"I feel like I'm being stabbed by a thousand tiny men": The challenges of communicating endometriosis pain

Visual reconstructions of endometriosis pain: An interdisciplinary visual methodology for illness representation

OBJECTIVES

Endometriosis is a chronic condition in which tissue resembling the endometrium grows outside of the womb, causing severe chronic pain. Research demonstrates the physical, emotional and quality of life impact on people with endometriosis, but pain is reportedly difficult to communicate, resulting in lengthier diagnosis. This work aimed to gain insight into the value of imagery production as a pain communication strategy through a novel synergy of psychological and linguistic/socio-semiotic approaches.

DESIGN

A qualitative, multimodal, participant-generated imagery study.

METHODS

Interpretative phenomenological analysis (IPA) and conceptual metaphor and metonymy analysis were utilized to examine visual representations of endometriosis pain. Data were collected in two focus groups with four and six women, respectively; all with a diagnosis of endometriosis, aged 25-40 years old (M = 34.5, SD = 4.2) and a mean diagnosis delay of 8.4 years (SD = 3.6).

RESULTS

The overarching theme across visual representations was 'Pain as Physical Violence' with 'colour as emotional representation', 'texture as sensory qualities' and 'materials as sensation' as sub-themes. These are realized through metaphorical and metonymical relations in both the visual representations as well as the accompanying linguistic representation of the process.

CONCLUSIONS

This study demonstrates the value of a creative mixed-methodologies approach to capture experiential aspects of pain and its impact that are not verbalized in linguistic accounts alone. This can facilitate a deeper understanding of one's pain, acting as a medium for therapeutic adjustment to occur, while facilitating effective and empathic patient-professional conversations surrounding pain.

"So It's Like a Painful Period?" Living with Endometriosis: My Journey

This essay details the author's personal process of being diagnosed with endometriosis, including her experience of medical gaslighting and societal attitudes toward "period pain." Many people who experience excessive menstrual pain report dismissive attitudes and/or trivialization of their symptoms, from both the public and health professionals. The author recalls conversations from throughout her diagnostic journey, which evidence the ingrained beliefs and attitudes of gendered observations of pain. Ultimately, the author contends that the "burden of proof" is with the patient, being forced to continually fight for their right to be heard in an archaic medical system. The people experiencing this condition are experts-by-experience, who are continually providing knowledge about endometriosis, and self-advocating to rewrite the societal narratives concerning menstrual pain. The goal of this essay is not to blame or cause discomfort, but rather to raise awareness and encourage everyone to talk more openly about menstrual related issues. The following prose is written as a first-person account of my experience with this condition, drawing on appropriate support from academic literature.

Sensing pain: Embodied knowledge in endometriosis

The article explores how sensations of pain are turned into embodied knowledge in endometriosis, a chronic gynaecological illness characterized by persistent, possibly paralysing pain. While previous studies have shown how people with endometriosis struggle to achieve accurate diagnosis and effective treatment, we examine the ways in which some of these difficulties are rooted in the complexities of embodied experiences of endometriosis pain and the challenges of translating the sensed patterns and shifts in pain into a language acknowledged within a clinical setting. Building on a phenomenologically inspired approach to chronic pain and drawing on interviews with people diagnosed with endometriosis in Finland, we examine how our interlocutors use their embodied sensations of pain to adapt to the evolving biomedical and lived surroundings in which their pain is evaluated and managed. The analysis shows how living with chronic pain involves constantly attuning to the multitude of symptoms as well as developing personal strategies of communicating sensations of pain to gain medical recognition and care. We argue that while the lived complexities of the body with endometriosis may fall outside the scope of medical practices of measuring, such complexities nevertheless require medical acknowledgment and careful attention.

The experience of pain and its ontological modelling from a philosophical point of view: Phenomenological description and ontological revision of the McGill Pain Questionnaire

The aim of the article is to identify, on the basis of the phenomenological and ontological analysis of the experience of pain and the ways in which this experience is expressed in natural language, an ontological modelling of the language of pain and, at the same time, a revision of the traditional version of the McGill questionnaire. The purpose is to provide a different characterisation and an adequate evaluation of the phenomenon of pain, and, consequently, an effective measure of the actual experience of the suffering subject.

The Language of Pain in the Hypermobile Ehlers-Danlos Syndrome: Metaphors as a Key to Understanding the Experience of Pain and as a Rehabilitation Tool

Ehlers-Danlos syndromes are a heterogeneous group of Heritable Connective Tissue Disorders characterized by joint hypermobility, skin hyperextensibility, and tissue fragility. Among the different types, the hypermobile Ehlers-Danlos syndrome is the most frequent and includes generalized joint hypermobility as the major diagnostic criterion. Joint hypermobility in hypermobile Ehlers-Danlos syndrome is often associated with pain that does not always allow the use of effective pain-reducing treatments. Patients with hEDS constantly describe their pain in detail. Eighty-nine patients with hEDS diagnoses were recruited and evaluated. They were asked to describe their pain in writing. The texts were examined through Linguistic Inquiry and Word Count. Correlational analyses were conducted between pain perception and language. A comparison of high/low pain perception and the quality of metaphors was carried out. The results showed that language quality varies depending on how much pain is perceived. The greater the pain is perceived, the lesser the positive effects and the greater the negative effects and dehumanizing metaphors are being used. Moreover, a greater pain seems to be related to a verbal experience of greater isolation and less self-care. In conclusion, the use of metaphors is a useful tool for examining illness experience and may help clinicians in the rehabilitation program.

Endometriosis pain and epistemic community: Mapping discourses in online discussions among sufferers

We focused in this study on how the private experience of pain is made public through online discourse by sufferers of endometriosis. Empirically, we analyse two highly active endometriosis communities on the online social platform Reddit. Drawing on a mixed-methods design, we leverage large-scale social data, and a combination of computational and interpretive approaches for text analysis to study the role and shape of interactions relating to 'pain' for the formation of epistemic community online around endometriosis. The dataset, consisting of 70,817 forum posts and comments, was collected in May of 2021. Our study shows how pain becomes meaningful for endometriosis sufferers in relation to a multidimensional discursive space of words and concepts that are used to express it. Pain was frequently disguised, underplayed or hidden altogether, from fears of misunderstanding, medical dismissal, and embarrassment. Clearly, peer validation can be found in the relative anonymity of Reddit discussions. While the experience of pain is individual and subjective, when communities share similar experiences this reinforces patient ownership of the pain, which in turn supports the epistemic authority of the patient collective. A detailed understanding of how and why pain is discussed in online spaces has much to contribute more broadly to discussions of experiential collective knowledge production among individuals with endometriosis and other chronic illnesses.

Clinician experience of metaphor in chronic pain communication

OBJECTIVES

This study investigated clinician experience of patient use of metaphors in chronic pain communication.

METHODS

Interviews were conducted with eighteen Australian clinicians working with chronic pain patients, age range 26-64 years (M=46.6), 50% female, experience working in chronic pain ranging from 2 to 27 years (M=11.16).

RESULTS

Thematic Analysis yielded four key themes: Metaphor as communicative tool, Metaphor as clue, Metaphor as obstacle, and Metaphor use in treatment. Clinicians identified metaphor as an important tool for patients to communicate their pain experience, whilst acknowledging that it could at times be unhelpful to patients. Metaphor was seen to contain useful information for clinicians and possess utility in assessment and treatment.

CONCLUSIONS

Metaphors play a significant role in chronic pain consultations, enabling clinician insight into pain type, psychopathology, and patient pain understanding. Metaphor in treatment phases may be underutilised. Clinicians should encourage patient metaphor use in chronic pain communication.

What is the evidence of effectiveness of non-pharmaceutical, non-surgical, biopsychosocial interventions for body image and pain management in individuals with endometriosis? A systematic review

Aim:

To identify and review the success of non-pharmaceutical, non-surgical biopsychosocial interventions in individuals with endometriosis, in managing pain and improving body image.

Methods:

Cochrane, EBSCO, IBSS, NICE, Open Grey, OVID, Proquest, Scopus and Science Direct were searched in April 2021, using inclusion and exclusion criteria.

Data collection and analysis:

Five randomised control trials, and one controlled clinical trial resulted from the search. Study quality was assessed using the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool. Studies were synthesised by intervention type, into physical only, and physical and psychological.

Results:

Across the six papers, 323 participants were recruited, through medical records or self-referral, and treatments largely administered by specialist practitioners. From the EPHPP quality assessment,2 weak quality papers, and four moderate quality papers found improvements to pain, with large effect sizes in four papers. No studies used established body image measures to examine intervention effects on body image, and all lacked health psychology theoretical basis. There were common issues in selection bias, confounders and blinding.

Conclusion:

Without gold-standard methodology, evidence of effectiveness cannot be concluded. However, there is promising rationale if these issues are addressed.

'I don't live in my body somehow': metaphorical talk in women's accounts of vaginismus and dyspareunia

Vaginismus and dyspareunia are common sexual difficulties; they often take a long time to be appropriately diagnosed, and their origins remain unclear. This paper examines the metaphors used by women to describe bodily experiences associated with vaginismus and dyspareunia, and highlights the contribution this form of analysis can make to the study of sexuality and sexual difficulties. A secondary analysis was conducted on primary data from biographic interviews exploring women's experiences of sexual pain and difficulties with sexual intercourse. Metaphor analysis was used to analyse a data subset of 28 interviews translated from German into English. Metaphorical concepts lying at the basis of the metaphors used were identified and grouped into three themes: characterisation of sexual difficulties; split body and 'self'; and sexual agency and objectification. Results are discussed with in the context of literature regarding the function of metaphors and the utility of metaphor analysis for research, and healthcare research and interventions more generally.

The Utility and Impact of the Painful Periods Screening Tool (PPST) to Improve Healthcare Delivery for People with Symptoms of Pelvic Pain

The objective of this study was to evaluate the utility and impact of the Painful Periods Screening Tool (PPST) to improve healthcare delivery for people with symptoms of pelvic pain. The design of this study was a survey study. After IRB approval, patients aged 18-55 years with self-reported pelvic, abdominal, or lower back pain before, during, or after menstrual periods were invited to participate in the study from September 2020 to June 2021. Participants filled out the PPST questionnaire on the day of their Johns Hopkins clinic visit and the follow-up questionnaire 1-14 days after the clinic visit. Demographics and duration of pain were assessed, and participants who completed the PPST questionnaire were sent a follow-up questionnaire to assess utility and impact of PPST. Of the 1352 patients who met study eligibility, 1000 participants responded to both questionnaires. Most subjects (82.9%; 95% CI: 80.4-85.2%) reported having severe pelvic/abdominal or lower back pain during menses. Nine hundred fifteen participants (91.5%; 95% CI: 89.6-93.2%) reported that if given regularly, the PPST would help women discuss their pain symptoms with their healthcare provider. Six hundred seventy-eight participants (67.8%; 95% CI: 64.8-70.7%) reported that the PPST helped them initiate a conversation about their symptoms. Seven hundred seven participants (70.7%; 95% CI: 67.8-73.5%) were more comfortable discussing symptoms of pelvic pain with their provider after filling out the PPST. These findings support the utility of PPST as an endometriosis screening tool and suggest that this tool facilitated communication between patients and providers about pain symptoms.

How Women Suffering from Endometriosis Disclose about their Disorder at Work

Endometriosis is a stigmatized health disorder that impacts approximately 10% of the female population around the world and is characterized by severe physical and psychological symptoms. Through the interpretive perspective, this study investigated how women with endometriosis disclose about their disorder in the workplace. Potential participants were recruited using Reddit and Facebook. Participants (N = 119) completed an anonymous, online, open-ended questionnaire. Open-ended responses were analyzed using thematic analysis. Five themes emerged related to how endometriosis patients disclose about their disorder at work: 1) frequency of communication 2) level of openness 3) type of content shared 4) preferred setting for conversations and 5) preferred conversational partner. Furthermore, the findings revealed that disclosure about endometriosis is significantly impacted by workplace environment. These findings are contextualized by the theoretical framework provided by the disclosure process model. Overall, this study offers a starting point for deeper empirical investigation of mechanisms influencing disclosure and informs future research directed toward developing interventions that may enable organizations to better accommodate affected employees.

Unravelling dystonic pain; a mixed methods survey to explore the language of dystonic pain and impact on life

PURPOSE

Dystonia is a neurological disorder characterised by involuntary muscle contractions. Pain is the primary non-motor symptom, and limited studies have investigated how dystonic pain is experienced. This study aimed to investigate how people with isolated dystonia describe their pain and compare across subgroups of dystonia.

METHODS

Anonymous online survey via social media asking participants to describe their pain in their own words, complete the McGill Pain Questionnaire (MPQ), and answer demographic questions. Thematic analysis identified common themes and frequencies were calculated for demographic and MPQ data.

RESULTS

One-hundred and sixty-five respondents were included (mean age 51 years, 85% female). Thematic analysis identified four major themes "Physical sensations", "Temporal features", "Destruction", "Impact on life" with several sub-themes. The most chosen MPQ descriptor was "exhausting" followed by "tight," "sharp," "pulling," and "aching". The most common descriptors showed similar prevalence across subgroups of dystonia.

CONCLUSION

As no objective tests for pain exist, pain sufferers must use language to describe their pain experience. People with isolated dystonia used sensory words combined with metaphorical language to detail temporal features of pain, as well as destructive internal battles or feelings of external forces acting upon them, and the significant toll pain has on everyday life. Implications for rehabilitationPain is a common and debilitating non-motor symptom for people living with dystonia and should be discussed in a persons treatment plan.Pain sufferers use language to discuss their pain experience with others and report they don't feel well understood by others including health professionals.People with dystonic pain commonly described physical sensations, temporal features, destructive forces, and the impact on life caused by their pain.Findings suggest the experience of pain with dystonia is varied and better pain management options for people with dystonia are needed.

Communicating Endometriosis Pain in France and Australia: An Interview Study

Endometriosis is characterized by persistent, fluctuating pain associated with menstruation, a biological function which is socially invisible. The degree and quality of pain cannot easily be measured, observed, or documented. Difficulties in communicating pain pose particular challenges when seeking diagnosis and support from health professionals. In this paper we explore the experiences and characterization of pain by thirteen Australian and thirteen French women with endometriosis. Data were collected through semi-structured interviews using a life-history approach to illness symptoms, diagnosis and treatment. We explore the experiences of women with endometriosis in two phases: from onset of symptoms to seeking advice from a clinician, and from first consulting a clinician to receiving a diagnosis. On average, initial pain symptoms were identified 2.1 years before consulting a health practitioner, after which women reported pain symptoms 8.5 years prior to diagnosis; that is, the time between consulting a clinician and receiving a diagnosis was almost four times the period between experiencing symptoms and consulting a doctor. Pain was often “made real” to doctors by findings consistent with endometriosis on ultrasound and MRI, mostly used in France, or laparoscopy, the predominant diagnostic tool in Australia. No woman described her practitioner using standardized pain assessment tools. Thus, the validation of pain relies largely on disease visibility and the clinician-classified degree of severity rather than self-reported grades of pain or impact on activities of daily living. The invisible and enigmatic pain of this chronic women's disease remains difficult to communicate to doctors, and the recognition of severe pain is often key to timely diagnostic procedures. Clinicians need to be more proactive about severe pain related to menstruation, taking into consideration women's individual circumstances, and maintain a high index of suspicion of underlying endometriosis as a condition characterized primarily by pain.

Addressing Challenges in Endometriosis Pain Communication Between Patients and Doctors: The Role of Language

Introduction: In the context of the complex medical, social, and economic factors that contribute to endometriosis diagnosis delay and its consequent impact on quality of life, this report focuses on patient-practitioner pain communication and examines the role of language in doctor-patient communication. Our study explored what patients and doctors consider challenging and effective in endometriosis pain communication. It further examined what commonly used metaphors by patients could be suggestive, or not, of endometriosis to doctors.

Method: A United Kingdom-based qualitative (open-ended question) survey with women with endometriosis (n131) and semi-structured telephone interviews with general practitioners (GPs) (n11). Survey and interview data were analyzed thematically.

Results: Both women and GPs reported the Numeric Rating Scale (NRS) to be insufficient as a standalone tool for communicating endometriosis related pain. Both also found descriptions of the quality, location, and impact on daily life of pain to more effective means of communicating pain symptoms. When presented with common metaphorical expressions surveyed women used to describe their pain, not all GPs recognized such metaphors as indicative of possible endometriosis. Further, some GPs reported some of the expressions to be indicative of other pathologies.

Conclusion: Findings reveal the importance of language in pain communication and the need for additional tools to help women and doctors find the most effective way to communicate the experience and elicit appropriate investigative care. They also show the need for further investigation into how metaphor can be effectively used to improve patient-practitioner communication of endometriosis related pain.

Constellations of pain: a qualitative study of the complexity of women's endometriosis-related pain

INTRODUCTION

Prior research into endometriosis-related pain has focused on specific aspects of the pain experience such as cyclical pain, emotional aspects of pain and certain types of pain such as dysmenorrhea and dyspareunia. However, research has paid less attention to the diversity and complexity of women's pain experiences, which can lead to failure to recognise some symptoms as part of endometriosis and poor symptom management.

METHODS

We conducted qualitative semi-structured face-to-face interviews with 20 women in the United Kingdom recruited from an endometriosis self-help group with a diagnosis of endometriosis via laparoscopy. A topic guide framed questions around experiences of pain. Interviews were audio-recorded and transcribed verbatim. Transcripts were analysed using inductive thematic analysis.

RESULTS

Women experienced multiple types of pain that they felt were caused by endometriosis and affected many different parts of the body including bowel, bladder, lungs, kidneys, nerves, upper body, lower limbs and head. These pains consisted of different conceptual categories: type, pattern and intensity. These categories came together to create a complex, interrelated experience for each individual that we termed 'constellations of pain' because each woman had a complex set of pain categories and no two individuals appeared to have the same pain experience.

CONCLUSION

The complexity and diversity of endometriosis-related pain found in this study has implications for improving diagnosis, medical and non-medical pain management and improving the clinical encounter between women and healthcare professionals.

Development of a visual, patient-reported tool for assessing the multi-dimensional burden of endometriosis

OBJECTIVE

Inadequate communication about endometriosis symptom burden between women and healthcare providers is a barrier for optimal treatment. This study describes the development of the EndoWheel, a patient-reported assessment tool that visualizes the multi-dimensional burden of endometriosis to facilitate patient-provider communication.

METHODS

Assessment questions for the tool were developed using an iterative Delphi consensus process. A consensus phase included additional practitioners and specialists to broaden perspectives and select revised statements. Semi-structured qualitative interviews were conducted with 13 women with endometriosis to assess the scoring and content of the measures.

RESULTS

Symptoms included in the tool were pelvic pain, vaginal bleeding, bowel/bladder symptoms, energy levels, fertility, impact on activities, emotional and sexual well-being, and self-perceived global health. Additional life impact areas included relationships, social and occupational activity, and self-perception. The 13 interviewees completed the tool in approximately 5-6 min (range 4.0-7.5 min). Most participants (92%) perceived that the tool would enable better patient-provider communication, including addressing symptoms and areas of impact not normally discussed during office visits.

CONCLUSION

Similar to visual circular tools used in burden assessment of other chronic diseases, the tool may facilitate improved patient dialogue with providers around endometriosis treatment goals and options.

Understanding Youth's Lived Experience of Anxiety through Metaphors: A Qualitative, Arts-Based Study

Living with anxiety can be a complex, biopsychosocial experience that is unique to each person and embedded in their contexts and lived worlds. Scales and questionnaires are necessary to quantify anxiety, yet these approaches are not always able to reflect the lived experience of psychological distress experienced by youth. Guided by hermeneutic phenomenology, our research aimed to amplify the voices of youth living with anxiety. Fifty-eight youth living with anxiety took part in in-depth, open-ended interviews and participatory arts-based methods (photovoice and ecomaps). Analysis was informed by van Manen's method of data analysis with attention to lived space, lived body, lived time, and lived relationships, as well as the meanings of living with anxiety. Youth relied on the following metaphors to describe their experiences: A shrinking world; The heavy, heavy backpack; Play, pause, rewind, forward; and A fine balance. Overall, youth described their anxiety as a monster, contributing to feelings of fear, loss, and pain, but also hope. The findings from this study can contribute to the reduction of barriers in knowledge translation by encouraging the use of narrative and visual metaphors as a communicative tool to convey youth's lived experience of anxiety to researchers, clinicians, and the public.

Parallel worlds and personified pain: A mixed-methods analysis of pain metaphor use by women with endometriosis

OBJECTIVES

Endometriosis is a long-term condition in which endometrial-like tissue grows outside of the womb, causing intense chronic pain. Previous work has demonstrated the physical and emotional impact on women who live with endometriosis, and metaphors can play an influential role in communicating the experience of pain, but there exists little understanding of the role and impact of such language for women with endometriosis.

DESIGN

A qualitative, semi-structured interview design.

METHODS

Conceptual Metaphor Theory (CMT) and Interpretative Phenomenological Analysis (IPA) were utilized in a mixed-methods study to examine the prevalence, types, and meaning of metaphors and metaphor use as a health communication strategy. Twenty-one women aged between 23 and 53 years (mean age 36.1 years) with endometriosis took part in audio-recorded interviews.

RESULTS

The women reported experiencing symptoms for an average of 11 years before receiving a formal diagnosis of endometriosis, and the mean age of diagnosis was 27.6 years. Seven distinct conceptual metaphors were identified in 221 metaphorical expressions used across all participants, with most common ones referring to pain as physical properties of elements such as temperature and pressure, physical damage, and an external attacker. IPA revealed three themes pertaining to the feeling of vulnerability and helplessness, pain being incomprehensible, and a drive to manage and conceal pain simultaneously.

CONCLUSIONS

This study demonstrates the power of language in facilitating understanding and empathy in the listener, alongside the challenge of communicating endometriosis pain to others. Imagery-based techniques may assist in adaptation to, interpretation, and acceptance of pain to reduce pain-related distress.

'Barbed wire wrapped around my feet': Metaphor use in chronic pain

Objectives

As there is no objective test for pain, sufferers rely on language to communicate their pain experience. Pain description frequently takes the form of metaphor; however, there has been limited research in this area. This study thus sought to extend previous findings on metaphor use in specific pain subgroups to a larger, heterogeneous chronic pain sample, utilizing a systematic method of metaphor analysis.

Design

Conceptual metaphor theory was utilized to explore the metaphors used by those with chronic pain via qualitative methodology.

Methods

An anonymous online survey was conducted which asked for the descriptions and metaphors people use to describe their pain. Systematic metaphor analysis was used to classify and analyse the metaphors used into specific metaphor source domains.

Results

Participants who reported chronic pain completed the survey (N = 247, age 19–78, M = 43.69). Seven overarching metaphor source domains were found. These were coded as Causes of Physical Damage, Common Pain Experiences, Electricity, Insects, Rigidity, Bodily Misperception, and Death and Mortality.

Conclusions

Participants utilized a wide variety of metaphors to describe their pain. The most common descriptions couched chronic pain in terms of physical damage. A better understanding of pain metaphors may have implications for improved health care communication and provide targets for clinical interventions.