I found I couldn’t pick up even lightweight items using that hand without feeling pain. I didn’t have medical insurance at the time, but as far as I can tell I strained the tendons in that wrist. It took years of RICE, wrapping, controlled weight training, and patience, but today I can use that hand without (significant) pain. The Marines say “pain is weakness leaving the body”, but really it’s the body say “stop doing that, dumbass.”

    You’d THINK that sort of warning would sink in, but no. I’m kinda dumb that way. In fencing, one of the more unlikely-seeming strains one puts on the body is on the plantar fascia, a tendon that runs the length of the bottom of the foot. You might feel it stretch if your foot slips on loose gravel. In college, I was particularly known for a move that puts EXCEPTIONAL strain on that tendon. I can’t point to any one incident that caused the damage, but it has taken its toll; I still fence, but on bad days I have significant pain in my leading foot. On really bad days, it’s serious enough that I simply don’t want to stand up because it hurts so badly. The fix for this is extremely expensive (and not covered by my insurance, of course) orthotic inserts for my shoes. Since it’s not all the time, I simply use a cane on those rare bad days when it’s necessary. But, what you might find interesting is, I make a point of concealing, even from my girlfriend, the days when I need the cane. Sometimes I grit my teeth and tough it out; other days I just try to arrange to not need to stand or walk much when other people are around. The reasoning is subtly different than in your case. I don’t want to worry those around me. My girlfriend, and my other friends, know I have this problem but I don’t want it to be a part of their lives. It’s something I want to deal with personally and without anyone else being involved.

    Thirdly, I do have medical problems that *aren’t* related to fencing – go figure! I have chronic headaches. Yes, you’re not talking about chronic pains, but it’s semi-relevant. I’m often reluctant to talk about these headaches, for a number of reasons. You see, I mention “chronic headaches” and to most people this means “migraines”. And on comes the sympathy: we all know migraines are so horrible, and how do I manage? But… they’re not like that. They’re mild. The kind of headache that maybe you pop a tylenol to treat. Except, well, I’m resistant to acetaminophin. And aspirin. And codeine. You get the picture. But, regardless, these aren’t serious headaches unto themselves. They became an issue in September of ’09, when I realized the last time I’d gone a day without a headache was in ’08. Early ’08. I didn’t talk about them, because they were just minor headaches. But after a year, a minor symptom becomes an issue. And there was a quality of life issue – imagine trying to get a good night’s sleep when you ALWAYS have a headache. And how mornings feel when everyone starts with dull, aching pain. I saw a doctor. He tried a couple of drugs, ran some tests, nothing worked. He sent me to a neurologist. That’s when I learned that sometimes people “just have headaches” like this. She was sympathetic. We ran tests (on the plus side, I can prove to my detractors that I DO SO have a brain, and I have pictures to prove it!). We have yet to find a cause. There’s nothing in any medical test that even suggests I have this problem. But, believe it or not, that’s normal. I’m currently taking a neuralgic pain inhibitor, and so long as I keep up my doses, I’m okay. But treatment is a far cry from cure; even my friends frequently labor under the misapprehension that this problem is “fixed”. If I miss a few doses of my drugs, the pain comes back. And it’s not a drug that I can pop and feel better in an hour, no, it takes days to build back up. Mostly I don’t talk about it, though – I don’t want to worry anyone.

    For contrast, I have a friend who, due to her own neurological issues, does in fact suffer from migraines quite frequently. I’m not in her head, but they seem to be of the more traditional, debilitating sort. Her response to them is sometimes to talk about them, but more often than not to try to go in to work anyway, because staying home and taking sick leave puts a strain on her co-workers – plus she always runs out of sick days before the end of the year. One cannot express how much this worries her daughter.

    What I find interesting in all of these is that the more responsibilities we have,t he more we’re expected to help others – and, admittedly, the more pride we have – the more likely we are to ignore or understate the pain we’re feeling, often to our own detriment.

    Link to this
  2. 2. Krystal D'Costa in reply to Krystal D'Costa 2:11 pm 09/30/2011

    Thanks for the comic, Hasufin. Someone pointed me to that on Twitter as well. I’m finally starting to feel like myself again. Trying to hide pain is exhausting, as you likely know from the days when you try to make it without the cane despite needing it. I think often we try to convince ourselves that things are far less of a problem than they actually are – particularly when we are the reason for the injury because otherwise it means admitting that we intentionally pushed ourselves too far and that we aren’t actually immortal. That’s definitely one of the things that pain forces us to consider: that we can be hurt, that “it” can happen to us. I like how you put it – that it’s out body’s way of saying “stop doing that, dumbass.”

    I also find resonance in your point about wanting to deal with your pain on your own without informing the world. As I mentioned, I tend to have at least one bad fall for the year, and I imagine it puts a lot of strain on the people around me. I’ve definitely learned to minimize how much pain I express and who I share that information with – and that means that even with S, I’ll sometimes gloss it over. There comes a point with acute pain (and sometimes with chronic pain as well) where people just seem to get tired about hearing about it, even the people who care about you the most. The manipulative potential of pain games is not something I had considered before writing this, but I can definitely see how that would work.

    Pretending nothing is wrong is an important coping strategy, I think. In my early twenties, I was also without health insurance, and I chose that time to put my hands through the glass door we had in our kitchen. (There were two lessons learned here: First, glass doors don’t belong in the house, and second, your mom was right when she told you not to run in the house.) I needed something like eight or ten stitches to close the wound and it hurt like hell. There was no avoiding the hospital, but I remember trying to downplay it to the doctor so he wouldn’t x-ray me and run up the hospital bill. The x-ray happened of course – we had to be sure there was no glass in my wrist, but I remember working so hard to prove I was okay. And I wasn’t.

    You may actually want to pick up the Kleinman’s Illness Narratives. One of the things he talks about is headaches, and how the ways we report them can influence how people respond to us. He asks s to think about what it is we’re really trying to communicate when we say we have a headache: exhaustion, chronic inflammation, misery of job loss, demoralizing marital relationship, etc.? That’s not to say that some people just don’t get headaches – my mother-in-law seems to fall into that category, but it seems to illustrate the need others tend to have to diagnose, so that if there isn’t a physical or biological reason for the pain, they start to look for social or psychological reasons – and of course this colors our tendency to report pain.

    I wrote this piece to show myself what I had helped do to myself. In feeling like a fool, and minimizing the injury, I likely prolonged the recovery period. Lesson learned, but it was a hard lesson to learn.

    Link to this
  3. 3. ProfRothbart 5:40 am 10/1/2011

    An Abnormal Foot Structure Can Make An Acute Injury Worse

    Acute injuries can be made worse by underlying conditions. For example, two people undergo the same type of injury to their tibia. One person is incapacitated, the other is not. What can account for this difference?

    Part of the answer is in the overall health of the injured person. Many factors can increase or decrease the subjective experience of pain, including sensitivity to pain, emotional and physiological wellness.

    However there is another underlying factor, commonly overlooked, that can make a seemingly minor trauma into a severe debilitating injury. That factor lies in the mechanics of motion.

    How the person stands and walks can directly impact how quickly or slowly an injury to a weight bearing bone or joint heals. This is well understood by car mechanics. If you repair a tire and place it on a car with a wheel alignment problem, the chances of that tire failing again are much higher than if you placed that same tire on a car without a wheel alignment problem. That is, how the tire spins (e.g., torsional mechanics) in great part determines the tire’s susceptibility to failure.

    This analogy can be compared to the human framework. Let’s use an injury to the tibia in the following example: Two people injure their tibia. One of the two has good postural mechanics and so will most likely heal faster, with less pain, than the other person who has poor postural mechanics. That is; how the tibia functions and moves (e.g., its postural mechanics) in great part determines how quickly it will heal after an injury

    Fairly recently, two abnormal inherited foot structures have been discovered, that have a dramatic negative impact on postural mechanics. These two foot structures- the Primus Metatarsus Supinatus and the PreClinical Clubfoot Deformity – can dramatically delay healing and augment the subjective experience of pain.

    I’m including a link to a report that I published in the Journal of Bodyworks and Movement Therapy (a peer reviewed medical publication) which goes into more detail on this: http://rothbartsite.com/uploads/Medial_Column_Foot_System.pdf

    Professor/Dr Brian A Rothbart

    Link to this
  4. 4. Hasufin 12:10 pm 10/3/2011

    I’m glad you’re feeling better. Do be careful; those injuries take longer to heal than you think.

    I like how you put that Krystal – making the pain my own. Of course, it’s more *keeping* the pain as my own. Odd to think of being jealous about pain, but it’s something I don’t want to share. There’s a contradiction there. One doesn’t want attention or acknowledgment for the pain itself: deserved or not, it’s just pain. But overcoming that pain, gritting your teeth and continuing is an Achievement, and dammit you want something for that.

    Hm. “exhaustion, chronic inflammation, misery of job loss, demoralizing marital relationship”… the thing about chronic pain is, it can cause those, or variants thereof. Until I got my headaches treated, I was on the verge of losing my job – I couldn’t concentrate, I was nodding off in meetings, I was irritable; and I didn’t even realize how much it was affecting me. Chronic pain, even not-too-terrible chronic pain, truly affects your outlook and can rapidly provide you with plenty of reasons to be in pain, which makes it even harder to seek treatment because the focus is on the symptoms and it’s harder yet to get to the cause.

    I’ll definitely try to find time to look into that book. Thank you for the recommendation.

    Professor Rothbart: that’s interesting and useful information! I know I have a somewhat odd posture – fencing and martial arts will do that to you. I’ve also noticed that I have a process on my calcaneus which projects slightly downward and laterally. It seems to give me an above-average strength and stability in walking on my toes. I inherited it from my mother, who has the same processes, large enough that her podiatrist has considered surgically removing them. I doubt I’ll get that fixed, but knowing always helps.

    Link to this
  5. 5. khwakaxoro 4:30 am 10/4/2011

    Thanks for an interesting read!

    Liked the point about emphasising somatic experience as a form of disassociation or objectification; was wondering if you had any thoughts on relationship between ‘feeling’ pain, and other kinds of feeling. Seems like pain should form one component of “learning to express” in a whole range of feelings – temperature discomforts, tiredness, emotions, &c. Creating a sort of ‘normal state’ template?

    Link to this
  6. 6. khwakaxoro 4:31 am 10/4/2011

    oh, and p.s. hope you get well soon!

    Link to this
  7. 7. Krystal D'Costa in reply to Krystal D'Costa 9:50 am 10/4/2011

    Thanks for the well wishes all. A lot of the pain has dissipated, but the RICE regimen will continue for a few more weeks. If nothing else, it has caused me to slow down a bit — which is an entirely new experience in and of itself.

    Hasufin, I find that I am jealous of my pain. It’s my experience and I find myself holding on to it in interesting ways. And it’s still hard to talk about even though I’m on the mend. When well-meaning folks ask how I’m doing, I find that I’m still glossing it over. There are only about a handful of people IRL who might come close to seeing me experience the pain itself. I have all sorts of questions about these responses and I might write more on them – we’ll see how much I want to explore here on SciAm.

    Prof. Rothbart, thanks for your point about the mechanics of motion. My husband is constantly telling me to stop “turning my feet out” – I have a tendency when idle to flex my feet so that the outsides bear my weight. I don’t walk around like that, but it’s a habit that he’s convinced has made me more prone to turning my ankle. A few other relatives have opined that my feet are unusually small and thus aren’t up to the task of bearing the weight of a body, and so I tend to fall more often. I, of course, think my feet are perfectly proportional to the rest of me :)

    Link to this
  8. 8. Krystal D'Costa in reply to Krystal D'Costa 9:50 am 10/4/2011

    khwakaxoro, the “normal state” template is an interesting idea. We certainly have culturally shaped expectations about appropriate responses that I think we learn as children. I once read something about the field experience of a young woman from the American mainland living with the Tlingit. Her status in the family was that of an adopted daughter for the purposes of relationships with the group members. Her expressions about her experiences – complaining about the cold, reluctance to get up early to make tea, etc. – gave her the reputation of being a bad daughter. The family tried to correct her behavior in the way that was customary – gentle criticisms and rebukes as needed – to get her to behave as she should, but the nuances were lost on her. (I think the anthropologist was Laura Klein, but I’m not sure at this point and can’t remember the name of the piece.) Anyway, the normal state definitely varies culturally but also varies from one context to another as do our methods for learning these states.

    One of the things I read while prepping for this post that stayed with me was measuring the appropriateness of one’s response to the situation at hand. So if my leg were broken, it might be permissible for me to cry because of the pain, but because I had “only” knocked it against a very hard surface, the expectation was that I should be able to hold myself together and recover. Part of this has to do with the visibility of the experience. So with temperature discomfort, if I’m just hot, then complaining might not be as tolerated as if I were manifesting symptoms of being hot: flushed cheeks, sweating, dazed look in my eye, etc. The normal state seems to be not just dependent on the individual but on responses to the individual as well.

    I think the entire foundation for “learning to express” is created when we’re children through our social interactions. If I decide to write more about my recovery experiences, I’ll try to flesh this out a bit more.

    Be well, everyone!

    Link to this
  9. 9. collettedesmaris 7:41 am 10/7/2011

    It is well-known that physical pain is the body’s way of telling us that something is wrong; either internally or externally. It would never occur to me to sustain an injury and be deceptive about it – by not sharing our experiences with one another, particularly when we have injured ourselves physically, we eliminate all possibilities of the information that we can benefit from through hearing someone else’s similar experience.

    The first and only time that I injured my ankle, it did the same thing you said yours did – it swelled. I injured it in a similar fall, in the early evening; and I experienced pain virtually immediately – and it was very swollen prior to going to sleep that night. The next morning, it was still swollen, but not to the extreme yours was – and, I had sprained my ankle. The ankle was unable to bear weight for days, so it’s quite odd that you say yours was swollen to the extent of “four times it’s normal size”, and yet you were able to walk on it? Certainly I applied ice immediately as well, but an ankle that swells to “four times it’s normal size” has certainly sustained a serious injury, and yet you said the ankle felt okay the morning after you sustained the multiple injury (“hit your shin”, and “tweaked your ankle”, you said).
    Then, you say the ankle swelled to “four times it’s normal size” the following day, after you walked from the train station – how could the ankle not have caused you extraordinary pain while walking on it; particularly since you say the walk was the causation for the extraordinary amount of swelling. It just doesn’t make any sense. Extraordinary swelling such as you described in the ankle would be indicative of extreme injury trauma at that site – and yet, you claimed to be able to go to work again the following day? My ankle was not swollen nearly as much as yours, and I was unable to bear weight on it for days immediately following the injury. Your information is perplexing, and questionable.

    Three questions that seem to be important to you are questions that don’t need to be asked. You wonder, “how
    much pain do we think we’re allowed to feel …” Perhaps you are wondering about that due to the fact that you’ve got that concept wrong. Pain is not something that we require permission to feel or not feel. It just is. If one injures oneself or suddenly starts having internal pain, it is not a normal reaction to ponder to oneself, “Hmmm – am I allowed to feel a lot of pain here, or just a little bit?” The level of pain one experiences is not something one needs permission for.
    Your next dilemma – “how much pain do we express?”
    Your best bet is to describe it honestly – ie: “this is where it hurts, and it’s the worst pain I’ve ever had there ..” or whatever; you state it sincerely.
    Your next thought, “how we’re supposed to respond when we’re hurt.” You respond naturally, of course. Here’s a suggestion: you say, “ouch! I hurt myself!”

    These are really not things one should be wondering about. It’s always been a “given” in the world I live in that the body should and does react naturally to sustaining an injury. Even a child knows that when they get hurt, they tell somebody. I can honestly say that I have never known anyone who was reluctant to say they have been hurt – you present an extremely odd and inordinate concept here; and an unhealthy one from a mental health perspective. I mean, why would you deem it necessary to put concealer make-up on a bruise? Perhaps that would be acceptable if you were a professional model or entertainer, but an office clerk? Vanity personified. You expressed more concern over what people might think of you if they knew you had taken a fall than your own physical health! That is not good. Look where it got you.

    Your reference to the DSM is not really appropriate in this article. It is an evaluative reference for mental health patients, not physical injuries for an individual who does not suffer from a mental health issue. But I may be mistaken; maybe you did mention it for that reason; and if I overlooked that, I apologize.

    It is very troubling that you appear, by all intensive purposes, to be an adult – and yet, the thoughts you expressed regarding injury and pain are not thoughts that the average, normal individual wonders about. Pain is a body’s natural reaction to injury, and I am quite elderly, and I can honestly say that I have never been exposed to a person who sought to exert an unnatural response to being injured, or hiding the pain they were experiencing. It’s a natural course of events that people who have been injured usually are in need of help – why would one want to hide the fact that they’ve been injured, or that they are in pain? How else to you obtain assistance to seek medical attention?

    Link to this
  10. 10. Hasufin 10:44 am 10/10/2011

    The thing about pain is, there’s no objective scale for it. It’s all very subjective, and doesn’t necessarily map to the actual level of injury. I’ve had my nose broken – that was a consuming, burning pain. But, all said and done, a broken nose isn’t a big deal and doesn’t require any action. On the other hand, I’ve overstressed various tendons and ligaments – those injuries hurt a little bit but not enough to force me to stop what I was done; however those pains signified significant damage which will never fully heal.

    When I was younger, I went skiing for the first time with my parents. Since this was my first time, we had to rent equipment for me. If you’ve never been skiing, let me acquaint you with ski boots. Modern ski boots have a rigid plastic shell which is strapped together over foam which both pads and insulates the foot. To work properly, the ski boot must be very tight. My rental boots were exceptionally tight; painfully so, in fact. Since these boots are, to the uninitiated, quite uncomfortable and as I was only 12 years old, my father determined that I was merely whining and insisted we go to the ski lift, painful boots and all. It wasn’t until we go to the lift that I decided if skiing was to hurt THAT much, I’d rather not ski at all; a return to the rental counter and I had boots which fit properly.
    This may seem merely that I was vindicated. However, my father was not unreasonable – 12-year-olds DO whine about perceived but not significant pains. 20-year-olds, and even 60 and 70-year-olds do as well, but less often.

    You don’t need “permission” to feel pain, but learning what pain is important and must be acted on, and what pain can and should be ignored.

    Pain is part of a larger set of considerations. The fact is, we’re not born knowing how to operate this complicated machinery that is our body. We tend to think of it as something we just understand, but it takes us several years to master basic locomotion; becoming truly skilled operators takes a lifetime of dedicated work.

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  11. 11. collettedesmaris 8:38 am 10/24/2011

    There is nothing subjective about an ankle “swelling up to four times it’s normal size”, and being able to walk on it – swelling is factual, my friend. Swelling to that extent doesn’t just go away overnight; and I reiterate; is indicative of a serious injury to the ankle. The examples you gave have no relationship to the injuries that Krystal said she sustained; or to the information I provided.

    Regarding pain – I have no idea what you are attempting to convey by saying that “pain is part of a larger set of considerations.” What the heck are you talking about? As well, the fact is; we ARE born with natural mechanisms set in place at birth – one of them being, the sense of pain. Like I’ve already said, pain is unarguably our body’s way of indicating to us that something is wrong – it is not something that has anything to do with “becoming truly skilled operators that takes a lifetime of dedicated work” at mastering.
    The level of pain is not something that we need permission to feel; conversely, it is the severity of pain that is a strong indicator of the level of injury or illness. For example, an appendix bursts – severe pain ensues before this happens to indicate that the body has a serious problem. Someone has a heart that eventually will attack them if they do not heed the warning signs of pain that precede it. I cannot fathom why you people don’t simply know this about your own bodies – it’s a natural phenomenon that is a simple equation: pain is the signal to attend to the area from whence the pain comes. Even an infant inherently signals it is in distress due to illness or pain by crying. Pain is NOT something that any human should wonder about, nor does one need permission to feel it – IT JUST IS – and pain is never present without an underlying physical problem; with the exception of the hypochondriac.

    Link to this

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