Smerte kan ikke ses eller måles, og den behøver ikke altid at skyldes en skade eller sygdom. Tusindvis af danskere i alle aldre lever med smerter hver eneste dag uden at ”fejle noget”. Man skønner, at alene i Danmark er der over 800.000 mennesker, som lever med kroniske smerter.
Smerte er svær at italesætte, og både i pressen, fagbøger og almindelig tale oplever man, at begreber som ”smertereceptorer” og ”smertenerver” fejlagtigt anvendes. Der findes ingen smertereceptorer eller smertenerver, ligesom der ikke findes et smertecenter i hjernen.
Traditionelt anskues smerte som et symptom på et problem, der kan identificeres og løses. Sygdommen behandles med medicinske midler og forsvinder. Hvis der stadig er smerter, forklares de medicinsk som følgevirkninger af det oprindelige problem. Der er altså en klar forventning til, at smerte altid har en årsag.
Af Lene Pilegaard
Artiklen blev bragt i magasinet sund-forskning – februar 2020
Smerte uden diagnose
Der er desværre rigtig mange, som lider af kroniske smerter, hvor man ikke kan finde en skade eller fysisk årsag ved hjælp af de diagnosticeringsmetoder, vi har til rådighed i dag. Det betyder ikke, at der ikke er en årsag til smerten, men at vores redskaber til at finde årsagen ikke findes endnu. Det gør ikke smerterne mindre virkelige, tværtimod, da det påvirker præcist lige så negativt eller mere som, hvis det var smerter, hvor man kunne finde en årsag.
Disse uforklarlige smerter er nogle gange værre, fordi man som smerteramt ofte bliver misforstået af omgivelserne og måske mødes med: ”Du skal da bare tage dig sammen”, ”du skal bare træne mere”, ”du skal da også bare tabe dig” osv., som de fleste med kroniske uforklarlige smerter sikkert er blevet mødt med. Den manglende forståelse gør det endnu sværere at leve med de uforklarlige smerter. og de smerteramte bliver ofte stigmatiseret og kan føle sig skyldige over alt det, de gør og ikke gør.
Usynligt handicap
Kroniske smerter er tilmed ofte et usynligt handicap, som der hverken i behandlingssystemet, det sociale system eller i befolkningen som helhed er nogen god forståelse for. Smertepatienten møder ustandseligt krav om at ”tage sig sammen” og fungere normalt, som om de ikke netop i forvejen typisk anstrenger sig til det yderste herfor uden held.
Alle disse uheldige følgevirkninger tærer på den enkeltes ressourcer og betyder yderligere psykiske stressfaktorer, der oftest vil forværre smerteoplevelsen.
Din smerte foregår i hovedet!
Ikke dermed sagt, at det er noget, man finder på. Al smerte er reel og foregår i hjernen – ingen hjerne – ingen smerte. Alle der fortæller dig, at det er noget, du har med dit hoved eller er psykosomatisk, underforstået at det ikke er reel smerte, forstår ikke fysiologien bag.
Hvad smerte IKKE er
Det hjælper mange med at forstå, hvad smerte IKKE er.
For mennesker med kroniske smerter lader det til, at følgende fire punkter kan have indflydelse på, hvordan de lever med smerten:
- Smerte måler ikke vævskade
- Smerte påvirkes af en lang række biopsykosociale faktorer
- Forholdet mellem smerte og vævenes tilstand bliver mindre forudsigeligt, desto længere smerten har stået på
- Smerte kan ses som bevidsthedens reaktion, når hjernen konkluderer, at kroppen er i fare
Det er faktisk hverken nødvendigt eller tilstrækkeligt for styrken af smerte, at den skal være forårsaget af en oplevelse, begivenhed eller skade på væv, for at der er sammenhæng med, hvordan smerten faktisk føles.
Ingenmandsland
Når smerten ikke kan forklares med en diagnose, bliver smerten til problemet i sig selv og udfordrer den traditionelle opfattelse af, at smerte altid har en årsag, der kan identificeres. Den smerteplagede havner i et ingenmandsland, idet man hverken kan defineres som syg eller rask. Som smerteramt uden diagnose risikerer man at blive defineret som psykisk syg, hypokonder eller ekstremt opmærksomhedskrævende.
Sygerollens paradoks
Et væsentligt dilemma opstår for den kronisk smerteramte. På den ene side har man brug for andres accept af, at man har smerter, både fordi man har behov for forståelse for de ting, man ikke længere er i stand til, og fordi smerten ikke kan undgå at have en stor betydning for ens identitet.
Smerten italesættes således, for at man kan kommunikere sine problemer til andre, og for at man kan italesætte sin nye virkelighed og bedre selv komme overens med den. Men italesættelsen foregår på en knivsæg, fordi ved at italesætte smerten udsætter man sig for en risiko: At man bliver opfattet som irriterende og hypokonder af andre.
Vi forventer, at smerte forsvinder, men det gør den ikke altid. Vi forventer, at de mennesker, der rammes, formår at skubbe smerten i baggrunden og leve et ”normalt” liv alligevel. Det sker langt fra altid. For nogle betyder det, at de misunder folk med synlige lidelser. Kroniske smerteramte uden diagnose falder udenfor kulturen, fordi de ikke passer ind i de normer, der eksisterer omkring det at være syg eller rask, og fordi smertens vedholdenhed på en gang skræmmer, irriterer og undrer menneskene omkring den smerteramte.
Kronisk smerte vækker andre menneskers ængstelse
Der er generelt stor bekymring blandt kroniske smertepatienter i at blive set som psykisk syg. Hvis smertepatienter i andres øjne har fordele af at være syge, holdes de ansvarlige for deres egen smerte. Selv om der for nogle kan være en form for fordele ved at være syg (fx en følelse af øget omsorg), er de ofte uvillige til at diskutere det, fordi de er bange for at blive set som psykisk syge.
Den legitime smerteoplevelse
Spørgsmålet om skyld er vigtigt, fordi det kan have stor betydning for vores selvopfattelse. Generelt set kan man sige, at det at blive opfattet som syg af omverdenen forudsætter, at den smerte eller sygdom, man oplever, forstås og anerkendes af andre. Gør den det, tilegnes man den legitime rolle som syg eller som smertepatient. Opnår man ikke denne legitimitet omkring sine smerter, mistænkeliggøres man derimod, og følelsen af ikke at blive taget alvorligt kan til sidst smitte af på ens egen opfattelse af smerterne: Måske er det mig, der er skør?
Vi risikerer dermed at sætte os selv i den situation, at vi gør alle de ting, vores krop siger, vi ikke kan, men som vi indirekte eller direkte får at vide, at vi godt kan, fordi vores smerter ikke er reelle, legitime.
Skal man tale om smerten eller ej?
Der er altid en fare for, at den smerte, man fortæller om, anses for at være mindre slem, end man siger. Men skjules smerten, isoleres man, fordi man fremstår på falske forudsætninger. Således kan smerte have store sociale omkostninger.
Fordi smertepatienten udfordrer den sociale orden, kommer der negative sanktioner. Lægebesøg og besøg på jobcenter ender ofte i stigmatisering.
Den stoisk udholdende, der aldrig klager, høster rent kulturelt stor anerkendelse, men for at vide at nogen er stoisk udholdende, skal man vide, at de har store smerter. Italesættelse af smerte indebærer således et paradoks.
Smerten bliver et æstetisk problem, hvis den opfattes som overdreven. Man kan således få sympati eller fordømmelse, afhængigt af hvordan smerten kommunikeres – eller hvordan den opfattes. Lader man sig ikke mærke med sin smerte, beundres man. Problemet er, at for at andre skal vide, at man har smerter, skal man fortælle om det. Smerten er således et dobbelt paradoks: Det er en privat erfaring, der afhænger af en social handling for at gøre den synlig for andre; og samtidig kan den selvsamme handling gøre folk mistænksomme over for smertens realitet.
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