Is it pain or suffering?
Pain in the Physical Arena:
In the early to mid-1970s, one of my aunts developed a terrible case of kyphosis (often confused with scoliosis). She began to hunch over badly and, from what I understand, the doctors predicted that it would eventually lead to organ failure. She was average height but for most of my life stood no more than four feet high, due to the curvature of her spine.
She was a mother and farm wife, both of which also came with challenges. In her older years (she didn't live particularly long), she often took it upon herself to help my grandmother as well. There's no question that she faced pains and restrictions that most people don't.
Despite the physical pain, my aunt was charismatic and fun loving. She spread compassion, lightheartedness, and love to everyone. Each and every one of us younger family members (my cousins, siblings, and I) were made to feel like we were her favourite. I really believe that whomever she was speaking to really was her favourite at that moment. In the small town that she lived near, everyone was her friend and I doubt anyone had an unkind word to say about her.
In the silliness of my young adulthood, I had a medieval themed wedding, and my painfully hunched over aunt took the occasion as an opportunity to dress as a jester! In the last months of her life, she still managed to phone me on my birthday and make me feel special. She was in pain, but was she suffering?
I'm sure she wasn't perfect; she had shortcomings, as we all do. There must have been some ways in which she did suffer, but it didn't overshadow her life and zest.
People could see that my aunt had physical challenges and refused to suffer them. They were eager to repay the compassion that she showed for them. Maybe some of that genuine care did help.
Many of us are fortunate enough to have met or heard of inspirational people, who maintained grace and beauty despite physical pain, restrictions, and challenges. How about mental and emotional pain?
Pain in the Mental Arena:
In 1889, a boy was born into some horrible conditions. His South London family was so destitute that there isn't even a record of his birth. His mother was unable to get regular work and his estranged father provided no income support.
Times were very different and by age 7, he was sent to a workhouse. After a brief rest from it, at around age 8-and-a-half, he was again admitted to a workhouse at 9 years of age. The work was needed in order to pay room and board. His youth was spent at schools for paupers and destitute children until he dropped out at 13.
His mother was eventually institutionalized with psychosis from malnutrition and syphilis. He then had to live with his father, whose alcoholism and life had even brought about a visit from The National Society for the Prevention of Cruelty to Children. His father passed away at age 38 from liver cirrhosis.
The young man was able to again live with his mother briefly but, when she was returned to the asylum, he had to tend to her at the age of 14. She would spend the rest of her life in the institution and he continued to provide for her in what ways he could.
At that young age, there were more times of homelessness, scavenging for food, and taking whatever work would keep him alive. This was a life of conditions ripe for extreme emotional and mental pain. It was a life that had certainly witnessed suffering first hand at a very young age.
While lucid enough, his mother had still managed to instill in this boy a sense that he had some kind of talent, that he was of some worth, and in Charlie Chaplin's words later in life, "I was hardly aware of a crisis because we lived in a continual crisis; and, being a boy, I dismissed our troubles with gracious forgetfulness.” (Chapter 10: Chaplin)
Charlie, like my aunt, was known to be charismatic and “the life of the party." He wasn't perfect either. With four marriages, scandal, affairs, and McCarthyism barking at his communism affiliated heels, I'd be remiss to announce that he never suffered. Again though, it didn't overshadow his life or zest. He had pain in life, he must have suffered at times... but was he suffering?
People who didn't know him couldn't easily see his pain. If anything, they may have only known him for his talents and successes. Some of those successes included fathering 11 children, a 1950s International Peace Prize awarded by the World Peace Council, 1960s honorary degree from Oxford, and for New Years 1975 he was knighted by Queen Elizabeth II.
When he passed away at 88, people had no internet to learn about these things and only those with a particular interest would have picked up his 500 page autobiography. Yet, he was well loved regardless, even by many who were vehemently in opposition to his political views.
So if there can be pain that doesn't equal to suffering, does suffering happen without pain?
Suffering Separately from Pain:
Sobbing in anger, tears ran down her reddened face and her brow furrowed as she pounded her fists and ranted, “I do everything possible, I go so far out of my way, I give everything, and I don't even get mentioned!” She went on, “They have everything, they have husbands to take care of them, it's easy for them to help but I do everything and I do it all on my own but I'm shit on for it!” The words of a narcissist that I know. Here, I'm not using “narcissist” in the sense of just displaying pride and conceit, but someone suffering—undiagnosed, but I strongly suspect—from Narcissistic Personality Disorder (NPD). 
Many people have been injured or abused by people with NPD. Social media, including YouTube, is filled with stories of those harmed by parents, spouses, and siblings with the disorder. There are organisations and chat groups dedicated to us.
I'd like to take a look at a person suffering the disorder rather than those harmed by her, though. Having spent a great deal of time with this person, I want to share the side of this disorder in which the narcissist is truly suffering.
The context of the fury and ranting above started the previous week. Some ladies, at her church, had been asked to help assure an elderly member of the congregation was getting food and company during the holiday season. They took turns throughout the week, attending to the person's physical and spiritual/ emotional needs.
During the church service, on the day of the outburst, someone in their leadership made a special mention about these ladies, expressing gratitude on behalf of the church.
During the same week, the suspected NPD sufferer had prepared a small donation of unrequested goods for a congregation member who she felt was having a hard time financially and left it on their doorstep anonymously. She did this despite her own lack of resources.
The act seems very altruistic and compassionate, until you relate it to the outburst. She was trying to demonstrate how much more charitable/ more Christian she was than the others. She expected that God would bless her for her effort and that the congregation would suss out who left the donation to recognise her during the church service. She felt truly injured by the omitted recognition, as she really believed that the efforts of others were insignificant and that she'd done very much more of worth. She truly felt that the congregation must know it was her who left the annonymous care package and being overlooked was a sort of assault on her.
This is very common for our sufferer. Any job, she's had similar outrages over, always doing all the work for everyone but never being recognised enough for her superior skills, efforts, and goodness. She sincerely believes that everyone must know of her superiority; which means, failing to recognise it, is done as a way to hurt her. She feigns modesty, expecting the listener to correct it. If it's not corrected, she feels that she's been called down/ injured again. The list goes on...
She doesn't have a physical pain affliction, the conditions aren't inherently emotionally painful; yet, there is a great deal of terrible suffering. So what is suffering?
Some Perspectives on Suffering:
In 2013, I had the privilege to join a Dialectical Behaviour Therapy (DBT) group. DBT is rooted in Cognitive Behaviour Therapy, Eastern Dialectic philosophies, and Zen. Dr. Marsha Linehan, developed the program with Borderline Personality Disorder sufferers in mind.
The goal is to learn coping skills and helpful behaviours for dealing with intense emotional disregulation. In order to do this, learning to accept the challenges and pain of the disorder with a dialectical perspective (both good and bad side of the intense feelings etc.), can mean the difference between pain and suffering.
In the 2500 year old tradition of Buddhism, practitioners are taught the 4 Noble Truths. The first of which is, Dukkha. Dukkha in essence means suffering, that all living beings have suffering/ it is part of life. Some western philosophers jump on this definition and use semantics to show that Buddhism is moot, explaining that it means you have to die to be free from it. This view ignores the remaining Noble truths and most of the religion, though.
Dukkha has been elaborated on, and definitions have come out as: pain, stress, or dissatisfaction. This helps a little with a better understanding. The 2nd Noble Truth is that Dukkha has a cause. The 3rd , that it is caused by desire, aversion, and delusion (of self or of a permanent self, separate from others). The 4th Noble truth lays out the foundations of basic Buddhist thought on how to get out of Dukkha, called, “The Noble Eightfold Path". I won't elaborate here, as I'm still focusing on defining suffering and not Buddhism.
To sum up the Buddhist view: Just as in Zen Buddhism influenced DBT, there is an implication that, while people must endure pain and challenges those can be separated from enduring suffering. Suffering takes on a different meaning as something that overshadows the actual nature of our experience, rather than the immediate truth of things as they are. Another aspect is that suffering is, on some level, brought upon us by ourselves (our own mind); whereas, pain could be either intrinsic or extrinsic.
In the Meditations of Marcus Aurelius, he says, “If you are distressed by anything external, the pain is not due to the thing itself, but to your estimate of it; and this you have the power to revoke at any moment.” This is a fairly good summation of the stoic approach to the matter.
Above, the translation “distressed" more resembles what I've been calling “pain", and is meant to include conditions of both, mental and physical pain. Those are things that happen to us in life. It again separates this from what we do internally, with the situation. In the translation the word “pain" more resembles what I've been calling “suffering”. We can see how easy it is to use terms interchangeably despite having an experiential difference.
In stoic philosophy there's less of a specific path to adopt and more a view on how to handle life. It is where clichés like, “Water off a ducks back”, come from. Holding your attention to a sort of direction that allows for pain to be what it is, a temporary condition.
How do we differ between Suffering and Pain, when evaluating someone's predicament?
Evaluating Someone Else/ AKA Judging:
“Look at her,” he remarked snidely, “she's perfectly happy. She doesn't need all those med's and there's no reason for her to be out of work at all!”
A friend was commenting on a person who'd long been enduring a chronic pain condition. If someone were to judge his own behaviour that way, including use of meds and extended time off of work, they'd get an earful; after all, he's suffering.
In his mind he has real suffering but endures it anyway. Back trouble and mental illness are the pain he's familiar with and judges other people’s pain in relation to how he displays and deals with suffering. He sees his own efforts but couldn't see effort in the other person; after all, she wasn't "suffering."
When my friend suffers, everybody knows about it. On one hand he alludes that he's coping well/ being strong, but with that, he also shows overt symptoms of the suffering. Whether it's a psychiatric issue or his back, he'll sit with clenched fists and tears welling up, in silence yes, but making no real attempt to hide it.
If he's experiencing psychiatric suffering, when people speak to him, he won't respond until they ask what’s wrong, he'll listen to a depressing song on repeat, or talk about how he never had a chance in life. Even if it's unfair to those of us who started life with less or went through objectively more difficult trials, he gets wrapped up in his suffering and blocks the rest out. It's something that overshadows life.
If it's physical pain he's suffering, he makes sure to display that he's got an ice pack and tells everyone that he had to use a linement (if they don't mention the smell) etc. He also points out how difficult things are to do.
My friend can actually be very compassionate when he sees what he relates to suffering in other people though. He's quick to lend an ear or hand to someone when he views their challenges as things causing suffering. He's not particularly judgemental when it comes to evaluating what makes a person right or wrong, good or bad, etc. either. So what happened? Where's the disconnect?
His opinion was formed in much the same way as anyone else's. His experiences and information (or ignorance) formed a simple evaluation. He just gauged the other person's situation based on his own behaviour when suffering. In his experience, pain that deserves real compassion is something that causes suffering and a display of it.
In this case, my friend noticed that the chronic pain sufferer wasn’t doing much and was unable to move early in the day, so chose not to do some house work at the time. Later she was happy, enjoying herself, and even went outside. My friend decided, if she was in pain, it must not be bad. If she could cope with it for an hour, smiling, joking, and displaying a good mood, most of it must be in her head or she might be faking it altogether. My friend, like the majority of people, decided that her lack of suffering demonstrated a lack of pain.
So if we judge based on our experiences, is suffering really more deserving of assistance and compassion?
Pain vs. Suffering and Whether to be Compassionate and Helpful:
In the last section, I gave an example of judging another person's situation. Opinions and comments, like my friend’s, are very common given the situation. Ask anyone with an “invisible illness" or pain conditions not readily noticed, and they'll have stories about being spoken of the way he did about the lady with chronic pain.
My friend felt that suffering is worth compassion and assistance but not pain in and of itself. Further he, as so many do, determines suffering based on the outward display of it. To him, if the suffering is apparent to others it must be much worse than pain alone. It deserves special treatment, medication, and accommodations if a person is suffering.
We do, as Buddhists and Stoics agree, all have pain at times. Anybody can end up with a headache, cold, stomach cramps, and general aches and pains. In life we all come across failures and endure difficult losses. It's easy to relate someone's pain to these general daily troubles when they don't seem to be truly suffering, and display it in a way we're familiar with.
If suffering is something that we experience because of our own internal views and conditions and is something we unintentionally do to ourselves, how much extra compassion do we really deserve? Do we earn compassion points by sharing our level of misery, even if it's self-inflicted?
After that question, we may be tempted to swing the other direction. We might be tempted to think of my aunt or the lady suffering from chronic pain, in the previous sections and make a judgement that, their situation truly called for more assistance whether they 'suffered' over it or not. Then pain seems more compassion deserving.
How about Charlie Chaplin, whose external conditions could easily predict pain but who still seemed to manage to overcome most suffering? He also achieved an amount of material success to be able to cope with most things independently (aside from a return to America: YES, I'm encouraging people to read his autobiography again). So what degree of help did he need?
PTSD  is something most of us are familiar with. A trauma is an experience/ pain that comes upon us when we are unable to cope with it. It delivers a shift from what we can anticipate/ is outside of our view of “reality”. PTSD is suffering firmly attached to specific extrinsic pains. Surely it deserves compassion and assistance.
Whether you have or show compassion for another is up to you. There may be no perfect way to determine who needs or deserves help. I like to think that we can remind ourselves; whatever the situation is, we don't have all of the details.
We don't experience someone else's life, but can be fairly certain that they've had a range of challenges from discomfort to suffering. Unless we visit it upon ourselves, it won't add suffering to our lives by giving a moment of compassion, reserve our irrational judgements, and where possible, lend a hand.
 "Definition of kyphosis: exaggerated outward curvature of the thoracic region of the spine resulting in a rounded upper back. (Merriam-Webster Dictionary)
 "Narcissistic personality disorder — one of several types of personality disorders — is a mental condition in which people have an inflated sense of their own importance, a deep need for excessive attention and admiration, troubled relationships, and a lack of empathy for others." (Mayo Clinic)
 Post-traumatic stress disorder (PTSD) is a mental health condition that's triggered by a terrifying event — either experiencing it or witnessing it. Symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event. (Mayo Clinic)