It Doesn’t Hurt, It Hurts All the Time

What if we thought of emotional trauma the way we do physical: as a wide class of wounds whose healing is unpredictable, whose scars take different forms?

On July 4, 2019, I was bitten by a dog. I was on the beach in Delaware with my family, and I asked for permission to pet a sweet-seeming buddy who reminded me of my own pup. His twenty-something chaperones told me to go ahead. As I was reaching toward him and looking up to ask what he was called, the dog—I never did learn his name—latched onto my upper arm with what I now know was more than two hundred pounds per square inch of force.

The details of what happened next elude me. I think his people were screaming at him, though I still don’t remember what name they were screaming. I know I had to pry his jaws off of my arm, that he seemed inclined to hang on until he tore a chunk out. I know I staggered backwards, shocked, and that at the same time (maybe?) my family rushed forward and someone shoved tissues into my hand, which I clamped to the wound. I vaguely remember my mother hollering “what’s your name? Does he have his shots?” as his people retreated down the beach, saying “he’s never done this” and “we’re not from around here.” (They were from Arizona and one of them was named Miranda. The dog did supposedly have his shots. That’s all I know.) The only part I recall clearly is lifting the wad of tissues I’d been holding to my arm, seeing glistening gobbets of blood and fat, and saying quietly, “I’d like to go home, but I think we should go to the ER on the way.”

I knew where the ER was in this beach town, and it really was on the way home; I don’t know if I would have insisted on going otherwise. It didn’t hurt, but it didn’t look right, either. Anyway, I spent the evening of Independence Day in the emergency room, getting stitches—only two, so you know it wasn’t that bad, but two, so you know it was bad enough. The stitches were to repair the worst damage, a combined gash-puncture where the dog’s top fang had penetrated. I also had a long scrape from his other fang, and—for months afterward, and still now if you know where to look—a perfect impression of every tooth from the front of his bottom jaw. After that initial glimpse of wet flesh, I was scared to look again until it was all stitched up and bandaged away, but a photo from the ER shows it was both better and worse than I thought: nothing torn open, but a good thirty square inches of lacerations and welling puncture wounds.

And still, I didn’t feel it.

I was stunned and bewildered—”how could a dog betray?” I texted my friends—and embarrassed, a fat middle-aged woman in the emergency room in my bathing suit and flip-flops. But I wasn’t in pain. At the time, I thought it was the shock, that I had self-protectively shut down all nerve response in the area. I joked to the ER nurse that my brain was taking good care of me. In the weeks and months after, though, a hand-sized (mouth-sized) chunk of my upper arm remained numb. I could feel only pressure, and only very bluntly, like being poked through layers of padding. I kept waiting for the moment when my nerves would prickle back to life and the hurt would finally bloom, like the day after a tooth extraction when the novocaine wears off—I felt somehow that I needed this, that it would make the whole experience feel less surreal. But the pain stayed locked away, as unreachable as everything else.

This is not to say that it didn’t bother me at all. Immediately following the bite, my worst suffering came from bandage adhesive, which made the non-numb parts of my arm flare up with a maddening, itchy rash. But for months, the bite itself also throbbed with a kind of sub-awareness phantom pain. It didn’t feel the way a dog bite ought to feel—no lacerating sharpness, no throb. It was more like a sunburn, or maybe just the knowledge of sunburn: that sense, the day after an overexposure, of being more aware of your back and shoulders than is strictly normal. Not pain like a puncturing tooth, but pain like an allover inflammation, a diffuse and steady ache, just a notch above subliminal and yet unignorable. My arm had lost all feeling, and it also hurt all the time.

*

The pain of a wound is separate from the wound itself. Like everything you think you experience, pain must first be mediated by the brain—so in the same way that you see not objects, but light bouncing off objects, you feel not the injury but the nervous system’s reaction. Sensory neurons called nociceptors (literally, perceivers of harm) register unusual levels of stimulation—crushing, cutting, extreme temperature, chemical response. Above a certain threshold of activation they send a danger message through the spinal cord to the brain. This process is very very fast, but it’s not instantaneous. There is room for interruption.

Ideally, the pain is a proportional response to the damage: as bad as it needs to be to make you stop what you were doing, sticking around no longer than it takes to heal. But it’s possible to unhook the sensation from the cause. Any number of factors can influence your pain tolerance: cussing loudly can decrease your experience of pain (this has been tested in the lab), and being depressed can increase it. Some injuries hurt less when you see them coming; some don’t hurt until you look at them.

And, of course, your ability to recognize pain can be impaired, by the wound itself or by other preexisting issues. There’s nerve damage, like I had from the dog bite. There’s episodic analgesia, which I initially thought I was experiencing, where a serious injury doesn’t start to hurt for minutes or hours; the brain undermines its own pain response by releasing a flood of endorphins. Brain damage can disrupt your understanding of pain—you experience nociception, but don’t recognize it as unpleasant. There are even people who are born impervious to pain, lacking the pathways that signal damage from the body to the brain. These congenital analgesics are in grave danger all the time, needing constant vigilance to make sure they’re not being mortally wounded. When you don’t know something is hurting you, it can go on hurting you until you die.

There has been a fair amount of research done on pain with no obvious cause—chronic pain that comes, seemingly, from nothing, all the danger signals firing off without anything pulling the trigger. Lack of pain is less scrutinized. We want to understand and thus perhaps alleviate suffering, not its absence.

If a wound doesn’t make you suffer, is it still a wound? It can still scar the same, if you’re lucky. It can fester if you’re not, infection or gangrene setting in because you have no warning signs. The pain is a reaction to damage, not the damage itself. They are linked, of course, but loosely; the worst hurts don’t always hurt the worst. Sometimes the shallowest injuries cause disproportionate suffering. Sometimes, even, the injuries you don’t feel are more dangerous than the ones you do. There are no nociceptors in the brain.

*

In mid-May, two months into New York’s coronavirus lockdown, I tweeted: “The current situation and the need to keep living my life and doing my job have combined into a permanent experience of that moment when something terrible has happened but you just woke up and haven’t completely remembered what it is yet.” This was not a unique observation, which is why I put it on Twitter, a medium that generally punishes unpopular opinions but rewards people for saying the same thing as everyone else in a pithier way. Someone who had given himself the descriptive moniker “Socialist Self-Isolating Steve” responded, “That’s trauma. You’re describing a trauma. Look after yourself!”

This seemed, on the face of it, absurd. For starters, we’re all going through it, Steve. (We weren’t, actually, but it still felt that way at the time; it would be another week or so before it became painfully clear how much my experience, as a New Yorker staying pathologically home with my growing collections of masks and Chrome tabs of COVID statistics, was at variance with the experience of people who must already have been planning their Memorial Day beach vacations with friends.) But it also felt grotesque to class my perpetual unease as “trauma” when healthcare providers were spending sleepless nights placing nonstop emergency ventilators, when minimum-wage workers were being forced to choose between health and financial survival, when the sick were drowning in their own lungs, when their family members couldn’t even say goodbye. Some of my own friends and family members were getting sick, sometimes very sick. By comparison with everyone directly affected, I was doing remarkably well.

In fact, I thought I must be doing better even than other people in my immensely privileged position, who were not sick and had not lost anyone and were not frontline workers and were not even trying to parent and teach and work at the same time. My social media feeds (which is to say, my entire social life) were crowded with monuments to the Before Time: lush reminiscences about mundane acts of social ease, rapturous details about favorite away-from-home meals, laments about missing family and friends. I, on the other hand, had snapped almost immediately into a kind of hibernation mode. I did think about my more carefree pre-pandemic life, but not about a recent routine I wanted to return to; instead I was flooded with random involuntary memories of much earlier times, as if watching my life flash before my eyes in excruciating slow-mo. The outside world, the ability to navigate it casually, already felt just as impossibly lost as youth, just as pointless to mourn. I didn’t want this to be over, because “over” was meaningless. I wanted it never to have begun, and what was the use of longing for a disappeared past? We all wish, sometimes, that we could travel back in time, but we don’t suffer from the lack of it.

And so I did not pine for diner pancakes, or drinks in bars, or the sound of the subway—or at least no more than I pined for video stores or smoking sections or thylacines. These were things that once existed and had stopped existing, and I had shut down fruitless longing for them like snipping a wire. Almost as soon as my office closed, my conceivable universe obediently shrank to fit within my 550-square-foot apartment. We have few windows, and no view—we’re on the first floor, and our windows are partially papered over with translucent film—so I didn’t even have to look at masked people or shuttered stores. I did feel a series of pangs as I watched the tree outside, the only thing we can really see, go from dead brown to full leaf, but beyond that tree the world did not exist. I naturally took on an attitude that reminded me of my dog getting a bath: I guess this is my life forever now, and maybe it always was.

I felt calm in isolation, even cozy. My husband and I cooked comfort food, burned indulgent candles, visited each other’s islands on Animal Crossing. (We celebrated two birthdays and a first anniversary in quarantine, so now we suddenly own two Switches Lite.) But I knew that this calm was a thin glaze over unfathomable depths; it could be shattered not only by bad fortune, but by examination, the way ice melts if you breathe on it too close. I had curled myself into a complacent hibernation because thinking too hard would tip me into panic.

It’s not that I didn’t pay attention to the statistics or the news; like everyone else at first, I paid compulsive attention to them, cross-checking the reported death tolls against the projections, the projections against other projections, the reports against other reports, multiple times a day. I sobbed over firsthand accounts by ER doctors and COVID victims; every time my husband cleared his throat I had a flash of him on a ventilator. But isolation and stasis let me keep that fear contained. I squirmed through the part of every video call, inevitable in the early days, where we all talked about how bad everything was, how scared we were; I didn’t want to talk about it or analyze it or, god forbid, be encouraged to take a walk. I didn’t want to connect with other people at all. I just wanted to be silent and impassive, aloof as an ascetic in a cell.

*

I was sure that the word “trauma” came from the German “Traum,” meaning dream; it seemed intuitively correct that disabling psychological damage bubbling up from your subconscious would be connected, etymologically, to nightmares. But of course, trauma was physical—as in “trauma ward”—before it was mental, and the word actually comes from the Greek for “wound.” It’s still in use that way, especially in medical circles, but I would venture a guess that most people who hear the word “trauma” think first of the mind.

This shift in primary connotation came late, late enough that my 1970s compact Oxford English Dictionary still contains almost no usage references for mental trauma. In the updated online edition of the OED, physical trauma is still the first definition, but it’s been swamped by technical and figurative uses of “trauma” in the psychological sense. The clinical meaning dates back to the late nineteenth century—the first OED citation, from the Psychological Review in 1894, includes the beautiful phrase “psychic traumata, thorns in the spirit, so to speak.” But the general usage didn’t kick in until the late 1970s, when the concept of “post-traumatic stress” entered the general consciousness of an America inundated with psychologically wounded Vietnam vets. PTSD was finally enshrined in the Diagnostic and Statistical Manual, the registry of psych diagnoses, in 1980, after a long campaign by a group of psychiatrists working on behalf of veterans. And this idea, that the mind could sustain an invisible wound, also percolated outward to the general population—perhaps because people saw so much of it, in an era that featured not only traumatized American soldiers but traumatized veterans of the battle for civil rights.

Unlike physical trauma, psychological trauma was notable for its invisibility—not only because the damage was internal, but because it hid itself. There are several reasons why a physical wound might not hurt and reasons why even a serious injury might not be obvious. But for trauma, this self-erasing power is essential. The traumatized mind might understand that it had been through something harrowing; vets, for instance, were aware of how they’d spent their time, and I’m sure mostly understood how the ordeal of war might relate to the post-war nightmares. A defining characteristic of trauma, though, is the way it burrows like a tick into the subconscious, erasing the traces that might hold it accountable. You might not even know what’s pulling your strings.

Like a lot of psychological terms, the clinical meaning of “trauma” remains much narrower than its public use. The OED general usage examples, which are from the late ’70s and early ’80s, are about things like labor unions and the American rapid transit industry. Our current usage can include cumulative effects like neglect or racist microaggressions, which rarely rise to the level of notable damage in each individual instance, but which build on each other to become complicatedly traumatizing. Meanwhile, though, the DSM, whose definition is imperfect but authorititative, limits trauma to ongoing effects precipitated by “actual or threatened death, serious injury, or sexual violence.”

There is not, I think, any reason for me to class living safely through a global pandemic as a form of trauma in the clinical sense; while we are arguably all living under the shadow of possible death, it doesn’t quite rise to the level of a threat. Being afraid of a virus is not the same as going to war. But a trauma also means a wound, and a wound has many forms. Some are abrasions, shallow but covering a lot of ground. Some are punctures, deep and sharp, or long lacerations, or internal bruises that don’t even show right away. Some bleed; some are cauterized. Some go septic. Some you don’t even feel.

*

Over the months of stay-at-home orders, which all felt like one long week, it became increasingly clear that while I was not supposed to go outside, and didn’t want to go outside, I also couldn’t. In the first week after my office closed, I was supposed to walk over and clear out the mail; instead, I had a hyperventilating panic attack. Once I stopped being expected to go out—once the prevailing sentiment became that, in fact, it was irresponsible to go out—the fear became quieter, less demonstrative, but still petrifying. It took a month before I could even go down the hall to the laundry room without crying, longer to go further; I left the building twice in April and twice in May. I was still having stray flashes of memory—say, a sudden image of walking down a particular street in the Village where there was a pet shop—but instead of wistfulness, these were increasingly accompanied by a glacial sensation, like my bones and guts had turned to stone. I worried that I was inventing this fear to use as an excuse—I didn’t want to go out, so I pretended I couldn’t. But why wouldn’t I want to go out? Everyone else did.

For a while, this didn’t matter. When I mentioned, offhandedly, that I was perhaps unreasonably afraid to go outside, friends reassured me that it was actually extremely reasonable, even righteous. But at the same time, almost from the first days of lockdown, my Twitter feed was full of gentle admonitions to get out, take a walk, just take one walk a day, my daily walk keeps me sane. As states started lifting restrictions, even many of my most science-minded friends were so starved for normalcy that they started cautiously meeting for distance hangs or taking weird anxious road trips. Even the people saying I don’t get it, is everyone else insane were posting that from the park, with masks on, at a safe distance from everyone else. And I was still inside.

When the Black Lives Matter protests started in the last days of May, the switch of public opinion immediately flipped: now, instead of it being a moral imperative to stay in, it was (or at least it felt like) a moral imperative to get out and be in the streets. The cause was so much more important than my personal anxieties, and yet I couldn’t make myself go to a rally a few blocks away—even seeing the ubiquitous masks, even when initial data suggested that protests were not big drivers of infection. My disgust with myself for my “excuses” intensified. Even if I was unable to overcome my anxiety to do my share of the grocery shopping, shouldn’t I be able to set it aside for a critically important cause?

Maybe I would have judged myself less if the fear had been more dramatic. But it was more of a quiet freeze, a powerful and irresistible desire to stop thinking about it, stop thinking, stop doing anything. On a rational level, I knew I likely wouldn’t get sick if I went outside, carefully, like everyone else. Marching or rallying while masked seemed relatively safe. Hanging out in a park with a mask on seemed extremely safe, in theory; the park near my house was a no-go in terms of distancing, but I could take one of those walks everyone was talking about. Except I couldn’t. The apartment had become my planet, and going outside felt like going into space: vertiginous, airless, fraught with peril no matter how much equipment and preparation you had.

Technically, agoraphobia is not just a fear of leaving your home. It’s a fear born of having a panic attack outside of your home—or in a subway, or at work, or any specific place where you are stranded or in danger. This fear feeds on itself, rebirths itself: having been so vulnerable in an unsafe place, you are now more likely to panic when you try to return, which then scares you more. Eventually you fear a repeat of the badly-located panic attack so much that it seems safer to avoid the location. This is one of the operations of trauma: it is self-replicating. It can even be self-originating. The immediate cause, the precipitating trauma, is something your brain did to you.

Agoraphobia also presupposes that there is nothing to rationally fear in the spaces you avoid—no war, no stalkers, no pandemic-level outbreak of a mysterious and unpredictable disease. Whatever was going on with me, it wasn’t a phobia, that parthenogenetic fear that creates itself from nothing: the thing I’d been terrified of, initially, was out there and truly scary. But my immobilization still came from a fear of the fear, the instinct to shut down all pain pathways surrounding that initial wound. I did not want to acknowledge the danger, or look at it, or think about it applying to me, or fully process everything it would mean for the future. Unlike the people protesting for their right to mask-free shopping or haircuts, I didn’t have the option to simply avoid or forget or resist the fear; I knew too much, and cared too much, and had paid too much attention. And so, the self-protective instinct: a radical numbing, interpolated between the wound and the pain it could cause.

*

This Fourth of July, I did nothing, of course. (I didn’t much feel like celebrating this country anyway.) I wouldn’t have thought I could top getting attacked by a dog, but that’s the name of the game in 2020: things you didn’t think could get worse get worse. My parents and my sister, brother-in-law, and nieces went back to the beach without me. They have cars and can get out of the city; they’d already crossed the streams of their households. I said we couldn’t go because we don’t have a car, and because my husband had to work, both of which were true. I was also scared, but I didn’t want to admit that.

It seems unacceptable, somehow, to say something as simple as “I am in danger, so I am afraid.” We have been blessed and cursed with access to cross-global communication, and it has in many ways overloaded our little primate brains: we are now constantly confronted with the suffering of thousands or tens of thousands of people at every moment, and for many of us, that knowledge comes with a sense of obligation. Social media’s specialty is asking people why they’re talking about this disaster but silent on this other one, why they’re donating to this organization when they could have donated to that, why they’re focused on their own tiny tragedies when the large ones are so large. All of these questions are righteous, the causes undeniable: we do owe it to each other to witness the suffering of the vulnerable, we do have a responsibility to do what we can, and the specific “we” I belong to—white, middle-class—should not be afforded the luxury of ignorance or inaction. But it gives you a new perspective on the smallness of your own suffering—and a sense of perspective, as Douglas Adams said, is the one thing living beings cannot afford to have. A glittering carpet of human misery is spread in front of us every day. Of course it feels obscene to say you’re sad.

My fear of going outside, I think, was more like the opposite of a fear, the buffering negative space around it—an anti-fear. Like episodic analgesia, where the brain holds pain at bay, it was a protective nothingness, a shutdown. We are all so afraid. We are all so angry. We are all so lonely for our former lives, and mourning the collapse of the future. We are genuinely in danger, from the virus. We are genuinely being endangered, actively, by a government that sees us as disposable or worse. It’s too much: a black hole, all gravity and no light. At the same time, we are relentlessly, inescapably aware of how much worse it could be, how much worse it is, for someone, for many people. How do you let yourself feel that bolus of emotions at all? How, especially, do you feel it knowing that this is what “lucky” looks like?

If I gave in, if I truly faced things, I would be lost. I don’t want that, and more to the point, I don’t feel I deserve it. In the abstract, it seems like it might be uniting to suffer the same psychic blow as everyone else, but in practice it means that we’re all trying to crawl into the same bed. How can I justify taking up space? Empathy, fellow-feeling, public-spiritedness seem to demand that I make way for people who have also suffered all the baseline traumas of this year, plus losing loved ones or being sick for months or having all the wounds of racism clawed open or getting their eyes shot out by “less lethal” police weapons. So I throw up these barriers to nociception: If I can’t see damage, then I won’t feel pain. If I don’t think about pain, then I haven’t been damaged. If I haven’t been damaged, then what I feel is not pain. It doesn’t hurt, it can’t hurt, and it also hurts all the time.

What if we thought of emotional trauma the way we do physical: not as worthy injuries and unworthy ones, but as a wide class of wounds made in different ways, whose healing is unpredictable, whose scars take different forms? It is worse to die, to be grievously ill, to lose someone you love, to lose your job and fear for your survival, to not lose your job and be forced to risk your survival every day. But it is also terrible to fear the future, to be betrayed by your leaders, to see ignorance weaponized, to have your life treated as a bargaining chip by the powerful. It is terrible to hang suspended over the pit and try not to look down. The teeth of this year grind all of us. Maybe, in seeing each other’s wounds, we can let ourselves feel our own.