The weapon metaphor—describing pain as stabbing, shooting, burning—is the most common way we speak of pain primarily because of its implicit subtext, namely injury to the body. It is through injury that we learn about pain as children, when we cut our hand on a sharp object, for instance, or move it too close to the fire. The sensation that follows, our parents tell us, is what pain is. Over time the connection between injury (exterior and visible) and the sensation (interior and invisible) is solidified. This is why we routinely think of injury—or weapons like knives and guns that cause such injury—whenever we experience pain, even when there is no external damage to the body. For the patient suffering from shingles or migraine, there is still damage, only now it must be occurring inside the body and we can't see it.
Physicians are well aware of this deeply ingrained connection and when trying to evaluate pain in their patients, they naturally gravitate toward the weapon metaphor and urge their patients to do the same. The McGill Pain Questionnaire contains lists of weapon-inspired adjectives that patients can choose from to describe how they feel. Here are some examples:
throbbing, pulsing, pounding, flashing, shooting, boring, drilling, lancinating, gnawing, crushing, pulling, wrenching, stinging, splitting, suffocating, piercing, squeezing, tearing.
The lists are helpful because they open the lines of communication often closed for those in pain, and thereby, make patients feel less isolated. Yes, this is how it feels. Thank God someone understands.
Equally important, the descriptors aid doctors in discovering the source of pain. Researchers have shown that certain combinations can point to specific diagnoses. For example, back pain that is "sharp" and stabbing" is more suggestive of cancer (bone metastases) than back pain that is "gnawing" and "aching," more likely musculoskeletal in origin. By the same token, a "throbbing" headache favors migraine over tension headache, which tends to produce "dull" and "constant" pain.
But despite the great upside of the weapon metaphor, there is also a very serious downside. While it allows us to collectively think and speak about a private experience, it does so in a highly circumscribed way: pain has become indissolubly linked to, almost the equivalent of, physical injury. So much so that when injury doesn't exist or can't be detected—which happens in the case of many of the 70 million Americans who suffer from chronic pain like fibromyalgia or lower back pain—then the pain becomes less real and easier to doubt. No injury, no pain. No lesion on the MRI, no pain. Clearly this leaves many chronic pain patients not only without a way to make sense of their problem but with a host of medical providers who simply don't believe what they're saying.
Another problem with relying so heavily on a specific metaphor is that over time, its novelty wears off. We begin to use words like "shooting" and "stabbing" automatically so that they no longer prod us to see pain—i.e., via the knives and guns and damage they cause—and the pain begins to fade back into that murky, imperceptible realm of private, incommunicable experience.
So while we would never want to part with it—any metaphor that enables us to speak is valuable—we must constantly imagine new ways of seeing and communicating pain other than in the context of weapons and direct bodily injury. In the next few posts I will discuss novel metaphors that return pain to the spotlight but with less emphasis on physical injury.