Some people say that life is pain. Those people are optimistic: life isn’t pain, it’s pains, plural – tooth pain, back pain, breakup-pain, the pain of watching your parents grow old and die, the pain of downwardly adjusting your expectations for life, stomach pain and sinus pain, pain you can’t quite trace to any one single source – a thousand different strains of this stuff, some not-insignificant percentage of which you’ll almost certainly experience before your (likely painful) death.
But which of these pains – limiting things to the physical – hurts the worst? To find out, for this week’s Giz Asks we reached out to a number of pain doctors and researchers, whose answers twisted and problematised the very concept of pain, and the function pain serves biologically.
David C. Yeomans
Associate Professor, Anesthesiology, Perioperative and Pain Medicine, Stanford University
The type of pain that quite a few people consider the worst is something called trigeminal neuralgia.
The trigeminal nerve provides all the pain information from the head and the face. If you have tooth pain, face pain, eye pain, whatever, it’s coming in through this trigeminal nerve. And what happens in some people is that a blood vessel gets dilated or hypertrophied, and it pushes against the trigeminal nerve. Often, patients describe the resultant pain as being like a bolt of lightning hitting the side of their face. The attacks don’t last long – maybe up to two minutes – but someone might have a hundred of these in a day, triggered by very mild stimulation: a puff of cold wind, for example, or brushing your teeth, or shaving. A lot of these time people with trigeminal neuralgia stop brushing their teeth for that reason, and so they get teeth problems.
Pain specialists use something called the numeric pain scale to rate a patient’s pain. The scale goes from 0-10, and virtually everyone with trigeminal neuralgia will rate their pin as a 10 – the worst pain imaginable.
It is to some extent treatable: there is a drug called tegratol that was designed for epilepsy, and it helps many people, at least at first. But it has side effects that people hate: it kind of lowers your IQ, and makes you spacey and somewhat dysphoric.
There’s are also two different types of surgeries that some people end up getting. In one of them, they actually go in and open the skull and put in a little pillow between the nerve and this blood vessel. The release is usually immediate, but something like 50% of patients eventually need to get it again. Or the patients will get very focused ionising radiation – targeted towards a site that’s deep in the body, frequently in the head – and kind of cook the system. That usually helps too, but it takes a while to work.
Many mothers will say that childbirth is the worst pain they’ve ever experienced, and it usually is. But someone whose had a baby, and then has trigeminal neuralgia some point later in their life, will tell you that the trigeminal neuralgia is worse.
“Virtually everyone with trigeminal neuralgia will rate their pin as a 10 – the worst pain imaginable.”
Principal Investigator at the PAIN Neurobiology Research Group and Professor of Brain and Behavioral Sciences at the University of Texas, Dallas
I think that the worst kind of physical pain is the type that you feel you cannot control. This is a huge issue with people with intractable chronic pain, as the pain often was originally a result of an injury that has long-since healed but there is no sign of the pain relenting.
One common way this sort of chronic pain can happen is when someone has a car accident and breaks a limb. That traumatic injury may also crush a nerve and the nerve crush causes neuropathic pain. Everything heals but the injury to the nerve causes neuropathic pain that never resolves
Another, increasingly common example is cancer chemotherapy. A patient gets chemo for cancer and the chemo kills the cancer, but the toxicity of the chemo is a neuropathy that does not go away after the chemo stops. The patient is cured of cancer, thankfully, but has burning pain in her hands and feet for years after from the chemo.
This kind of pain is devastating to quality of life and basic function. Few people realise that between 7-10% of the population suffers from this type of “high-impact” chronic pain. Unfortunately, this type of pain is also extraordinarily hard to treat.
“Between 7-10% of the population suffers from this type of ‘high-impact’ chronic pain.”
Co-Director, Comprehensive Pain Management Clinic, University of Arizona College of Medicine
Many people, when they meet certain criteria and we’re not able to manage their pain, fall into the category of fibromyalgia. And fibromyalgia is notoriously hard to manage. Not impossible – just hard. The symptoms can vary from person to person – diffuse pain, primarily, but also depression.
But from a physical standpoint, the worst pain is probably pain without a known diagnosis – when you do all the tests, and they all come out negative.
Psychology plays a significant role in this kind of pain – and psychological issues can often manifest as pain, too. One way to treat it is to open patients up to the idea that their pain might be coming from another, non-physical source. Another is to get psychiatrists involved in the treatments. But it’s hard to treat something when you don’t know what to treat.
“From a physical standpoint, the worst pain is probably pain without a known diagnosis.”
Senior Research Scientist and Group Leader at Neuroscience Research Australia and the current chair of the back pain group of STREAM Health
Well, it depends on who’s experiencing it.
Often when people think about the worst kind of pain, they expect to hear something like “getting a needle pushed underneath your fingernail” – something traumatic. Those kinds of things can be very painful, but they often don’t last very long, and we tend to measure pain by both intensity and duration. It’s difficult for us to then say that something like that is more painful than chronic back pain, for instance.
But trying to determine the worst kind of pain also depends on what we think pain is, and what we think pain’s purpose is.
The purpose of pain is to warn us about something which is threatening to our body: nerve cells are stimulated, and they warn us that there’s a threat to our boy, and they fire up into the spinal cord and up into our brain, and then our brain has to interpret those, on the basis of context.
A few years ago, there was a navy diver in Australia who was doing some practice dive in the Sydney Harbour, and as he was coming up from one of them he felt a piece of driftwood bang against his sides and against his leg. I annoyed him a bit, so he pushed it away. But he realised he couldn’t use his hand. And then he thought: “Well maybe it’s not driftwood.” And then he looked down and saw that his whole leg was inside a shark’s mouth. His hand was inside the shark’s mouth as well. And he said that once he saw that, he experienced the most intense pain that you could possibly imagine.
His nerve endings were screaming danger! into his brain, but he still didn’t think he’d been bitten by a shark. That tells us a little bit about pain: how it’s related not just to what’s coming in from your body, but to how your brain processes that signal. If it processes that signal as very threatening, then that will determine the amount of pain that you experience.
Most of think that pain tells us about what’s happening in our bodies – people who have back pain, for example, might think that they have a disc slipping, or that their vertebrae are cracking. But actually, the pain they’re experiencing is because they feel unsafe, and often a lot of these thoughts feed into that to make the pain worse. And that’s sort of where we are in modern pain science, in terms of thinking about why people experience pain for a long time when it should’ve gone away: it’s not that they’re in any danger, it’s that their brains have changed the processing of the information.
“Actually, the pain they’re experiencing is because they feel unsafe, and often a lot of these thoughts feed into that to make the pain worse.”
Assistant Professor and Assistant Director of the Center for Advancement in Managing Pain at the University of Connecticut School of Nursing
In my opinion, the ‘worst’ kind of pain is chronic pain. Acute pain, say from a broken bone, or labour/childbirth, or post-surgery pain, can be severe, but acute pain typically offers up information about the condition of the body and is transient, meaning that when the injury or damage resolved it will go away.
Chronic pain, on the other hand, is pain that doesn’t resolve when the injury or insult has healed. It is much more medically difficult to treat – opioids and other traditional medications are largely ineffective and chronic pain is associated with high rates of depression, anxiety and disability along with reduced quality of life. Acute pain is unpleasant (even extremely so), but chronic pain is about suffering.
Director of Sensory Science at the Chronic Pain and Fatigue Research Center at the University of Michigan in Ann Arbor, where he studies the brain mechanisms of chronic pain
This question seems relatively simple and straightforward, but in fact it’s quite complex, and there is no one correct answer.
Pain is subjective, and how pain is experienced differs greatly between individuals. Something that may be painful to one person may not be painful (or as painful) to another. Therefore, the most accurate answer to the question ‘What is the worst type of physical pain?’ may be that it depends on whom you ask.
We see these individual differences when we measure pain sensitivity in the laboratory. For instance, many individuals find that immersing their hand in ice cold water is very painful and withdraw it almost immediately, but others do not and keep their hand underwater for much longer.
Many factors contribute to this variability, including genetics, functioning of the nervous system, history of drug use and previous painful experiences, as well as societal and cultural expectations. The context in which a painful event occurs is also critical, as context helps define the meanings and consequences associated with having pain. For example, labour pain and pain from a traumatic accident can both be severe, yet the former is an anticipated aspect of childbearing and typically associated with a positive outcome, thus making it more tolerable and less unpleasant than the latter in most cases.
Individual differences aside, certain characteristics have been identified which amplify the pain process. Pain that is prolonged, unescapable, and unpredictable is associated with more suffering and a lower quality of life than pain that is brief, avoidable, and anticipated. For these reasons, poorly-controlled chronic pain that can last many years, such as that associated with arthritis or nerve damage, and the pain associated with torture, are examples of what many would consider the worst types of pain.