There Are Many Ways To Have A High Pain Tolerance… Pain Scales, Desensitization, and Functional Pain Tolerance
Defining Pain
There is no one way to define pain, but for the purposes of this post, we will be considering pain to be signals your body interprets as a marker of physical damage regardless of the actual physical harm.
This definition includes all forms of physical and neurological pain such as:
-CRPS
-Fibromyalgia
-Arthritis
-Migraine
-Neuropathy
-Cuts, burns, broken bones
Etc.
But excludes pain that you can differentiate as emotional such as:
-Heartbreak
-Grief
-Depression
-Loneliness
But includes mental health-based pain if it corresponds to a physical symptom for example:
-Chest pain during an anxiety attack
-Psychosomatic pain
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Pain Is Subjective
All pain is subjective. There is no way to determine pain besides asking the person in pain what they are feeling. While we can try to ask better questions to get a better idea of what they are feeling there is no way to know what someone else's pain feels like. There is an entire field, philosophy of mind that places large focus on these "qualia" or subjective sensations that I highly recommend reading up on if interested in this problem.
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Mental Pain Tolerance
Because this post explicitly excludes mental pain in our definition I wanted to note that this doesn't mean mental pain tolerance doesn't exist. It is just exceptionally hard to discuss and measure because of the lack of studies and descriptors for mental pain.
But just as people with chronic pain are able to function at higher levels than a normal person suddenly thrown into their everyday pain long-term depression, anxiety, PTSD, BPD, and so on have developed more resiliency to the horrible emotions they face on a daily basis.
One way this can be observed is how many patients with chronic anxiety perform really well in emergencies. They are used to operating when anxious so they can do it more effectively than people who do not know how to think straight when they are anxious.
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Pain Tolerance
When we talk about pain tolerance we often mean many things that each related differently to the pain we are experiencing. The three I will explore here are:
Relative Pain Skewing
Desensitization and Dissociation
Functional Pain Tolerance
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Relative Pain Skewing
"If 10 is the worst pain imaginable"
The answer to this question is biased because there are many levels of unimaginable pain that raise the top of the scale for those who have experienced more severe pain in the past.
This sort of pain tolerance is really not pain tolerance at all, in the sense that how you answer a question doesn't change how much pain you are in. Yet this is what most doctors think of when they think of pain tolerance.
Pain scales that attempt to solve this issue are numerous including the McGill Pain Index which attempts to give numbers based on relative pain, chronic pain scales that try to capture the adjustment between a chronic pain persons 10 and a normal person, and scales that try to find "objective" benchmarks like medication necessary to alleviate pain. Because of the subjective nature of pain no single scale can capture the experience of pain.
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Pain Desensitization & Dissociation
Allydonia and CRPS are by this definition conditions arising from high sensitization to stimuli such that even tiny sensations produce large amounts of pain. In this way, they can be considered the effect of low pain tolerance.
But these patients usually have extremely high pain tolerance by the other two metrics.
In contrast, patients with depression or PTSD may dissociate easily and therefore not react strongly to bodily harm.
Doctors who subscribe to this theory tend to push CBT, meditation, and other "desensitization" techniques on patients with chronic pain. While these can be helpful to some patients, failing to also include other definitions of pain tolerance can be extremely traumatizing to patients or lead to pushing them far beyond acceptable limits.
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Functional Adjustment To Pain
This is our outward tolerance towards pain.
Most commonly what chronic illness patients mean when they say high pain tolerance, functional adjustment to pain is being able to operate and look coherent when you are actually in large amounts of pain. This pain tolerance is the most important for doctors to understand about chronic illness patients because without this understanding they will be unable to accurately asses a patient's symptoms.
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How to express different types of pain tolerance:
"My pain scale is skewed by my past experience with _____. A broken arm (or other referenceable events) would be x/10 for me."
"I am very desensitized to pain so my nervous system doesn't react strongly to most things."
OR
"My nervous system is overactive and even small amounts of stimuli are extremely painful to me."
"My everyday pain level is ___ so I function like a normal person at that level."
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Misunderstandings
Misunderstandings occur when patients and doctors are using different definitions of pain tolerance. The most common struggle is differentiating between desensitization and functional pain tolerance.
Doctors generally say pain tolerance to mean how well a patient tolerates a known painful event compared to average. This means that they see patients with CRPS and Fibromyalgia as having low pain tolerance.
Patients generally say pain tolerance to mean how well they function at high levels of pain. This means patients with fibro or CRPS see themselves as having very high pain tolerance.
Doctors often take having a high functional pain tolerance to mean that patients are in less pain. This leads to widespread under-treatment of chronic pain.
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Defining Pain Tolerance
Now you could just define pain tolerance to be 1 thing. By our previous definition of pain, pain tolerance is the same as functional pain tolerance. How well a patient tolerates (functions) at a given level of subjective pain.
But that would mean that patients who experience little subjective pain during severe injuries do not have a high pain tolerance at all. This is not what most people mean when they talk about pain tolerance. Additionally, just switching definitions doesn't help chronic pain patients as a dismissive doctor would likely just believe they are lying about pain tolerance instead of believing they are lying about pain.
As such I believe it is more helpful for chronic illness patients and doctors to raise awareness of functional pain tolerance and desensitization/sensitization as their own specific terms than it is to try to redefine pain tolerance completely. Clarity of language is the necessary link to better understanding and less miscommunication.
Pain tolerance is not a single concept. There are multiple ways to have a high pain tolerance and it's important that doctors and patients understand each of them and do not make assumptions.
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September is Pain Awareness Month. People with Myalgic Encephalomyelitis aka MECFS are certainly no strangers to chronic pain. My additional pain diagnoses include chronic migraine, fibromyalgia, TMJ and cluster headache and I also suffer from joint pain and peripheral neuropathy due to Behcet's and recently bone pain from MCAS.
Pain Tolerance is often used when talking about severe pain and chronic illness. In particular, chronically ill people are forced to develop high ability to function with pain. We do not outwardly show the level of subjective pain we are in.
Because subjective pain is pain. It is my strong belief that no other definition is appropriate. Only the person in pain can say how much pain they are in. This is true of physical pain as we discuss here and it is also true for mental pain which I in no way mean to diminish.
The language we use to discuss qualia like pain is essential. We will never be able to truly know what it is like to be in someone else's body. But increasing our specificity of definition and description is the best way to try. And remember: you don't have to understand to be understanding. Often times the best thing you can say is "I cannot imagine what you are feeling." Because if you have never experienced that level of pain you cannot.
Medical gaslighting is awful. But it is not always intentional. Doctors Of Instagram please learn from the Spoonie Community so you can help Patients.
While I don't claim to be an expert on expressing pain tolerance, some phrasing I have found helpful is:
"My pain scale is skewed by my past experience with _____. A bad burn from the stove (or other referenceable events) would be x/10 for me."
"I am dissociating right now so I cannot gauge my pain well"
"I have severe sensory sensitivity to ___."
"I am experiencing allydonia (optionally add in my ____). Even the smallest touch is unbearably painful."
"My everyday pain level is ___ so I function like a normal person at that level."
"My everyday pain level is ___ so this sensation isn't registering as painful to me but I imagine a normal person would rate it x/10"
