Jenny was upset.
‘How on earth can I carry on when everything I want to do is so painful? Last week, I fancied cooking some pasta with a bolognaise sauce, but when I sat down to eat it, I got such bad griping, I had to throw it in the bin. If I plan a night out with friends, the pain comes as well and I have to go home early. Even when I go for a walk in the country, the pain is there and I worry about finding a loo. On the occasional time, somebody asks me out on a date, the pain always seems to spoil it. It’s so embarrassing. And if ever I am stupid enough to feel like having sex, I get pain instead. It’s not worth looking forward to anything. It’s just bound to be destroyed by this awful belly ache.
Pain has blighted Jenny’s life. Even the thought of going away on holiday has its inevitable camp followers of pain and dread. ‘Will I be able to cope with the journey? And what about the food? The heat will upset me. And all those insects. What if I need to find a loo or go back to the hotel and rest? Why bother? I’d just as well stay at home and read a book.’
Jenny is in her twenties; just out of university. She has her whole life ahead of her. But there is no way she can plan for the future, build a career, get a home, start a family? The pain robs her of any motivation. Her GP said it was just irritable bowel, but to Jenny, it’s a nasty, vindictive, malicious bowel that is wrecking her life. It makes her so frustrated, then depressed, but that only intensifies the pain. If she can distract herself with a book, or listen to some music or perhaps do some drawing, it may recede into the background for a while, but as soon as she starts to think about what she ought to be doing, it comes back, like the proverbial prophet of doom.
Pain is so much easier to deal with if there is a cause. An injury will heal, most illnesses will get better; then the pain will go away. But if there is no obvious reason for the pain, then the fear of what it might be amplifies the torment. Friends and family may be sympathetic for a time, but this soon wears off. As Jenny puts it, ‘I’m sure my friends see me as that unhappy face who is always complaining, can never join in and needs so much care and attention. I feel that I’m the pain. Even my GP is fed up with me.’
Of course, there are some long term inflammatory diseases that cause recurrent anguish: the dull crippling ache of rheumatoid arthritis, the crushing chest pain of angina, the griping of Crohn’s Disease and the pain of duodenal ulcer that bores into the stomach like a knife. They are all made worse by fretting about them, but they can also be controlled by medications and adjustments of diet and exercise.
But pain can also be instigated by emotional trauma and rekindled by anything that reminds one of it. When something has happened that was so dreadful that it can’t be thought about, it may be expressed as a physical pain, which in some way represents the trauma. This is perhaps easier to understand if the emotional trauma occurred in association with or because of an injury, a life threatening illness or a serious operation. The patient may have blanked the episode from conscious thought but the pain lingers on as a bodily memory.
Pain is perceived by the brain and referred to the part of the body that most appropriately represents it. This may be because that part is actually damaged or because it was damaged in the past and pain continues as a somatic memory. Amputees can feel pain in the fingers of the arm that has been removed. People, whose gall bladder has been resected may still continue to feel the symptoms of cholecystitis. Pain is encoded in our long term memory and can be evoked by anything that reminds us of the circumstances of the surgery or the injury.
But pain may have no actual physical connection with tissue damage, but may instead function as a metaphor or symbol for something that happened or is happening now. So headache may indicate impossible pressure caused by too many demands. Backache all too often seems to represent an emotional burden that is too heavy to cope with – the syndrome named after Atlas, who carried the whole world on his shoulders. And for abdominal pain, there are so many individual connotations, but for some it might be that dreadful sense of fear or shame; a visceral secret that ‘ties the guts in knots’ and is evacuated as diarrhoea. But like dreams, there are no stereotypical interpretations for symptoms; they only mean something for the person who experiences them.
If pain was just a physical sensation, it could be easily treated or prevented, but pain is as much emotional as physical. Pain is suffused with personal significance and meaning. In life, it’s not always what is that upsets us but what we think it is. Pain can represent what we fear most: loss, incurable disease and dying. The clue is in the words we use to describe it – devastating, torturing, griping, frightening, dreadful, alarming. Even the words for despair – panic, depression and anxiety – have their derivations in pain. Anxiety has the same root as angst and angina and represents a painful sensation in the throat that chokes off the air supply.
Treatment needs to address both physical and emotional aspects of pain. Some painkillers, such as aspirin-like drugs or antispasmodics suppress the generation and transmission of pain. Others like morphine and antidepressants damp down its perception. Complementary therapies, such as hypnotherapy, acupuncture, relaxation, therapeutic massage and reflexology are particularly useful in managing the emotional component of pain. They replace the fear and despair with confidence and hope and provide the emotional space for people like Jenny to regain the purpose of their lives. Psychotherapy can confers the additional benefit of facilitating insight into what the pain might represent.
But, what of Jenny? By our third session, she felt able to tell me that the severe pain in the pit of her stomach came on shortly after the abortion she had the previous year. She talked about what happened: the botched operation, the infection, and the terrible guilt and shame of it all. Over the next few months, she began to understand and forgive herself and the pain gradually receded. It is now more than three years since I first met her. She sent me an email last month. She told me she is working as an architect, has a long term partner and is expecting a baby. She has few episodes of pain nowadays.