“The bloodiness and horror of it”

frame: ILLNESS IS DOWN Foetal position: vulnerability, early life.

frame: Knowledge of novel/film. Emergent structure: Endometriosis pain is incapacitating and constrictive and constant (i.e. chronic). Sufferer feels vulnerable and restricted. Pain as an intense physical experience. Figure 2. Blended space 1: Intertextuality As the illustration shows, in the conceptual integration process, the generic space is constituted by the sensation of force being exerted so as to cause or prevent movement at a given time. In the blend, the first input space is formed by recollection of the pain episode, where the woman sees herself lying in a foetal position feeling a strong Pain, intertextuality, metaphor 18 unpleasant sensory physical experience caused by an endometriosis pain mechanism that is made akin to being pulled towards a lower location. The schemata around the physical and emotional events during such episodes and the knowledge of the vulnerability or need for protection conveyed by the foetal position serve as background to the blend, as does the conventional understanding of the DISEASE AS LOCATION metaphor whereby ILLNESS IS DOWN (i.e. ‘pulling down’). The pain as a pulling sensation confining the woman to a foetal position also recalls one of the types of PHYSICAL DAMAGE metaphor outlined by Semino (2010) (cf. Table 1), although not lexicalised in the account. The second input space contains the characters in the novel, the people of Lilliput, imprisoning Gulliver by tying him up with ropes attached to stakes on the ground. The input space is informed by background knowledge of the story’s plot. The blend inherits its main organising frame from the second input space. The most salient elements from both input spaces are Gulliver being pulled down by ropes manoeuvred by tiny people the morning after the shipwreck and the woman being reduced to a foetal position by the pain as an example of the experience on any given day. She understands the pain mechanism as a pulling sensation (cf. Table 1 above) created by an animate agent within her body (i.e. a group of tiny people). An agent-instrument and/or cause-consequence relationship accounts for the emergent structure at the completion stage. The blended space results from the selective projection of the represented woman’s incapacitation and the intertextual reference to Gulliver’s imprisonment by ropes staked to the ground. Pain is therefore conceptualised as an intense incapacitating physical experience, reducing the woman to a position of vulnerability and helplessness. The referent to time, ‘on a good day’ tells us that her Pain, intertextuality, metaphor 19 pain is permanent or chronic, that is equivalent to type (b) of endometriosis pain outlined by Bourdel et al. (2015). A slightly different type of reference framing the account of pain with similar effects is presented in Extract 2, below. (2) I can’t describe it, it’s so hard to describe it. it’s the most primal shitty feeling, it’s horrific… the bloodiness and horror of it… visceral deep pain… it’s a nightmare (Interview 21). This is a different kind of reference, known as interdiscursivity, defined as “the transfer of particular linguistic features that are typical of one discourse or genre to (other) texts” (Koller, 2010, p. 2) which they “reaccentuate, rework and mix in various ways” (Fairclough, 1992, p. 103), for example, involving the discussion of pain by borrowing elements that are characteristic of the genre of horror. In the description, the speaker makes sense of her pain within an alternative conceptual framework containing interdiscursive references to the genre of horror fiction, or The Gothic, which seems to structure the sense-making of her pain. The Gothic fiction genre combines horror and death, and texts are characterised by darkness, negativity and transformation (Botting, 2014). Figure 3 below illustrates how the blend operates in this account of pain. Pain, intertextuality, metaphor 20 Generic space: Blood and viscera; emotion. Input space 1: (1) Cyclical pain aspect, (2) bleeding and internal organs involved, (3) emotional reaction. Input space 2: Horror genre: (1) Liminality & transformation, (2) corporal transgression & monstruosity, (3) negativity and language of excess.

frame: Schema of menstrual cycle.

frame: Experience of genre, suspense, intensity and audience involvement. Emergent structure: Endometriosis pain is an experience of discomfort and gore. Through a metonymic relationship: body element (blood and viscera) for emotion, pain is an emotional experience and it is cyclical. Figure 3. Blended space 2: Interdiscursivity From the first input space, the blend inherits the cyclical pain mechanism, the bleeding and internal organs affected by endometriosis and extreme emotions (‘horrific’, ‘shitty’, ‘horror’). From the second input space, the blend inherits a frame structure with the compositional elements of the genre of horror or The Gothic, i.e. liminality and transformation (‘nightmare’); corporal transgression and monstruosity (‘bloodiness, visceral’, ‘primal’); and negativity and language of excess (‘shitty’, ‘horrific’) (Aldana-Reyes, 2014; Botting, 2014), as well as schematic knowledge of experience of the genre and audience involvement. In this case, the second input space in the blend is not necessarily anchored to a physical entity (i.e., a particular text or intertext), but rather to a concept (i.e., reference to a particular genre). In the blend, the Pain, intertextuality, metaphor 21 cyclical aspect of pain in input space 1, is mapped onto the narrative space conceptualised as a liminal space (i.e. nightmare) in input space 2, the blend inherits the extreme emotions, where the elements involved in the menstrual cycle (i.e. blood and viscera) stand as metonymic elements for the emotional reaction to the pain. The two input spaces share the structure represented in the generic space: blood and viscera and emotions. The networks are linked by analogy of their structure. Furthermore, negative feelings structured by the schematic knowledge of watching horror may also influence the interpretation of the pain experience. The blend gives rise to an emergent structure projecting back to its counterparts in the input spaces whereby endometriosis pain is conceptualised as a primal emotional experience where the body elements and organs metonymically represent the understanding of pain as a horror experience. We therefore see the pain experience as intense and emotional, potentially heightened by hormonal processes, as well as physical. This is also consistent with psychology and neuroscience literature that have found an intrinsic connection between emotions and the pain experience (e.g., Gatchel & Maddrey, 2004; Martucci & Mackey, 2018). But most importantly for the purposes of this study, we also see that the woman relates pain to blood, ‘the bloodiness’, which also tells us that her pain is cyclical, i.e. during the menstrual cycle, mapped to endometriosis pain type (a) outlined above (Bourdel et al., 2015). 6. Discussion In this article I have deployed different conceptual tools to analyse endometriosis pain description data collected from online forums and interviews. The collocate analysis in the corpus of online forum data revealed PHYSICAL DAMAGE CAUSED BY A MALEVOLENT Pain, intertextuality, metaphor 22 ANIMATE AGENT as recurrent and “stable knowledge structures in long-term memory” (Grady, Oakley & Coulson, 1999. p. 102) in women with endometriosis who contributed to the forum. An examination of individual accounts of pain allowed me to capture the dynamic aspects of women’s online representations of pain that enabled them to draw from intertexts in order to generate short-term, yet novel conceptualisations of the pain experience. As such, a conceptual integration approach to the analysis of intertextuality and interdiscursivity affords insights into inferential processes that allow a more comprehensive assessment of the pain experience. In so doing, I gained a deeper and fuller insight into the severity, quality and impact of the pain in these particular women (Morotti et al., 2016). We learnt that for one of the women, the pain was an extreme physical sensation involving a feeling of pressure, which is long lasting, or chronic. For the second woman, we learnt that pain had emotional aspects and that it was mainly cyclical. I am not, however, suggesting that intertextual references are only found in the interview data; after all, the corpus data have only been subjected to computer-assisted collocate analysis. I have not looked for intertextual references in the corpus data, as the aim of the corpus analysis was to find generic patterns of metaphorical pain descriptors; however, it is worth considering that the very nature of the interview data, which includes storytelling of personal experience, may partly account for the presence of intertextuality and interdiscursivity. Further explorations as to whether other aspects of storytelling can be found in the elicited data might reveal interesting findings, as it would do to explore further the notion of prosody and interpersonal meanings that I briefly touched upon in the previous section. Pain, intertextuality, metaphor 23 It may also be the case that audiences do not necessarily trace the connection to the references alluded to. It is worth pointing out that such references relate to well-known stories that most English speakers are likely to have come across. By referencing well-known texts, rather than more specialised texts or less popularised ones, women could be seen to find ways of establishing common ground with the interlocutor and construct “a shared story-world” (Ritchie, 2010, p. 140). The scope of this article does not allow me to focus on the cognitive processes of the interlocutor, but the notion of a shared story-world is an important one worth exploring further when it comes to crucial interlocutors, i.e. doctors or healthcare practitioners, who would need to step into such a frame, understand the assumptions and entailments associated with the characterisation of pain and map it to the endometriosis pain mechanisms available in their encyclopaedic knowledge, in order to assess the pain experience successfully. The alarming diagnosis delay of endometriosis and the extensive body of literature and evidence suggesting communication issues between women and doctors may indeed be indicative of the need to explore this notion of shared story-worlds further. In fact, eliciting stories from patients through open-ended narratives is an emerging practice in narrative communication, which makes this finding particularly pertinent for the practitioner-patient interaction context (Houston et al., 2011). All in all, metaphorical scenarios referencing popular texts seem to be grounded in the “semiotic experience” of “culturally salient texts”; as such, metaphors are “the product of a specific cultural situatedness of the metaphor producer” (Zinken, 2003, p. 509). They can be seen as being motivated by the speaker’s adaptation to a certain cultural structure, which allows for metaphorical choices with a particular communicative aim: that of communicating “experiences of undefined illness in ways Pain, intertextuality, metaphor 24 that empirical accounts alone do not” (Overend, 2014, p. 66). From the accounts observed, we see that metaphorical/intertextual accounts, if paid close attention to, “provide a new and helpful perspective” (Demjen & Semino, 2017, p. 396). 5. Conclusions In this article, I have discussed the fact that endometriosis is characterised by a lengthy diagnosis that severely affects women’s lives. I have mentioned that the invisibility and complexity of endometriosis pain lead women to resort to elaborate language tools and step into imaginary scenarios to be able to convey their pain experience. This, however, is not always perceived to lead to successful communication and, more often than not, women report having their pain dismissed and normalised as part of the female condition, due to its association with the menstrual cycle (Bullo, 2019), or even linked to psychological processes such as ‘catastrophising’ (Gosden, et al., 2014). The deligitimisation of female pain, caused by normalisation and dismissal, and leading to alienation and disempowerment, is widely reported in the medical and social literature (e.g., Bullo, 2018; Culley, et al., 2013; Seear, 2009). The metaphorical patterns of pain identified in this article through the use of Conceptual Metaphor Theory and intertextual analysis testify to such feeling of disempowerment and victimhood, as evidenced by the predominance of the metaphor PAIN AS A MALEVOLENT ANIMATE AGENT inflicting PHYSICAL DAMAGE that causes incapacitating effects and severe emotional and consequences on women and their quality of life. Each analytical framework deployed in this article has allowed an insight into the accounts of pain that the usual tools used in consultations (e.g., 1–10 scale) reportedly do not capture. The predominance of the PAIN AS A MALEVOLENT ANIMATE AGENT Pain, intertextuality, metaphor 25 causing PHYSICAL DAMAGE metaphor clearly indicates the general severity and incapacitating nature of endometriosis pain. Further to this, an insight into the inferential processes afforded by Blending Theory allowed a more detailed exploration of the processes indicating the quality, and potentially mechanisms, as well as the impact of the pain experience. The analysis of the intertextual metaphorical scenarios also shed light on the evaluative and attitudinal values that women attribute to their pain experience (Musolff, 2006). The co-deployment of the analytical tools to the data sets has therefore proven useful in gaining a more holistic assessment of the endometriosis pain experience, as reported in the medical literature (e.g., Morotti et al., 2016) as well as further attesting to the devastating effect of endometriosis pain on women’s lives and revealed the need to invest in pain assessment strategies to help legitimise endometriosis pain (Wright, 2018) in early consultations. Within the reality of the medical consultation with limited time frames and the requirement of the system to prioritise life-threating conditions, practical solutions are required. The findings reveal that devising tools that consider an integrated account of the pain experience beyond measuring severity (on a 1–10 scale) could be a helpful way forward towards earlier diagnosis. 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Discourse & Society, 14(4), 507–523. https://doi.org/10.1177/0957926503014004005. Pain, intertextuality, metaphor 32 Notes 1. Some researchers may consider this a case of ‘deliberate’ metaphor (e.g., Steen, 2008). The notion of deliberate metaphor is a highly debated one in the metaphor research literature (e.g., Gibbs, 2015; Steen, 2008). However, it is beyond the remit of this article to engage with this debate. As the article’s focus is on metaphors used to describe endometriosis pain in a rather small sample where women have been prompted to describe their pain, it is not possible to assume that all similes are used deliberately or not for special rhetorical purposes. 2. It is assumed that most participants are native speakers of the English language. All posts constituting the data set were written between 2012 and summer 2016 and were publicly available to all internet users without login requirements. The estimated number of women contributing to the forums was calculated by counting the average number of entries in each forum with consideration to starters and replies to each post. 3. Available from http://bncweb.lancs.ac.uk. 4. The reader can refer to an image illustrating this scene in the novel by following the link: https://thefablesoup.wordpress.com/2016/02/21/gulliver-in-lilliput-examining-the-allegory/. Address for correspondence Dr Stella Bullo Manchester Metropolitan University Geoffrey Manton Building Rosamond Street West Pain, intertextuality, metaphor 33 Manchester, M15 6LL U.K. [email protected] Biographical notes Dr Stella Bullo is a senior lecturer in Linguistics at Manchester Metropolitan University. Her main research is in the area of discourse analysis. Her current research is in the area of health communication investigating discourses surrounding female pain and gynaecological conditions, and endometriosis in particular, and cross-cultural discourses of health.