Pain Language
TLDR: Pain is not suffering, and is sometimes good. Pain evaluation can be improved. Utopia uses precise language for pain as part of a general push for internal clarity.
Prerequisites: None
In my experience, there’s lots of confusion around certain concepts in the space of pain, sadness, suffering, and aversion. It’s not limited to the negative, either. People are also bad at thinking about things like pleasure, happiness, contentment, preferences, and values. Everyone from philosophers to doctors to teachers to priests (and laypeople, too) seem at least a bit confused, even when they write books on the topic and claim expertise.
Part of the failure here, I think, is not being able to literally point at what’s being discussed. We tend to be pretty good at talking about things like transistors and stars, but the second that the topic drifts to something incorporeal like “freedom” or “purpose” things get sloppy. The illusion of transparency grabs us without anyone even noticing.
Imagine that someone says “I’m sad.” What does that mean? You probably have a concept in mind about what “sadness” involves, probably formed from an experience that you have sometimes that you call “sad.” But are you sure that your experience of sadness is the same as other people’s sadness? People are quite different! How would you even know?
I tried writing this essay several times to address the entire space, and attack the underlying confusions. But there’s too much there. Instead, this essay will focus on a single piece of the human condition and how we can do better as a society in thinking and talking about it: I want us to have better language for pain.
What is pain? Obviously it’s the kind of feeling we get when we stub a toe, burn ourselves, or get cut. But there are instances of pain that extend beyond those examples, and even gesturing at it like I just did relies on you having a first-hand experience of things like getting burnt. Given the natural difficulty in talking about internal states of being, we must put effort in to be precise. How could we talk about pain if we want to be sure not to be misunderstood? How might we describe it scientifically, from the outside?
Pain from the Outside
When we step back and take an outsider’s view, we can see that cuts, burns and stubbed toes are all injuries — instances of the body taking damage. But what humans call “pain” goes beyond that. Cluster headaches and spicy foods are examples of pain (albeit on wildly different ends of the intensity spectrum) without any obvious injury attached. And while pain comes from many injuries, it often lasts a different duration than the damage to the body. Pain usually fades well before an injury is totally healed, but occasionally persists even after the wound is gone. “I’m in pain” cannot therefore be synonymous with “I’m injured,” even though “I’m hurt” often blurs the line between the two.
The key is that injury is distinct from the sensation of injury. Even when we know that we’re uninjured and the pain is not pointing to damage, we cannot help but experience the signal in a very similar way to how we’d receive actual damage.
When a foot is bashed against an object, several types of signals propagate along the nerves up towards the spine. Some are the normal signals associated with the motion of the limb and the touching of an object. But others are special — only triggered under strong pressures or in the presence of inflammation or chemicals that are released when nearby cells are destroyed. The sensory cells that send these signals are called nociceptors, and signal pathways from different nociceptors have different properties, most notably traveling at different speeds. Mechanical and cold sensors send fast signals, while heat and chemical sensors send relatively slow signals.
Humans can notice the different kinds of sensation when they injure their feet. The sensation of impact occurs nearly instantly, but it can take a second or more to feel the deep/hot/throbbing sensation that follows and persists even after the impact sensation is gone. The delay is lengthened for taller people, and lessened if the injury is inflicted closer to the head.
Nociceptor signals are received by a wide variety of nerve areas. Bundles of nerves in the spine trigger reflexes like yanking a hand away from a hot surface. Nerves in the midbrain release different hormones when they encounter nociceptor signals, triggering wakefulness and other sympathetic (“fight-or-flight”) nervous system (SNS) responses. And of course, these signals feed into the cortex and are processed by the broader perceptual system, eventually leading to vocalizations like “ouch!”
It’s worth noting here that the only thing that marks a nociceptor’s signal as painful is how/where it is received. It’s ultimately all just electricity — the distinction is in how that electricity is interpreted. And in fact, there are a class of people who experience nociception differently than others, coding it as a neutral sensation. It turns out that not being able to feel pain (either because those nerves don’t work or because they’re coded as non-aversive) is really bad, with many of the afflicted dying from accidents and untreated injuries at a young age.
We can thus see that while it’s bad to be injured, and pain is strong evidence of injury, it would be foolish to generally eliminate pain directly. Nociceptive pain is like a fire alarm; disabling the alarm is a very different action than putting out the fire! It’s only thanks to pain that we survive and successfully avoid taking damage. Hurrah for pain!
Pain and Pleasure
“Hurrah for pain!” is hardly going to be a popular phrase. Humans tend to despise pain and tend to do whatever they can to avoid it, sometimes at extreme costs such as opioid addiction. This aversion makes total sense, evolutionarily — avoiding pain is a good way to avoid injury, which is a good way to survive. The map-territory distinction between pain and injury is too fine-grained to make it into our automatic experience, so we steer away from pain as a general rule.
Except… what the heck is going on with spicy food?! Peppers are filled with capsaicin, which activates the same nociceptors in the mouth that are used to detect burns! Spicy foods hurt very literally, but are deeply loved by billions of humans all across the world, including me!
Humans are extremely adaptable creatures. While pain is naturally aversive, it’s not necessarily aversive. Affinity for spicy foods is learned. It comes from many good experiences being tied up with the pain and coming to understand that spicy food isn’t dangerous, despite the warning signal.
The spice from food isn’t simply tolerated, either; it’s kinda the whole point! People like being hurt, at least in that local domain. And spicy food isn’t the only place where people enjoy pain. Many people like strenuous exercise, for example, or particularly hot/cold water.
As nociceptive signals reach various parts of our brains and bodies we get a jolt of the same sorts of chemicals that are associated with all exciting activities. Like being on a roller coaster or watching a scary movie, the rush of the moment can be pleasantly accompanied by a feeling of relief and safety. Beyond the side-effects, feelings of pain can be interesting and even artistic in themselves, offering intense experiences that are unaccessible while comfortable. By exploring pain and the phenomena that accompany it we prove to ourselves and others that we’re tough enough to endure it. When one sees and understands the distinction between pain and injury, pain can be an exercise in holding mind above matter.
Our world is dominated by so much unwanted pain that it’s easy to be seduced by the claim that it’s a simple evil that needs to be eradicated. Painkillers and anesthesia were a major step towards a better world, and there’s a long road ahead of us to a world where pain is never unwanted. Chronic pain is an especially important target in this struggle, accounting for much of the day-to-day hardship in the world.
But if we want to make progress towards clear-thinking about pain, we must be precise. It’s not pain per se that is bad. Pain is a useful alarm signal that keeps us safe, and often an essential component of desirable experiences. Losing pain would, like losing boredom, be a catastrophic loss for humankind.
Wasted Pain
Making things worse, it’s not merely that the distinction between good and bad pain is whether it’s wanted or unwanted. It’s not even clear what that means, in fact. To explain, let’s use a metaphor of cooking.
Sometimes when I’m cooking, the dish I’ve made comes out poorly. Perhaps I’ve burned it, or added too much salt, or I made a substitution that messed with the texture. When I begin to eat, I realize that the food is kinda gross.
In that moment I often very much do not want whomever I’m cooking for to think it’s gross. When they taste the food, is their perception of my failure as manifest in the quality of the food wanted or unwanted? It’s certainly unwanted by me right then, but it might be wanted or it might be unwanted by them. Taste, like nociception, helps protect the individual from eating the wrong things. The person eating my cooking might reasonably want to notice that the food is gross, so as to not eat as much of it, and perhaps to avoid having me cook down the line. In that world their perception of grossness is both wanted (by them) and unwanted (by me).
But perhaps the other person agrees with my immediate desire. They might reflectively believe that a bit more salt won’t hurt them, and they’d rather enjoy the meal, free from disgust and social awkwardness. Is their disgust reaction totally unwanted? Not necessarily. While we both might agree in that moment that it’s bad, it might turn out in a broader timescale, that it’s important to be in touch with the reality of the situation. The bad taste is a result of a mistake I made, which I might not learn to correct without the penalty of having the food be gross. The person eating my food might be fine in the moment, but their future self might regret not having learned a lesson after I give them food poisoning next week.
Pain is good, I claim, when it carries useful information and directs the receiver towards a good life (whatever that involves). This is true whether it’s a simple alert of an injury, or if it’s an artistic canvas upon which interesting and exciting experiences can be made.
Pain is bad, then, when it’s deceptive, random, redundant, distracting, disabling, and vague. Pain can have truly awful side-effects, like being unable to think, to talk, to walk, or to sleep. I often feel like pain persists far too long. When I’m dehydrated and get a headache as a result, that pain lingers well after I’ve fixed the issue.
Pain Sensitivity
Again, because it exists only within the body, unable to be gestured at or examined, we lack good ways to talk about quantities of pain. Earlier we discussed people with pain asymbolia or congenital insensitivity to pain who have much worse/shorter lives as a result of being unable to respond appropriately to injuries or sources of potential harm.
It’s possible to run a test to detect these people, but what about people who are more/less sensitive to pain? Changes in how the pain signal is processed could mean that your notion of what it feels like to burn your tongue is very different from mine. Are tough people better at blocking out pain, or do they simply not feel it as strongly in the first place? How would we even distinguish?
Traditional pain scales are pretty bad. Sometimes infamously so.
A standard objection to the pain scale is that it’s extremely subjective and poorly defined. This goes hand-in-hand with our general lack of precision for internal states. But even more to the point, it entirely fails to capture the difference between people. To what degree can we personalize care when our metrics are entirely apples-to-oranges?
Three good first steps:
Set up a consistent frame for evaluating the pain.
For instance: “We’re hoping to understand what is happening in your body, and pain can be a good indicator of injury. Can you locate one or more pains right now? For each distinct sense of pain, let’s start with you describing it using words like burning, itching, throbbing, sharp, et cetera. Then we’ll move on to trying to quantify aspects of it, so we can find you the right treatment.”
Alternatively: “We want to make sure you’re comfortable and not experiencing any pain. How are you feeling? Do you notice any pains in your body?”
Or even: “We’re trying to get a sense of how you experience pain compared to other people. You feel some pain from the [injury/spicy food/experimental setup], yes? Let’s start with you describing it along some dimensions…”
Clarify what dimension we’re evaluating.
Intensity — Pain is a sensation like light or sound. Just like we can evaluate the brightness of a light or the loudness of a sound, we can be interested in the intensity of the pain.
Distraction — Pain pulls at the attention of the experiencer, limiting their ability to focus on other things. We can be interested in how much the experiencer is capable of thinking about things other than the pain.
Distress — Pain is naturally aversive and upsetting. We can be interested in the degree to which the experiencer wants to escape or find some way to cope with the pain.
Disability — Pain will, as it builds, reduce the experiencer’s ability to do activities such as work, talk, or move. We can be interested in the degree to which pain is disabling.
Provide reference levels to help anchor reported quantities.
“10 = the worst pain imaginable/you’ve experienced” is not very helpful, because the maximum value is going to vary so much between people.
For intensity or distraction, it might help to compare pain levels to light or sound. “1 = I can find the pain only when I search for it in my awareness; 2 = The pain is like the sound of a buzzing insect near my head or a person talking; 3 = The pain is like loud music at a concert or blasting in headphones; 4 = The pain is like being pressed up against a police siren; 5 = The pain is so intense I can’t compare it to other sensation.”
For distress it may help to ask what the experiencer would trade to make the pain stop, though this runs the risk of being insensitive, especially if the person is in severe pain. In such cases it’s probably just best to just treat the person immediately, without trying to measure their pain at all.
For distraction and disability, it seems wise to connect numbers to basic tasks. “1 = My pain makes me irritable and/or impatient; 2 = My pain makes it hard to do mental work or carry on a conversation about arbitrary things; 3 = My pain makes it hard to do anything besides taking care of myself; 4 = My pain makes it hard to understand people or care for myself; 5 = I am screaming/nonverbal and unable to engage with this metric.”
In addition to self-reports, we are beginning to move into an age when pain signals can be detected technologically. These technologies are still in their infancy, and run the risk of making errors that invalidate the experiences of people in pain. My best guess is that for the time being they need to be used cautiously, and not for determining appropriate medical treatment.
One obvious starting place in objective measurement is to check SNS response. When a nociceptor is activated, the signal excites the body as well as the brain. Heart rate increases, pupils dilate, digestion shuts down, and sweat glands activate. (Polygraph machines “detect lies” by noticing changes in these variables during conversation.) If someone experiences more/less pain due to their nociceptors carrying stronger/weaker signals to their spinal cords, we should be able to see that in their body.
But of course, the primary concern of pain is usually the effects in the amygdala and other brain regions. Using fMRI and other brain-scanning techniques, it may be possible to directly detect people with abnormal responses to pain by measuring activity in their neural tissue.
Emotional Pain
So far I’ve been using a definition of pain that’s anchored in nociception and connected to injuries in the body (even if sometimes the nerves produce pain in the absence of injury).
There is another definition of pain used by society that’s related to the term “emotional pain.” Recent work in neuroscience has revealed that there is a statistical similarity in the brain-states of people who are in nociceptive pain and those who are in the grips of grief or deep sadness. Other factors clearly link the two. We cry both when injured and when sad. People in deep emotional distress sometimes naturally talk about how much it hurts or how much pain they’re in.
Just like it’s useful to distinguish nociception (signals sent by nociceptors) from nociceptive pain (the direct sensation/perception of injury), it’s useful to notice the connection between pain and grief and have a concept relating the two. More concepts are good, as they let us distinguish between aspects of reality.
But it does seem to me that by using the word “pain” to describe a negative emotional state that’s distinct from any nociceptive signal is linguistically confusing. We already have a plethora of words to describe this other concept, such as suffering, misery, and distress. The fact that both breaking a bone and being rejected can cause suffering, and we can see that suffering in brain scanners doesn’t mean that we should reduce the concept of pain to be about suffering. If we do, we’ll lose the linguistic nuance needed to appreciate spicy food and other good pains.
Even more confusing, sometimes nociceptive pain signals can be generated internally in the brain in a way that’s similar to visual/audio/tactile hallucinations. Sometimes these pains come during periods of heightened anxiety or depression. And of course, because pain is perception, this pain is a true pain of the sort we’ve been talking about (though it might not influence SNS activity in the same way; I’m not sure). If we lump together pain and suffering, we may miss the distinction between people who are imprecisely talking about their suffering as “being hurt” and those who are experiencing pains that feel nociceptive.
Utopian Pain Language
Why does this matter to Utopia? In most of these essays I’ve focused on things like better password technology, why land taxes make sense, and how to effectively protect animals. These are things that can be pointed to outside the mind, examined collectively, and optimized to produce a better world. But in my conception of Utopia the biggest change is not that people ride more trains or count in base six; it’s that people in Utopia are far more1 enlightened.
Enlightenment is an elusive property. It’s hard to talk about using the words and concepts that are common in 2022 English. Enlightenment happens in the mind/soul, and is thus fairly invisible. It usually takes knowing someone a long time and having deep conversations with them to notice that they’re living a different kind of life, and have an inner world that’s lighter, freer, and less burdened than average.
Enlightenment is an explicit goal in Utopia. Much of education is about cultivating wisdom in the young (and old) so that their spirits might be more free. And as part of this pursuit of enlightenment, Utopia prioritizes self-knowledge. Practices of deep introspection and meditation are fostered and encouraged in all people, especially teenagers/young adults. Journals are widely considered sacred, with strong taboos against spying. And, relevant to the discussion of pain, language and concepts are shaped around helping people better understand their experiences.
In Utopia it is common knowledge that pain is not suffering, just as neither of those are grief. Words are used precisely when possible, and confusion is flagged when someone can’t introspect clearly enough to distinguish.
When Utopian doctors assess pain, they do so to understand what’s going wrong in the body, asking more about location and quality of pain than simply whether it hurts and how much. Painkillers are widely accessible and are given out liberally to those who ask for them, but it is not assumed that just because someone is in pain they want that pain gone. Heavy-duty painkillers that can be abused (i.e. opiates) are available to those with a license that indicates they can be trusted not to hurt themselves by falling into addiction. Those without a license can also easily get heavy-duty painkillers, albeit with more tracking systems in place to ensure safety. Doctors are trained to respect patients’ self-reports, and to step away from biases that might lead them to cruelly invalidate other’s experiences.
When Utopians attempt to measure pain they use physiological signs along with self-reports that involve specific dimensions and reference points along the spectrum. Brain-scanning machines are also occasionally used, especially for research purposes. One of the most common instances where measuring pain in this in-depth way is done is as part of a Utopian trying to understand their mind/body/experience, especially in contrast to others. It is common for Utopian teenagers (especially boys) to try and prove how tough they are by engaging in scientific studies of how they process pain.
Spicy foods, like sad movies and scary roller-coasters, are common in Utopia.
I greatly enjoyed an idea presented in Dear Hank and John #414: Tell Me What Your Pain Sounds Like, in which Hank Greene suggests using a "pain scale" that's not in numbers or words, but rather just *sounds.* Saying my pain is like [screeech] has an immediate qualitative distinction from [AUGHGHGHG]. I'm not sure it actually works as a full-on replacement, but it's a cool thought.