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Writing Pain: Pt 1- What it is and How it Works

After slogging through all my Whump Challenge posts, I thought you all deserved something nice. So here is the first of a 2-part series on pain. Enjoy!

Basics:

Pain is an unpleasant physical and emotional sensation caused by actual or perceived tissue damage. Under normal circumstances, pain indicates some kind of tissue damage. This damage can be from an injury, an infection, or a disease like arthritis. Very simply, when tissue is damaged, cells release certain chemicals. When the concentrations of these chemicals get high enough, nerve endings send a signal to the brain, which is interpreted as pain. Painkillers work by either blocking the formation of the chemicals, blocking how they interact with the nerve endings, or by blocking the transmission of the nerve impulses to the brain.

Pain Scale (intensity):

In healthcare settings, pain can be measured on a scale of 0-10. On this scale, 0 means no pain, and 10 means either the worst pain the patient has ever felt, or the worst pain the patient can imagine. Quantifying this for fiction purposes isn’t always easy, but think about it like this:

Pain score of 1: “Pain Threshold.” Where pain first begins to be felt. Barely noticeable and very easily ignored. Character likely would not express discomfort and may change positions, but not much more.

Pain score of 2: Character may voice discomfort, but may still not do anything about it.

Pain score of 3: “Pain Tolerance.” Pain becomes difficult to ignore and character finally begins to seek some form of relief.

Pain score of 4-5: Pain becomes nearly impossible to ignore completely, pain symptoms of tense muscles and a change in respiratory pattern develops. Irritability, nausea, and a change in vitals likely.

Pain score of 6-7: Pain is debilitating. Difficulty concentrating occurs, fine movements like writing are significantly impaired. Muscles are tense and hands are balled into fists.

Pain score of 8-9: Sleep is impossible, and pain is completely debilitating. Very difficult to read, think, speak or focus on anything that isn’t the pain. Change in vitals very pronounced.

Pain score of 10: Unconsciousness immanent. Worst pain character has ever felt. Incapable of thought, movement, or speech.

Pain is a very subjective, individual experience. One person’s 2 might be another person’s 6. Notice up there where it says “pain threshold” and “pain tolerance”? Pain threshold is basically how bad the pain needs to be to be felt at all. It’s the “1” on the pain scale. Pain tolerance is where the pain needs to be for the person to want to do something about it. It’s usually about a “3” on the pain scale.

Pain tolerance is different for everyone, and changes based on life experience (are they used to dealing with pain?), fatigue (being tired or chronically sleep-deprived may make pain feel worse), and emotional situation (being scared or sad may make pain feel worse). People’s perception of, and need of treatment for, the same pain may change day-to-day, or as they gather more experience.

Pain on this scale is also self-reported. People may exaggerate or minimize pain when reporting it depending on life experience (some people may be used to only getting treatment if they rate their pain at 10/10, and so routinely exaggerate in order to be taken seriously), culture (some cultures highly value stoicism, and may under-report pain so as not to appear weak), or religion (some religious groups view pain as penance, and so may under-report pain to avoid treatment). This is something to think about when building a character.

Describing Pain (quality):

Pain, while a universal concept, is not a universal feeling. Pain quality is what the patient reports the pain as “feeling like.” Different manifestations of pain can mean different things (see the list below for examples). Depending on the location or the reason for the pain, it can feel different. Here are some ways pain can be described/experienced (examples of related injury/illness in parentheses):

Achy (body aches from illness)

Crampy (gastrointestinal illness, menstrual cramps, heat cramps)

Crushing (heart attack, sometimes asthma attack)

Dull (injury to internal organs, bruises)

Piercing (pain from a surgical incision, some pain from loss of blood flow (ischemia))

Pounding (headache)

Sharp (pain from a surgical incision)

Sore (overuse, muscle injury)

Tender (bruises, soft tissue injury, musculoskeletal injury)

Tight (swelling (skin feels tight), asthma (air passages feel tight))

Throbbing (localized infection, soft tissue injury, swelling)

Any one of these and many others can manifest at any intensity.

Non-Verbal Signs of Pain and Pain Signature (newly added to post):

Writing for a character who doesn’t like to admit to being in pain? Rest assured, you still have something to write about. Non-verbal signs of pain obviously become very difficult to hide as pain increases, but even small amounts of pain may result in non-verbal expression of pain. Non-verbal signs of pain could be great for tipping other characters or audience off to pain.

Non-verbal signs of pain include:

Facial grimacing (especially the little crinkle between the eyebrows)

Increase in respiratory rate, heart rate, and blood pressure

Decrease in blood oxygen saturation (from breath holding)

Guarding of painful area

Decrease in physical activity and energy level

Loss of interest in surroundings

Difficulty keeping attention on task, may miss information

Restlessness

Constant shifting in position

Change in appetite

Repetitive movements, such as crinkling paper, wrapping fabric around hands, rubbing feet against bed

A “pain signature” is a person’s unique but consistent combination of the above signs. Even people who try to hide their pain often display a pain signature, though they may attempt to write it off (decrease in energy can sometimes be compensated for and change in appetite and restlessness can be caused by a lot of different things). If you know your character will be in pain, it might be a good idea to include their pain signature as part of character planning. 

R E F E R E N C E S

Craven, R. F., & Hirnle, C. J. (2009). Fundamentals of nursing: Human health and function. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.

Lippincott, W. &. (2013). Brunner and suddarth’s textbook of medical -surgical nursing 12th ed. nursing diagnosis, .. Place of publication not identified: Wolters Kluwer Health.

Stay Tuned for Pt 2: How to Get Rid of It