If we talk with patients, metaphors are very often used. To descibe actions of a drug, or to describe qualities of pain.

Pain: red hot or tight band?

In an article on metaphors, from 2003, the authors, Geraint Fuller and Tom Hughes from the Department of Neurology, Gloucester Royal Hospital, Gloucester, UK, made a nice contribution related to pain, we would like to quote:^[1]

Patients often use analogies when describing pain that we will only briefl y consider. Common spontaneously generated analogies in neurology clinics are face pain ‘like a red hot needle’ and headaches ‘like a tight band’ or ‘vice’. We associate the first with neuralgic pain, typically trigeminal neuralgia, and the last two with tension-type headache. These are descriptions that intuitively carry a high level of diagnostic information. However, the range of analogies used in describing pain is very wide, and often complicated as well, so often they do not provide the same level of diagnostic force.

We have all seen patients who give a detailed report that fleshes out the quality of the pain in astonishing detail – ‘the pain is like a man drilling behind the bridge of my nose, who sometimes stops and hits my eye with a pick axe’. Such analogies often convey a powerful description of the patient’s experience and as such help in syndromic diagnosis. Pains are also often likened to common experience. For example, likening pain in the hands to the pain ‘you get in your fi ngers when they are warming up after being in ice-cold water’ or ‘after you bang your fi nger with a hammer’. These too flesh out descriptions although it is not clear whether they increase diagnostic discrimination. 

The Human Body as a Car: mechanistical and defaitistic

An other metaphor presented by the authors is clearly well recognized and is a part of our heritage from dela Mettrie, l'homme machine...We feel this metaphor creates more problems than that it helps with solutions. It decribes our body as a mechanical device, and no neurogenesis or compensation mechanisms fits in. Even more sad, it reinforces the opinion of many patients, that we as doctors need to quickly fix the problem, taking all the responsability out of their hands... Judge for yourself!

..‘If your car is not working properly you take it to the mechanic who opens the bonnet to look inside and see if there is anything wrong, but on fi rst inspection everything looks fi ne. You can even drive your car away but it still doesn’t seem to be working properly. But really what needs sorting out is the tuning. You are like that car. The doctors have had a look and everything is as it should be, but you still feel things are not right. You need “tuning”’. The enthusiasm with which the audience received this analogy highlights its power.

Using a metaphor in helping the patient

Because metaphors can have a very strong impact on patients, metaphors also can be used in helping the patient to cope with the pain, or letting the patient understand that the right sollution is not always directly available, and is a search. Here is one of our own metaphors relating to the latter:

Digging for diamonds in a diamond mine can give you a fortune, when you find the right size and and the right clarity. The place to digg first is the place where the most precious diamonds where found in the past, that's where we start. In the case there is nothing to be found, other corners of the mine can be explored. And usually, more medium size diamonds, with mediocre quality and clarity, can make together also a fortune. We are together for you on the search for diamonds. We will have to put both effort in finding them, cleaning them, and checking them. On this path for a search, we can find the right diamond, or a few diamonds that can help you to get the fortune of relieve.

August 2010, Jan M. Keppel Hesselink, MD PhD, and David Kopsky MD

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