What does a pain patient look like? Are you sure?

You can not see pain, and therefore you probably will not see pain avoidance. Some bright investigators are changing that.


McCracken LM, and Samuel VM.writing in Pain. 2007 Jan 18 have shown remarkable observatory skill in understanding what avoidance activity really is and how to recognize it.

The problem for pain subjects has always been that life can only be maintained for so long until pain begins to modify it. This change can become massive over time, yet still unrecognizable because some of the avoidance activity can bear an uncanny resemblance to normal behavior. Perhaps pretending to be jovial to hide suicidal ideations or giggling in embarrassment over pain is the most frequently discussed phenomena and we have written about that here elsewhere.

Less obvious, but perhaps more important is the almost mandatory pacing of activity in order that scarce energy resources can be allocated in a way that still permits life to go on. Severe pain is exhausting, as Buytendijk has pointed out.

Another problem is the failure by many clinicans to recognize avoidance for what it is. The person who might deeply desire to be out mountain climbing may be watching a mind numbingly boring television show as a type of avoidance. Anything which causes pain must be avoided, yet the resulting behavior may not have the obvious flags out that is IS avoidance. McCracken and Samuel have taken an important first step in characterizing avoiding and pacing, which are of course two very important aspects ot living with severe pain.

The authors say regarding the role of avoidance, pacing, and other activity patterns in chronic pain, “These data suggest that activity patterns are complex and multidimensional, and that avoidance appears to be the overriding process with regard to daily functioning. Moreover, avoidance patterns may be subtle, sometimes resembling healthy coping, and sometimes presenting along side patterns of high activity.”

You cannot say it any better than that. Pain therapists everywhere should look at their patients in a new light; or, better yet, just ask them. Pain patients know they are doing these things, and it may seem simply unavoidable.

Consider for example the CP patient with severe dysesthesis who cannot wear proper clothing. As one might expect, if such a person is out in winter in shorts and light t-shirt, passersby will comment. The response may be, “Oh, I burn from the touch of clothing more than I burn from cold.” This sounds so odd, the response will almost always be laughter. CP patients are odder than they seem. It is also odd that doctors have not simply asked the patients how they cope, instead of assuming that whatever behavior they observed was by choice on the patient’s part. For this new way of seeing things, we thank McCracken and Samuel. This is clinical medicine at its best.