drmargaret

People have different perceptions of pain. The point at which pain can be perceived is someone’s pain threshold. Some people have a high threshold. They notice pain at very low levels. In the fable the Princess and the Pea the Princess could perceive the pea under 40 matresses. This is a very high pain threshold. She can notice very insignificant levels of pain for most people. In contrast was a man who had become very sick. He had no awareness of how sick he was. This is a low pain threshold. I reviewed his history. I specifically wanted to hear how often he had broken bones. He had broken bones quite a few times. It was no big deal to him. He had driven himself to the hospital most of the times, with cracked ribs, a broken arm, and with a broken leg. He didn’t notice he was in pain. So when he started developing diabetes it wasn’t caught until it was very late in the course of his illness. When he caught a bacterial infection, he had already developed septicemia and the infection was well into his blood stream before he felt the first twinge of pain.

Pain works to help people recognize something is wrong. Too soon with too high a pain threshold and there is no sign of the underlying disease process. I see the MD about two weeks prior to the lab tests showing something abnormal. I notice pain early, prior to anything showing up as wrong. Wait a couple weeks and then there are signs of the infection. It’s a running joke at the medical office, that on my tombstone it will say “But her labs were normal.”

The second thing about pain is tolerance. A low pain tolerance means that pain can’t be tolerated well. A high pain tolerance means that pain is tolerated better than average.

Pain threshold and pain tolerance work together. They are based in part on how many pain receptors the body has in a particular area and on how someone deals psychologically with pain. The man I talked about appears to physiologically have few pain receptors. He doesn’t notice pain. He has a high tolerance for pain and a low pain threshold. He may become seriously ill and take no notice. To combat this he needs to be seen regularly and have routine labs drawn to ensure he isn’t medically ill since he has no awareness of pain.

I have an acute awareness of pain but a high tolerance of pain. So although I notice pain at very low levels I can tolerate fairly high levels of pain. The problem with this is that I notice pain prior to medicine picking up what is wrong.

There are people who have an acute awareness of pain and a low pain tolerance. These people experience lots of pain. They complain about pain from minor injuries, from bumps and bruises, from little scratches. These people just experience a lot of pain. When something big happens that causes most people pain, they are doubled over screaming.

Doctors use a 10 point scale to have people describe pain. That really doesn’t do justice to pain. It gives them an idea of how bad this pain is in relation to their other pain in their life but it doesn’t tell them how pain is. I prefer to anchor the scale better on both ends. When I ask about someone’s pain I ask about what their worst pain was like and what they remember about that experience. Were they doubled over? Were they vomiting continuously? Were they blacking out during the episode? Were they in a hospital? Did they break a bone, lose consciousness, need an operation, give birth? Now that’s the worst kinds of pain. So that would be the 10.

Now the least kinds of pain are little things like a scratch, a little bruise you didn’t even notice you had a couple of days after you got it, a minor ache, something so small you wouldn’t seek treatment for. That’s the 1. And less than that would be no pain at all, nothing. That’s the 0. Then I have them rate their current pain and describe the symptoms.

So my appendicitis was an 8, even though I went shopping an hour before I went to the hospital. The guy I saw was a 9, even though he described his pain as a twinge, a pressure in his chest, it was worse than when he broke his leg. He was in the hospital for 4 months, intubated, in septic shock.

I meet people who complain of severe pain all the time. Some people have debilitating pain. Some people have pain complaints that exceed anything realistic. Some people use pain complaints to get pain medication. Pain medication is psychologically and physiologically addictive. The psychological part can be more problematic than the physiological part. For chronic conditions the idea is to control the pain on the least amount of medication possible. Often controling inflammation, depression and anxiety are also helpful.