Understanding why people feel pain differently: Disease versus Illness

So far, I have discussed a number of pain syndromes (some of which are more prevalent in men and others in women) as well as ways to block the associated pain. I have also often discussed the significance of chronic pain in Canada and how it is managed (or more accurately NOT managed) in most provinces. I would now like to discuss one a more obvious topic: the fact that not all people feel the same pain, even if the underlying cause of the pain seems identical.

Let’s take two people of the same age (let’s say mid 60s), with the same degree of degenerative changes (commonly called “arthritis”) in their neck. One is in serious pain, takes several medications and still has very limited function. The other one takes no medications at all and leads a nearly normal life, accepting some neck aches and stiffness as “natural part of getting older”. Why are these two individuals feeling pain and reacting to it so differently?

To try to understand these differences I will walk you through several concepts slowly and carefully. First of all, let’s discuss the concept of “illness versus disease”. When your doctor talks to you about “disease”, he/she means that something is wrong with a part or a function of your body as in disease of the heart, the kidneys or a leg that suffers from lack of blood flow. In other words disease means something specific that can be determined with tests or physical findings. On the other hand, illness is a much bigger and more complex process than disease. To understand illness, we must analyze 4 elements in the sequence of events. At first your body will send you a signal (such as a jab of pain in your stomach). The second event involves your interpretation of what you think is wrong with you. This perception involves past experiences and numerous psychological and cultural factors. Thirdly, you describe what happens to you and express what you feel in your own way. Finally, you end up developing certain forms of behavior to cope with your body’s signal.

Whatever meaning we assign to these body signals will mobilize our attention and pain is exacerbated when we focus on it. The interpretation of symptoms and the meaning we assign to them varies tremendously between different cultural or social groups or individuals and can profoundly affect the way we cope. The way we express pain and cope with it also influences the way others judge our pain. Those who complain of pain too much using words, gestures and different emotions may be looked upon by others, including health providers, as hyper-reactive or histrionic, others may even think that the pain is “all in their head”. Others who behave in a stoic fashion may be taken more seriously by doctors, nurses and other health practitioners or to the contrary may be dismissed as having no pain or very little pain.

So let’s look at a specific example of two people who receive the same body signal (let’s say acute stomach pain) but interpret it and react to it very differently. Person A thinks: Here we go again. I ate too much pizza yesterday night and this is indigestion (his interpretation). Then he reaches out for this Tums and sits quietly waiting for the discomfort to go, as he had felt something similar in the past. Person B, however, says: Oh God, this is how my father’s stomach cancer started! He gets frantic, the pain mounts, he runs to the local emergency, and settles only when the doctor assures him that in all likelihood his stomach pain is attributable to the bloating caused by gas pain.