Misery is fundamentally a psychological thriller. The escalating horror stems not just from explicit violence but also from its strong connection to reality. A central theme is the "reasonableness" of insanity. Annie is both shrewd and sly, either in spite of or due to her paranoid delusions. Paul, the imprisoned author, needs to adopt some self-deception to comprehend and predict Annie's behavior, allowing him to produce his finest novel under her immense pressure. Throughout the novel, the line between sanity and madness is in constant flux.

Paul's fight for survival can be seen as a test of both intellect and endurance. He names his conflict with Annie and his novel "Can you?," reflecting a storytelling game from his childhood. During his harrowing experience, he continually repeats this question like a mantra, which drives him to persevere. His habitual response is, "Yes, I can."

Ultimately, enduring pain equates to misery—a concept that gains depth as the novel unfolds. Misery is also the name of Annie's pig, symbolizing raw existence in a harsh, mindless world while highlighting absurdity in extreme circumstances. The pig, after all, is named after Misery Chastain, the fictional protagonist of Paul's popular, sensational romance series. Writing Misery's Return serves as an escape from Annie's torments; Paul becomes a Scheherazade to Annie's sultan, as well as to his own sense of identity and determination to live. In the end, misery is equated with survival: life inherently involves pain. Recurring motifs, such as sharp teeth and exotic caged birds, emphasize the theme that a miserable existence is preferable to death.

Paul Sheldon thinks, early in Misery, that he “wrote novels of two kinds, good ones and best-sellers.” Later, he comes to understand the snobbery of this and to appreciate that popular fiction must have its own integrity, its own quality. One can see the novel originating in part from King’s musings about his own situation as a cultural icon and about what does and does not make good writing. The novel also offers striking descriptions of the writing process, the experience itself as well as its joys and travails.

Annie Wilkes seeks to control Sheldon, but she cannot control herself, while Sheldon, through self-discipline, finally triumphs. She is greedy—keeping Sheldon as her captive, urging him to tell him the ending before he has written it—and, during her depressive episodes, a horrendously sloppy compulsive eater. Annie becomes as dependent on the unfolding story of Misery’s return as Paul is on the care and drugs Annie provides. Interestingly, back in New York after his ordeal, Paul is himself sliding downhill, replacing his painkillers with alcohol, until he begins his next story.

It is easy to see King implying that self-control is a masculine virtue and that appetite and smothering control of others are female vices. Certainly, fat, controlling females are often sources of horror in King’s fiction, such as Eddie Kaspbrak’s mother and wife in It (1986). Still, Annie Wilkes is no embodiment of femininity; she is portrayed in some ways as frighteningly masculine. Moreover, whatever King’s social views, Wilkes herself is sui generis, above all an individual—and above all crazy.