Dolorology (PAIN) with Rachel Zoffness

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Oh hey, it's that smoothie cup you should have washed yesterday. Alleyward back with an episode of Ologies you will. Let's get into it. Dolerology dollar means pain in Latin. Dolerology. It's the study of the nature in management of pain. It's a real thing. As it turns out, the folks who study it are pretty fired up about talking about it, and it turns out a lot of listeners are like, I have questions. So this ologist reached out to me, told me that her mission as a neuroscientist is to

Four?

Four for four, that's kind of a lot. Three. No, I'm three. I'm not downing. I'm saying that sounds painful. And after we battled some Friday afternoon traffic, we arrived at this ologist's Oakland office with Los Angeles style punctuality, and then we settled into our couch to chat pain. Turns out she knows her stuff. She has long brown hair. She was wearing knee high boots. She has a very

Rachel's softness.

Rachel's softness. She her got it of dolerology. It's a thing, it's a thing. Okay, how long have you known this word?

The honest answer is since I decided I wanted to be on ologies.

I'm not kidding.

I was like, I know there's a word because I do pain psychology, which is an ology, but I study pain science and pain neuroscience, which is outside of psychology, and there's a word for pain science, which is dolerology.

What's the the worst pain You've ever been in?

Oh?

Wow, the worst pain I've ever been in. I had chronic pain as a kid, and I was always I had like constant abdominal pain. But as an adult, I also had a running injury and it lasted for five years and I was like on the couch for the better part of a year.

So that was probably the worst one.

What do people say hurts the most. I've heard kidney stones, I've heard birth, I've heard shingles, I've heard bullet ants. How do psychologists figure it out?

So the honest answer is this, people are trained to ask people about their pain on all these pain scales. And there's a lot of pain scales out there, and the most common one is out of ten? What is your pain on a scale of zero out of ten?

Yeah? I just did that to Jarrett outside for probably the one hundredth time since his surgery two weeks before.

And the funny thing is, and it's actually not funny at all. Sometimes people will say my pain is a ten out of ten, and it will be something that health care provider will think should not be a ten out of ten. So the health care provider will say to the patient, well, imagine someone taking.

Off your arm.

That would be a ten out of ten. So now tell me what your pain number is to try and get that person to lower the number, like sort of suggesting to the patient like, oh, you're exaggerating, But in my mind, what's worse? Like can you do anything worse to someone who's suffering than say, like the number that you gave me is inaccurate. The answer is the most

That's a good answer, okay. And when people are studying how sharp pain is, how do you even know.

That is all you have? There's absolutely no other way to measure pain other than what someone tells you. So if someone says their pain is ten out of ten, that's what their pain is.

The end.

I mean, that's also why it's really hard to compare, Like, you can't compare your pain to my pain. Like you break your ankle, I break mine. But if you're a ten out of ten and I'm a five out of ten, it's not like one of us is lying. Yeah, Like your pain experience is unique to you.

And as a kid is someone who experienced chronic abominal pain, which I cannot imagine this one in a running injury.

For five years.

Were you in a position to choose your career at that point when you had a running injury. Were you like, you know what, I'm going to change my major. When did you decide I'm going to crack this code? Because you are super passionate about this, Yeah, you're like, I looked up the word for this, I wrote a book about this. I want to talk about it. Yeah, yeah, where does that passion come from?

So when I was in college, I knew I wanted to live at the intersection of a bunch of things, Like I was fascinated by neuroscience and psychology and science writing and working with kids and medicine, and I just I wanted to find this thing that would let me live at the intersection of everything. And I took a course a neuroscience course in my freshman year brand because I was a nerd. Like to be clear, I was like a library mouse, had no friends in high school,

So pain is in the brain. Big revelation here. Much more on that in a.

Bit so, And it's this thing that goes across psychology and medicine. Effects adults, it affects kids. It had affected me as a kid. So when I went to do my honors thesis, my mentor, who's a dear human being who recently actually not so recently passed from cancer, said to me, there's this researcher here who studies pain. You should see if he'll take you on as a mentee.

So Rachel will explain the gait theory of pain in more detail later and how essentially kissing an Awi does a sweet neurological sleight of hand, kind of like a cool button Mitzvah magician. But in terms of her backstory, doctors Off got her bachelor's from Brown University in brain and behavior, two masters, one in psychology and education from Colombia, one in clinical psychology from San Diego State, and then her PhD in clinical psychology from University of California, San Diego.

And as a post doc after I got my PhD in psychology, I did my post doc in pain management and it was non pharmacological approaches to pain, and I just went back down that rabbit hole and it was just so interesting to me that there were all these ways of treating pain that don't really get talked about in medicine or at all in psychology. Like if you're a psychologist, you never learn about what we call physical pain never, and physicians very rarely talk about the psychological

Can I tell you a story?

Yeah, yeah, that's what I mean for.

One of the first kids they sent me was a kid who had been in bed for like four years with chronic pain.

Yeah.

He had chronic migraine, chronic body pain like diffuse amplified body pain. He had been on about forty medications, including thorizine.

Okay, I want to do like an hour long aside on thorizine, but I'm gonna make the snappy instead. I'm gonna put it in bull of points. Invented by a French doctor in nineteen fifty two to help with pre surgery, anesthesia was also used as an anti inflammatory. Now primarily used to manage hallucinations and mania and some symptoms of schizophrenia, but it's also been prescribed for everything from behavior problems

Needed, like knocks them the f out. And this is a child, and he was on thorisine for his pain, and it would knock him out for days at a time. So he wasn't going to school, he wasn't seeing friends, he wasn't functioning.

It was wild.

He had seen like more than fifteen physicians, and I had been reading there's all these protocols for treating chronic pain in both adults and children. And I had worked with a number of other patients, but I had never worked with a kid who had been in bed for four years. And I almost called the referring physician to say, I can't do it, Like if you guys can't do it,

Yes.

I know, it's a dubious decision, and I said, I can help you, but you have to do everything I say.

And I knew.

I mean, especially as a pain psychologist, nobody wants to go to a psychologist for pain because pain is sold to us as this purely physical or physiological problem. And if you go to a psychologist, the popular thought is, oh, they're saying it's all in my head, or they're saying my pain isn't real, or I'm faking it right.

But that's not true.

There's all these treatments that are evidence based for pain, that are non pharmacological. So I said to him, I can treat you, but you have to do everything I say. He said okay, and we went through this cognitive behavioral therapy protocol for pain management, which is now what I live and die by. And we started out doing very small things.

At first.

It was like just stand on your porch in the sunlight every day, and even that was hard for him.

And we did like a lot of work together.

So then it was like walked the corner mailbox and mail a letter and you know, and he was doing pt and OT at the same time. And then it was like, can we get a tutor to help you catch up in school. It was like small bits of activity, small goals, and really pacing him to desensitize his brain and body. Within three months, he was getting back to life. He was doing jogs around the block. He did get a tutor, he caught up with friends. He eventually went back to school in soccer.

Wow.

Yeah.

And the more he did, the more he realized he could do, the more his brain desensitized, the more his body was able to function, and he was able to get back to life and his pain remitted and his anxiety and depression did too. And he actually graduated from high school a couple of years ago, and he invited me to come. My god, Yeah, So I went to his graduation and this kid he got on stage and he said, if you had told me four years ago I'd be graduating from high school, I never would have

Ever.

The way we mistreat pain just drives me nuts. So I think that really drives me. I think I went on a tangent like maybe a lot on Beautiful.

So before we learn how pain psychology works, let's just be be back it up and address the fundamental question. What is pain?

Right? What is pain?

What is it in? How much is it? Yeah, mind? How much is it body? How much control do we have over it?

You're asking amazingly hard and awesome question, and I'm going to answer them. So you can ask forty different people and you'll get forty different answers. And I'm going to try and sqush all the things together and make it as like digestible as possible. So if I don't do a good job, I'm gonna rely on you to.

Calm me out.

So pain is your body's warning system. By that, I mean it exists to protect you and save your life. So I remember learning in this dorky neuroscience class that there are people who are born without the ability to feel pain. What Yes, And I remember thinking that sounds delightful, and then our professor said, yeah, and they don't live very long.

Oh fuck right, Because if you.

Imagine you put your hand on a stove and you don't take it off, you go for a run and you break your leg and you just keep running. Because pain is actually your body's danger detection system. But like every system in the human body, the pain system can fail. So one of the biggest errors we often make is humans is believing that just because you have pain, it means necessarily that a body part is damaged or broken.

Biopsychosocial.

Okay, yeah, what does that mean? Pain is biopsychosocial. So what that means is one hundred percent of the time, whether your pain is acute, which means short term, so any pain three months or less, or chronic pain, which is pain that's three months or longer or beyond expected healing time. Your pain lives in the middle of these three bubbles or domains that I'm gonna call it. So

Okay, pay attention. So Doctor's off is going to break down the three sources of pain, starting with biological.

In the middle of these three things.

So the biological components of pain are the things that you hear about all the time. So it's genetics and tissue damage and system dysfunction and like immune functioning and sleep and diet and exercise, and those are all very important when it comes to pain.

We all know that.

However, if you think about this ven diagram, if you're only focusing on the biocomponent of pain, you're actually missing two thirds of the pain problem. Because we know that pain is this biopsychosocial phenomenon, and I promise I'll explain why. But then there's this these all these psychological components and

So so here is the second source of pain. And also where I freak out.

In the psychological domain of pain, we've got believe it or not, thoughts, because neuroscience tells us that how you think shockingly affects how you feel.

So right, so if you imagine that you have this like if you imagine.

You have like this pain volume that lives in your brain, this pain dial when you have anxious, stressed out and depressed thoughts, pain volume actually gets turned up. So the things you think affect the way your body feels one hundred percent of the time. Then in the psychological bubble, we also have things like trauma, because trauma one hundred

When you have pain? What do you do?

So some people, including me, as I mentioned, for a year will stay inside on their couch, not exercising, not seeing friends, not moving, But what we know is that that's going to amplify pain also.

Okay, so those first two bubbles were biological and psychological. What is the third bubble?

And then there's the social or the sociological bubble and that's everything else. So socio economic status and access to care, I mean, if you're not talking about that, are you really talking about healthcare at all? Or pain or disease? Race and ethnicity and racism in particular, what does that do to your stress system and how does that affect your pain. There's also friends and family, like do you have a support network, do you feel like you're connected

No, it was great. It was visual, oh, and a fascinating fact. So the definition of pain has recently been

Right, but that that makes sense A and B, Like they have done all this research that shows you do have receptors in your body that respond to things like touch and temperature and like no susceptive input, which is like potentially dangerous input. But what they've discovered is here's like this really cool, really nerdy fun fact is that pain can't possibly live exclusively in the body.

But we all think that.

We all think like, well, if I have back pain, that means definitely there's something wrong with my back, right, Or if I have knee pain, that means that the pain lives exclusively in my knee. But here's how we know that pain does not live exclusively in the body. There's a condition called phantom limb pain, and phantom limb pain is when someone literally loses a limb like an arm or a leg, and they continue to have terrible,

And how do you know of those three bubbles, what is the biggest contributing factor? Like if you have a slipped disc in your back and that definitely hurts, versus if their X rays show nothing but there is chronic pain, how how do you know how to start to address it.

Here's the answer.

So the answer is all three things are always contributing all of the time, and yes, in any given moment, something in any one of those bubbles might be like activated or up, but they're always all three are always acting all the time. So there's always this like recipe for pain, whether it's high or low, and the recipe always one hundred percent of the time includes all three bubbles.

Tissue like yeah, and you're healing.

But so with acute pain, yes, you want to check that out and find out what's going on with your body. It's a little bit different with chronic pain. And I'm going to tell you why. But to go back to your original question, if we don't address all three things, we're not ever addressing pain. So if you imagine there's this like common analogy, if you stub your toe on a day you get fired, you've just lost your income and you don't know if you're gonna be able to

If you stub your toe.

When you're out with your friends eating ice cream, you're out in the sun, you're having a lot of fun, it feels qualitatively different to you. Your brain interprets the message differently depending on circumstance, environment, how you're feeling emotionally, where you are, who you're with, what's happening, how you interpret that the sensation. So the answer is even with acute pain all the time, all those things are working

And what about the biological methods that we have right now, Like how does aspirin work, how does leave work, How does ibuprofen work, How do opiates work, what are they blocking? Because sometimes that absolutely blows my mind that I can take something and a migrain will go away.

One hundred percent absolutely, yes, that is totally true. And all the medications work in different ways, but they target receptors in your brain to block what I'm going to call pain messages.

So yes, chemically it's pretty complex, but just think of pain relievers fitting and locking into places and thus just ruining the vibe of the pain messages. Real cock blockers.

But what's really interesting to me about opioids, by the way, and all these medications, but opioids in particular, because there's so much talk about opioids and pain, is that opioids work on an endogenous receptor in your brain. By that, I mean you already produce a chemical in your brain that opioids imitate, and they're called endorphins. So when you if you hear of like a runner's high after you go for a run, your brain produces this opioid substance

In side note, we're going to do a whole episode in the future on mechanology, which is the study of opium and opiates, including the epidemic of opioid addiction. But yes, medicines have pluses and minuses depending on their use.

And I also need to be very careful and clear with so I am in no way anti medication, Like I'm like a person who's like, thank God that opioids and other analgesics exist for post surgical pain and things like migrain and all the other horrible things that happened to human beings, like super helpful, super wonderful and very important.

Google opioid induced hyper algesia. It's like a closet just stuffed with items, but instead of umbrellas and bowling balls falling onto your face, you're just going to be covered in studies about pain and opioids, so doctor Zoff explains.

So, actually, what happens over time is that your brain gets more and more tuned in to the sensory messages coming from your body. So if you ever try and go off, of course, you're going to feel awful and terrible. And again, I am not anti opioid, I'm not anti medication, but it seems important for people to know that long term, their brain is going to get extra sensitive.

Now, what about someone who is experiencing pain, let's say it's chronic, let's say it's ongoing. Where do you even start that CBT or something that is non pharmacological, Like do you just do like a pain check in? Do you just sit and try and figure out like what hurts where and why?

Can I answer your question in a sort of backwards way, yes, So chronic pain is its own animal. It's considered its own disease process. So here's what happens with chronic pain. So to answer your question, the first thing that I do is I explain how pain works. And I always ask people who come to my office who have been in pain for like ten years, Hey, has anyone ever explain how pain.

Works to you?

And they're like no, One hundred percent of people say no, which is so wild to me, Like you've had pain for ten years. People will explain how the liver works, but they've never explained how pain works. That's crazy pants. So we've established that pain is constructed by the brain, of course, in conjunction with the body. We've established that a cute pain and chronic pain are different. They work differently.

Absolutely, give me a thing ukulele.

Oh that's the best one. Yes, great? Great.

Have you noticed with the ukulele, like eventually your fingers sort of know what to do?

Yeah? Yeah, absolutely, And I can go faster on a song. I never have played in front of anyone. It's just something I do because it's fun to do alone.

You know.

If I had known that, I would have demanded that you no, you can't.

Do it in front of him. But yeah, and I can, and I can think about the song before positioning each finger.

Yeah, so totally right.

So I'm gonna say it back to you a little differently, in like the neuroscience nerd way. Okay, the pathways in your brain are like the muscles in your body. The more you use them, the bigger and stronger they get. So if you said to me, Zoftness, I want huge biceps, I would say, Ali, of course you do go to the gym and lift weights a lot, or like actually be isolated at home. Whatever, Yeah, lift weights a lot, and over time your biceps will get big and strong.

But it's having a.

Picnic with your friends dangerous And the answer is no. But your brain is producing these danger messages and telling you should go home and isolate and be alone and not move and not see your friends. And that is a big fat lie. And if you listen to your brain and you do those things, and you go in isolate and you lay on your couch for forty years, you are not going to get better. So the treatment for chronic pain is the total opposite of what you think.

It is.

Your body and your brain are telling you isolate, stay home, don't move. And the treatment for chronic pain is like my metaphor is like if you've ever been in a dark room and someone opens the blinds a little bit.

And you're like, ah, close the blinds.

I can't see because your brain is sensitive to light when you've been in a dark room. But if you sit there for two minutes, your brain desensitizes to the light and then you're fine, right, And if they open the blinds a little more, you're.

Like, shit, close the blinds, I can't see.

And then eventually, two minutes later, your brain desensitizes you're fine. Treatment for chronic pain. And that's what cognitive behavioral therapy is. By the way, it's helping someone's brain and body desensitize to little bits of stimulation a little bit at a time until like someone who's in a dark room, suddenly you're in a room full of light, gradually, little bits at a time, and your brain and body are OK. So that's the treatment, but you're you're not going to

And is the amygdala it all involved in this? Like is anxiety and fear? Is that a big part of pain perception?

Yeah?

Ah, had a feeling old amy up there? Fucking shit up.

One hundred percent?

Yeah help?

Yeah, okay, So crash course in pain neuroscience, PAINAROS signs one or one.

Here's how it goes.

Ready, okay, I'm so ready. Let's hear what parts of your head are being a literal pain in your ass.

So there's lots of parts of your brain that contribute to pain. With some things, it's like, oh, there's just one part of your brain, but with pain, it's a diffuse neurological process. And what that means is there's lots of parts of your brain that contribute to this experience we call pain. So I'm going to tell you a couple of parts of the brain.

Okay.

One is your cerebral cortex. Okay, your cerebral cortex is the part of your brain responsible for thoughts. Thoughts contribute to pain all the time. The second part of your brain is your prefrontal cortex, and that's the part of your brain responsible for executive functioning and attention, what you're focusing on, what you're thinking about. And the third part of the brain is your limbic system. Yes, your limbic system, and your amygdala is a major part of your brain's

So yes.

So now I want you to imagine we sort of touched on this earlier, that you have what I'm going to call a pain dial, like the volume knob on your car stereo, and you can turn it up and down. And it lives in your central nervous system, your brain and your spinal cord, which work together to control all the shit, including pain. So here's how this works. Lots of things can change pain volume, whether it's a cute pain or chronic pain, whether you've had it for five

Oh no, I know. Right during a pandemic.

During a pandemic, chronic pain during the pandemic went through the roof. Opioid related overdoses went up forty percent, Calls to suicide hotlines went up eight thousand percent. Oh my god, dude, people are suffering. People are really so people in pain because of all the snur signs we're talking about. It makes sense, right, So stress and anxiety. Thing two is mood and emotions always change pain volume, and thing three

So, so again, that was stress, emotions, and attention.

When stress and anxiety are high and your body and your muscles are tense and tight, which is what happens when you're stressed and anxious and your thoughts are worried, your brain sends a message to this pain dial, turning up pain volume. So whatever pain you had before, when you're stressed or anxious, like you just lost your job or it's a pandemic, or like whatever you're stressed out because you're fighting with your partner or whatever, your brain

We've all had that experience. That is not magic. That is your brain's pain dial.

So your brain, your prefrontal cortex will lower this pain dial when you are absorbed in things and you're not thinking about your body and you're not thinking about pain. So that's why when you go to give a child a vaccine, which everyone should do and get an injection, you give them a screen and they can watch their

And so what are some of the first steps If someone doesn't have the privilege of being your specific patient, for example, or maybe they're psychologists or their medical doctors don't have this much information and their brains about it, where do you start with? People? Do you start with? Just like start meditating, go on the porch? Where do you even begin?

So I do this treatment called cognitive behavioral therapy, and there's a lot of misunderstanding and misinformation about what that

Come to my house.

We're going to have a party in my backyard. It's going to be really fun. And you have this thought in your head. You think to yourself, I am a loser and nobody likes me, and if I go to the party, no one will talk to me and I'll just be standing by myself.

At this point, I was feeling depressed and ashamed.

That thought is going to afect your emotions. How might you feel if you thought that thought?

Oh, depressed and ashamed?

One hundred percent?

Yes, yeah, right, So you're feeling depressed and miserable and ashamed. So how does depression affect your body?

I think I would have a harder time getting up and getting ready for it, that's right. I think I would sink into whatever soft fabric I am sitting on at the moment.

One hundred percent.

Yes, So we know that negative emotions impact the body, right, And I'd like to say that negative emotions don't just live in your head. They also come out in your body. And if you've ever been stressed out or nervous and your palms get sweaty and your mouth goes dry and your heart races, of course, emotions come out in your body. Or if you've ever been depressed, you know that you

You sink into a couch and then I send a text about being on deadline, which is.

A love right, right, and you like put on your fuzzy pajamas and you get a tub of ice cream and you binge watch Netflix totally exactly, but the cycle spins around. So now you're missing out on the party and you're sitting on your couch and you're in your pajamas, eating a tub of ice cream, And what are you thinking to yourself? Now, I'm a rock star. Are you thinking, I.

Know I am the lizard that I thought that I was.

Yes, yeah, And that's what we call the cognitive behavioral therapy cycle of how thoughts affect the brain affect the body.

Right. But now let me give you the opposite. Someone says Ali Ward. Come to my house. We're having a great party. You can wear whatever dress you want, put on your.

Nice to shoes, and you think to yourself, I am a rock star.

People love me. I'm the life of the party. I'm gonna break dance.

I'm gonna pull out my break dancy moves, and I'm gonna like bake brownies and like bring them.

Everyone's just gonna think, how does that make you feel? Oh?

I lighter and excited and a little nervous.

Great love that consolation of emotions, right, excite, totally excited, a little nervous.

So how does that affect the body?

Usually when you're excited, you have a lot of energy, you know, you feel like motivated, And then what's your behavior?

What do you do?

Definitely put on lipstick, do some mascara, dig out the liquid liner, bake some brownies, eat some of the batter if I want to totally yeah, and maybe even leave the house on time.

That's right, So you go to the party, that's right. You show up at the party in your dress and you bring some brownies. Chances are pretty high some person is going to be talking to you. And if you're really feeling like if you're thinking I'm a rockstar, I'm gonna have fun, chances are high you probably you probably will, You'll tract someone to come talk to you. Right, So, the things you think affect the things you feel affect

Also.

When you have pain, a lot of the thoughts that I hear are I'm broken, I'll never get better. Nothing has helped me, so nothing is going to help me. Why bother?

Right? And that makes you feel anxious and depressed.

And what we already know from pain neuroscience is that that's going to amplify pain. So your body's going to feel worse, and how are you going to act as a result. You're going to stay inside on your couch with a tub of ice cream and your snuggie or whatever, and it's going to be very hard for you to

Right, So it's like, what is your cycle? How do I help you break it?

And you can break it by going after the thoughts, and you can break it by going after the emotions, and you can break it by going after the behaviors. So what I happen to like to do with my patients the best is change behaviors first.

Oh so you go backwards on the wheel.

So I should have said this. The wheel can go in any direction.

Because if you think about it, if you just start with the behaviors, you're laying in bed for five years? Yeah right, what are you thinking? And Harry, you feel like you can start. That's what I like about the wheel. Everything affects everything. It's multidirectional, it's always spinning in every direction. And what I like about behaviors is like, thoughts are really complicated.

It's really hard to challenge your thoughts.

But with behaviors, it's like, Okay, what's one thing I can do today that will get me off the couch?

Like I want to make fudge?

Can I send my friend out to help me buy ingredients?

And like walk to my kitchen? You know?

So what are small little things I can do to

And so do you ever recommend having like an accountability buddy or a journal or what's a tool that you can use to kind of keep your mind in the CBT other than a therapist in a workbook.

I love accountability buddies definitely. So science shows that social support absolutely always changes the brain. So if you have someone you can do the things with one hundred percent, Yes, I do also like journaling. I think that's very helpful too, because when you write stuff down, you're your own accountability partner sometimes and when you write stuff down, you can track your progress and you can see your change like, oh, I did that thing, and then I felt.

More of what motivated to do that thing.

I do also think that workbooks are useful for people, and they're sometimes really dorky, but it's like a guided path toward accomplishing a goal.

And it's very hard to know what to do.

Like here I am spouting like I'm making it sound easy. It's so hard to live with pain every day. It's so discouraging. It's so hard.

So Doctor's Offness says, working with anyone on this can be helpful, whether it's O a friend or a partner, an accountability buddy, or you can get a physical therapist or an occupational therapist, any therapist who could maybe go with you through a workbook, or you could try to find a pain psychologist, which is what exactly?

So what is pain psychology? Again?

I wanted to live at this intersection of neuroscience and medicine and psychology and helping people in science writing and

How your brain is working.

But it's also changes in stress and anxiety and what's happening in your environment around you and diet, and it's all the things working together, right. Yeah, So a pain psychologist looks at this complicated picture and tries to figure out what do we need to do to help your pain and what does your pain recipe look like? And I want to tell you what a pain recipe is.

Since she explained this to me, I have thought about it every single day since.

So a pain recipe in my mind is like, I don't know why I'm talking so much about brownies.

I must like just really want them.

But if you're someone who like bakes brownies. You know, there's a recipe for awesome brownies, and it's like you have to mix these particular ingredients together and particular amounts of them, and you have to put it in the oven for a particular amount of time, and if you don't, the brownies are not going to be cooked, or they're going to be burned, or they're going to taste really disgusting because you've forgot.

The chocolate, you know. So, and it's the same with pain.

There's always a recipe for high pain, like a really bad migraine day, and there's always a recipe for low pain, like a day I'm feeling awesome. And if you ask people, they will all often know what their high pain recipe is.

Oh. Absolutely. With migrains, I know exactly like not enough sleep, not enough water, stressful day and I and I know that it's got to have those three usually those three factors, and it's like, don't.

Baby, you got it. Yeah, that's exactly right.

And so so the trick for me is, if we know what the high pain recipe is, how do we puzzle out what the low pain recipe is? So you're right, like sleep on high pain recipe it's often like this combination of sleep and I'm not eating well and I'm like fighting with my partner, or there's a lot of stress at work or you know whatever. There's like a lot of other stressors and things going on in my life too, and I'm not exercising and I'm not taking

My body and managing my.

Stress and anxiety and staying hydrated, and you know, putting limits on toxic relationships and saying no like I have a problem saying no, Like I say, people come to me and they're suffering, and dude, it is so hard for me to turn people away and say no, or like do things where.

I'm spreading this to me feels so critical this.

Information about pain, and I have opportunities to do that and I want I want everyone to know and to have power over their bodies. So anyway, there's all these lines we have to draw in the sand if we want to have a low pain recipe, like how do we take care of our bodies in any given moment so that we're going to feel okay? So that is my like down and dirty, like what does a pain psychologist do?

Oh?

I love that.

I love that thinking of it as a pain.

Recipe one hundred percent.

Yes.

I have so many questions from listeners. Can I fire them at you?

Oh? You do? Yeah? Oh wow?

Because pain is like that's the thing that's like exactly why I want to do stuff like this. It's like, pain is this ubiquitous human experience that no one has been told anything about.

It makes me mad, I know.

But real quick, before we take your questions, we're going to give some money away. Each week we donate to a charity of the ologist's choice, and Rachel says that she sometimes sees kids with medical conditions who come out as gay or trans over the course of their treatment, and she says she's always so honored to be part of their journeys and that more safe spaces need to be created in medicine for kids to talk about gender and sexuality, especially because suicide rates are so high in

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Okay, let's start by answering your burning curiosities about fiery redheads from patrons Mark Heulette, Jason Krauss, Andrea Marsh, Carly Lowe, first time question askers Melissa Avignon Redford, Aaron Sorenson, Alyssa Benson, self identified smoking hot redhead, Nina Giacab and Okay, Nadine says, I've heard that redheads have a different pain tolerance than the general population. Is this true? Nadine is a first

You?

See my gray roots? So I am not a real reddit, but yeah, what's going on genetically with that?

Here's the honest answer.

And by the way, you know a good healthcare provider when they give you this answer. The honest answer is, I don't know what the research says.

However, I will tell you this if.

You are someone who is sensitive, and I have absolutely no idea if there's any actual data on whether redheads are more sensitive than any other person. But if you are someone who is sensitive, and by sensitive I mean you were a sensitive child smell and touch, and your senses are heightened, or you're emotionally sensitive and you pick up on things that means by the by friends and listeners, your brain is sensitive. When your brain is sensitive, guess what,

Okay. I looked up this flim flam this weird myth about redheads and anesthesia because it's so annoying that it persists, and I found out, get this, it's true. Research backed this is real, y'all. So you can see the two thousand and four study in the Journal of Anesthesiology titled Anesthetic requirement is increased in redheads. They're like, here you go. They found that redheads are more sensitive to pain. They need significantly in quotes more anesesia than people with dark hair,

You know, being sensitive is recognized as a predictor of pain and chronic pain, development of chronic pain. By the way, trauma makes your brain more sensitive. Why because trauma, having trauma as a child, your brain needs to be sensitive. It's adaptive, Like if something terrible has happened to you, your brain is always scanning the environment, your internal and external environment, like is a bad thing happening?

What about now? What about now? Is their danger? Is their danger? Yeah?

So if you have had trauma, your brain becomes more sensitive.

At least Fan Meerbeek wants to know. Is there an observed relationship between pain tolerance and genders?

Ooh, that's so interesting. So what we do know is rates of chronic pain are higher in women in Okay. The thing about pain tolerance is I don't exactly know what that word means. It goes back to that super subjective pain scale, that pain rating measurement, where you know, you ask two people or twenty five people, you know, does this hurt and how much? And everyone's going to

Yeah, I wonder if they've done studies too on people who are gender nonconforming and how much trauma that they've experienced too. I'm sure there's quite a bit of that.

I'm going to guess there's almost no research on that because not enough research has been done on that.

But should there be definitely?

Yeah, I wish that this had a name. Oh it does. It's called the gender pain gap because for many, many hundreds of years, people who were not men were just not included in research, which hurts. And I want to get real spicy about it. Speaking of America, Caku says, can we talk about the TRPV one receptor and pain tolerance with spicy foods? Is there any relationship between spice

So the answer is yes, you have receptors in your mouth okay that respond to touch and heat and sensation. So you have sensors on your tongue that pick up on how hot or spicy a food is, but it doesn't become interpreted as pain until it gets to your brain, and your brain inputs all the other information also, So people who can eat extremely spicy food usually are people who have been doing it for a long time, and they started with load medium and over time they.

Worked their way out to super spicy. And guess what's happening.

Their brain and their tongue are desensitizing over time, like being in that room, that dark room, and it gets a little bit brighter at a time, So you can develop a really high spice tolerance if you want to, using this grated exposure a little bit at a time.

So fun fact, birds can't taste spicy, but squirrels can, which is why some bird seed is sold laced with hot sauce. So squirrels would be like, fuck this. Who am I? Paul Rudd? What is this? A YouTube show about hot wings? But birders say better just to get a squirrel proof bird feeder and to help prevent the spread of bird diseases, make sure to clean your bird

It's got to be. I don't know the data. I mean, these questions are so amazing. I don't know the data on migrain and rain, but I have so for me. I live with chronic leg pain, and my chronic leg pain also changes with weather. Changes, so before rain, my leg will also throb. So I've heard people say that that's like I hate this phrase, like an old wives tale whenever that means. But I've heard people say that that's not evidence based, and I've never looked into the evidence, but now I'm going to.

And I don't know if.

There's sufficient data to show, but it would make sense to me that would be part of a pain recipe because of course there's barometric pressure. Like if the chain environment around you changes, yeah, it seems reasonable that your pain would change too.

I had to look this up and sure enough, there's a twenty nineteen study titled Blame It on the Weather, The Association between pain in fibermyalgia, relative humidity, temperature, and barometric pressure. Someone's out there asking these questions. So the short of it is that lower barometric pressure was associated with more pain in fibermyologia patients and our right of spatients and even people with migraines. But the cause it

Oh my god, that question makes me so deeply happy. There are these wonderful, wonderful researchers who study social neuroscience. I'm going to answer your question a roundabout way. And they studied the neuroscience of social exclusion and I end being ostracized. Oh, the science of ostracization, which is a very hard word.

To pronounce, ostracization.

And they found that social and emotional pain maps exactly onto the parts of the brain that process physical pain.

So is there a difference?

Yes, do they overlap and affect each other one hundred percent of the time. Yes, does emotional pain hurt physically?

You know it does.

Like ask anyone who's going through heartbreak how their body feels like you have chest pain when you are heartbroken. So emotional pain and physical pain, always, always, always.

Are connected in the brain.

It's funny because it's like looking at Instagram, you might as well actually be hitting yourself in the face with a frying pan. You might as well just do that.

Amazing, that was amazing.

It does hurt. So yes, physical and social pain overlap in an area of the brain called the anterior singulant quartix. And yes, Jade Balcolm Randall and first time question asker Carrie Anderson. Pain relievers can soothe broken hearts or at least smooth ruffled feathers. So for more on that, you can see the very directly titled aceda Menafin reduces social pain. fMRIs showed that acidamnifin reduced neural responses to social rejection and I don't know how they tested that, but I

Back pain is one of the most common types of chronic pain, and the answer to your question is if you're not treating it in a biopsychosocial way, your back pain's gonna stay exactly the same. So if you ask every single person you know how they've treated their back pain, I'm going to bet a bazillion dollars which I don't have to give you, but I do have the capacity to receive that they have been told to treat their

Great answer, Tabatha Waite wants to know why do some people hold their breath when experiencing high levels of pain? Asking for me love that right.

So if you remember that pain metaphor we were talking about this volume knob that operates. One of the things that happens when you have pain, believe it or not, is that stress and anxiety go up. If you ask human beings in general, what are the biggest stressors on human beings? Like death of a loved one, moving, but pain, Pain is one of the biggest stressors on a human being. It's so stressful to be in pain. So we do these things, like we clench, even sometimes we don't even

So holding your breath is a pain behavior. It's a clenching.

It's often involuntary because pain hurts, which is the most basic thing I've said, all that pain hurts, So you're clenching and you're trying to fight it off, and the irony there is, as we know from the pain dial, the more you clench and the more tense and tight your body is, the higher your pain volume is actually going to be. So I know, so somehow finding a way to help your body relax and be calm is actually one of the things that we're going to need to do to help a pain and by the way,

That makes sense. Quinn west I had a question, if you take medication that blocks pain signals, is the pain still there? This is kind of a philosophical question.

Great question, So I'm going to answer that with another question. If pain is produced by the brain and you're blocking the messages in the brain, are you actually blocking the pain messages?

I think the answer has to be yes.

Because you're blocking the messages that your brain is interpreting as pain. So the sensory signals coming from the body are not yet pain. So the sensory message is coming from the body, whether it's like a broken foot or a bad back, it's not pain until it gets to the brain. It's just sensory information. So when you target the brain in your treatment, yes, you're blocking the ability of the brain to interpret that message as pain.

Okay, So a lot of folks such as Roberta Amalia Kanti Cheese, Leona Schuster, Alice Claire, Dori Kaufman, Brent Mapis, Michelle Jacobs, Leela Weller, Lindsay Mixer, Catalina First time question askers Kelly Shaver, Andrew R. Cassidy and Arose, Monica Sweet and Molly had questions about fiber miyolsha, which is a disorder that causes pain and tenderness all over the body. It also causes sleep problems and fatigue. In my opinion,

There are no good tests for fibromyalgia, so diagnosis of fibromyalgia has been a shit show. There's like lots of different ways of diagnosing. It's like certain number of body parts has to be in pain. But as everyone with fibromioga knows, different parts of your body hurt.

In any different given moment.

So if you only have pain in eight body parts tonight, does that mean you don't have fibromyalgia. So there's no real great test, is the honest answer. But if you're living with fibromyalgia, you absolutely have a biopsychosocial pain recipe and we need to figure out what that is. And again, I always want to talk about the stigma around recommending psychology for the treatment of pain.

I live with that stigma every day.

I always recommend psychology for everybody living with chronic pain. Why because if you're not targeting the brain, you are not targeting pain, and psychology really goes down the rabbit hole of what are you thinking, how are you feeling, and how are you acting? So I would honestly, from the bottom of my heart, recommend a pain psychologist or even any psychologist for people living with FIBROMYLDRA.

In addition to all the other things you're.

Doing pt and OT and going for walks with friends and doing fun things and baking brownies.

So some pharmaceutical therapies for fibromyalsia are actually also used for neurotransmitter balance and the brain's ability to tamp down pain signals. And researchers who even tried low doses of naltrexone, which is prescribed for alcohol use disorder and opioid use disorder. But in many studies, cognitive behavioral therapy provided what researchers call worthwhile improvement in pain related behavior and coping strategies

Impass Oh my gosh, these questions are lighting up my brain. Yes, sympathy pain is real. So they do these studies in neuroscience where they look at a mother's brain and a child's brain, and if the child is suffering and experiencing pain, the mother's brain, the pain pathways in the brain light up as if she's in pain, which is why moms have such a hard time tolerating their children crying. Right, It's just it triggers you in that way. So, yes, we have mirror neurons in our brain, and we do

A lot of people who I will listen to, aside Marianna Hulsen, Dene Dryden, and Ashley Home, want to know how touch inhibits pain and if scratching or apply pressure helps alleviate pain. What's happening there.

I want everyone to know. I'm doing a dance of joy in my chair.

So I mentioned back in the day when I was a nerdy undergrad that one of the things that really excited me about pain was this thing called the gate control theory of pain. And the gate control theory of pain is just this nerdy neuroscience. It's like back in sixty five, these guys came up with this gate control theory of pain, and they forever revolutionized pain science. And it's still evolving there's the neuromatrix theory of pain now,

What's the first thing that you do. You rub your knee.

And the reason you rub your knee is because touch messages get up to the brain faster than messages that code for the sensory information codes for pain. So touch is actually one of the things that can lower your pain volume. So one of the things that can be on a low pain recipe for people, by the way, is getting massages and hugging people and sensory things that really make you feel soothed and calmed, like a snuggie

Hah.

So adopt a dog you got.

Yeah, or like rub your bashni or get massages, back massages or yep.

Maren Ellis first time question asker asks, why do we forget pain? I've had three babies with nomads, but I have forgotten the amount of pain I was in with each and gladly had the next. What is happening there with really really intense pain.

So there is research on childbirth pain, and that is a unique kind of pain. And the research shows that after giving birth to a baby, you are flooded with all these wonderful, delightful chemicals. It's like a bath for your brain. It's like oxytocin and which makes you feel connected, and dopamine, which is like this reward chemical, and serotonin which makes you feel happy and joyful, and endorphins which

Again, we might go extinct.

Yeah, so your brain does this like funny trick, but that is not true for many other types of terrible, terrible pain. And you ask anybody who's been in a car accident or like some terrible trauma. They have not forgotten their pain and their body has not forgotten their pain either.

Yeah, I guess like with Jared's knee surgery, it's not like his knee is gonna suckle for the next year. He might who knows, never know. But I thought this was a great question from Val McKelvey. How well does mara juana work for pain relief as compared to traditional pain relief medicines, like all of the CBD that's on the market, the THHC, things like that good for pain, not good for pain, somewhere in the middle.

Here's the complicated answer. Okay, I think the thing that we know now is like with pain, it's always a complicated answer. So here's the complicated answer. Research shows that the chemicals in marijuana can actually lower pain volume.

Righteous they can.

Here's the problem. Marijuana, and I am not opposed in any capacity, also can do funny things to sleep in not a great way that can negatively affect pain. And the thing that actually is most concerning for me is the patients I'm working with who are using it as their only pain management strategy and nothing else. So if you become if you lean on any one thing, it doesn't matter what the one thing is. As your primary or only coping strategy for pain, you're targeting only the

So the answer is yes.

Sign shows it can lower pain volume, raises pain tolerance, whatever that fancy word means. But there's also a couple of other complicating factors. I do think it's great for things like cancer pain because people can't eat, but that's also sort of a problem because with overuse of marijuana you can stop eating. There's like an emesis syndrome that develops where your stomach doesn't want you to eat any

Cool last listener question, Daniell Larman, Alia Myers lux a rib want to know. In Alia Myers words, so what's up with masochism asking for a friend? Perhaps their friend was one of these patrons. Chris Bauman, Piper, Donnielle, O'Neil, lux Arib, Mikaela Kwant who asked why does it make me so horny? Or the wonderful Scaliborealis who responded to that. I spent several minutes trying to type this out in a concise way and saw this comment and was like, Yeah,

Also, such a delightful question, And I'm so glad we get to touch on it before the end of this, because I really wish I had even said this sooner. Pain is a subjective experience, like when we're talking about the definition of pain that should have been in there. It's always subjective, and like we said, context and environment matter.

If you're choosing it, it's going to change your experience.

If someone punches you in the face and you're not expecting it and they're stealing your purse, it's going to feel very different. Slaps you, it's going to feel very different than in the context of sex, or like you're turned on, you love your partner, you trust them or whatever, or you just you want it. So context, environment, all the things are always going to matter when your brain is interpreting the message. So, yes, pain can be pleasurable.

So so always the.

Context in which the messaging happens determines how your brain interprets the signal.

I want to make sure did that make sense? That that makes sense?

Absolutely? Sometimes I just I love the interview so much I make sure we're still recording because in my nightmare, we've somehow totally it's not the batteries. Now, the thing that sucks most about pain?

What is it?

What sucks so much about your job? What sucks about pain? What's frustrating? Vented out?

The thing that sucks most about my job is the stigma associated with psychology and pain, Like that thing where people think you're saying they're mentally ill. That drives me mad. The thing that sucks most about pain is the lack of agency and control. We feel like we have over it, and we feel that lack of agency and control because

No one ever why. So that, as you can tell, infuriates me.

It flame flames, flames on the side of my face.

Who doesn't deserve to understand pain? It's ubiquitous human experience. We are all going to have it. None of you are going to get away with not having pain, So we might as well know what it is and know what to do about it. What also infuriates me about pain medicine is the way that nobody gets educated about it. So here's a fun statistic. Ninety six percent of medical schools in the United States and Canada have zero and

So side note, In addition to being a clinical psychologist, doctor's Oftness is also a researcher and a lecturer at UCSF, and she and her colleagues there conducted a six part pain training with UCSF doctors and in a study just published in June, they found that ninety percent of the physicians said that the pain curriculum changed the way that they conceptualized and approached or managed pain. Ninety percent said it changed the way they did it. So the conclusion,

So in my mind, if we're ever going to target the opioid epidemic, if we're ever going to target effective pain management, we have to start with education, which is why I chase people like you, because how do you spread the word? Like, how do you tell people by the way, there's hope for treating your pain. We just have to do it differently.

Yeah, I think you should be the Brene Brown of pain banishment. Okay, great, Yeah. I feel like the typical thing we're used to seeing is just a laminated placard on the wall with a series of emojis. Yeah, dude, like that's that's my god. That's pain education for doctor. You got it.

And so, so what Ali's talking about is it's called the pain scale. It's actually called the Faces pain Scale, and you've probably seen it before. It's like I think it's zero to ten, not one to ten, but I can't remember. But it's all these faces that show how much pain are you in? And have you ever read Hyperbole in a half Yes, Allie brosch Am I saying her name right, I don't love her. That girl is so brilliant and so talented, and Ali Browch she probably listened to this podcast.

I wo is that is it? Ali brousch Am, I saying it right?

Okay or brush, I've had no idea. Okay.

So she if you google hyperbole and a half pain Scale, you will laugh your ass off.

She revised, I use.

It in my lectures. She revised the pain scale. Yes, it's I think it's zero to twenty, and twenty is like this face like the eyeballs are falling out and blood is coming out of the ears, you know. And she also redes like this zero to ten pain scale, and she's like this, this is just not accurate, Like five looks like, you know, I got Ben and Jerry's cookie dough ice cream and there just isn't enough cookie dough and it, yeah, like the faces don't adequately convey

Half, Well, what about your favorite thing about what you do? Oh?

My god, so absolutely this is the most addictive work I've ever done in my life. And I also feel selfish doing it because that kid who had been in bed for four years.

When that kid.

Stood on stage and went off to college, I felt so rad And I am not performing magic. You know, this is something I was trained to do. It exists in books, that the knowledge is out there. I'm just a conduit for the thing that already exists. But when people get better and they get their lives back, this kid got asked by.

Two girls, not one, but two, and it's just like so delightful to see.

People re engage in the world, get their lives back, and feel like they have power again over their bodies and their lives. That is like, I will never do anything else. It's like the most addictive thing I've ever done. And like people wearing me these crazy emails that make me cry, just like yeah, if I start talking about it, I will cry. It's just crazy. The work changes lives

Is that the word?

Yeah? Absolutely?

It makes me so mad. You can tell I just I feel like love it. Yeah, Like, why is treatment only for people with money?

It's nonsensical.

Finances drive pain management? How is that? Okay?

Bonkers? Any one piece of advice that you want people to know to keep them going?

Yeah, pain is treatable. You do not need to be alone on a pain journey. A lot of people are suffering alone. There's a lot of support available. Pain psychologists. There's not many of them again because just psychology programs don't train us in pain, and they should, and it's a problem. So this is a call to action for anybody in the world of psychology and in medicine to up your game when it comes to pain education. But a couple of solutions for people who are suffering alone.

Through it with you.

You don't have to go through the journey alone. It's isolating, it's miserable, it's painful, and support is available and help is available and change happens. Pain treatment is totally totally possible.

Thank you for being on.

Thank you so much for having me. This is so cool.

Seriously, Forrene bor out of pain, I'm calling.

It rad.

H So, for God's sake, ask smart people do feed questions because your brain can learn from the things that their brains learned from other people's brains. And I hope that this episode helps anyone with pain get better care, helps loved ones understand that pain is real and give some hope and maybe some alternative approaches to turning that pain dial down. So doctors Off sells her workbook for

Seriosity get value.

You can't argue with that.

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