Mind Power

Opening the Medicine Box in the Mind: The Psychology of Pain

Thank you for coming. It’s really a pleasure to be here. And I hope everyone in the back can hear me. I tend to speak very loud but just raise your hand if you need me to speak more loudly. If you’ve heard any of the recent statistics, then you know that 100 million Americans live with ongoing pain, pain that’s experienced on a fairly regular basis. And so we’re very interested in understanding how to better treat pain, how to better manage pain, and how to do it in a way that helps people live the best quality of life possible. So as was mentioned, I’m a pain psychologist. I’m also a pain researcher. And I just want to take a moment to tell you a little bit about Systems Neuroscience and Pain Lab at Stanford. We do a lot of different types of studies. I’m going to be telling you about many of them over the course of the next hour. But if you’re interested in participating in pain research, this is our main website.

The URL is at the top. And you can learn about all of the cool stuff that we’re doing. And you may be interested in joining one of the studies. This is one specific study. This is actually a whole center on the treatment for back pain. And this is funded by NIH. And we’re investigating how various treatments work. So cognitive behavioral therapy, that’s a psychological treatment, mindfulness-based, stress reduction, acupuncture, and real-time FMRI for chronic pain, for chronic back pain. So when you join the study, you get free treatment. We also pay you to be in the study. And we’re interested in learning from you how these treatments work. We know that they’re effective, but we’re learning what are the mechanisms behind how they work.

As was mentioned, I am the Co-Chair of the Task Force on Pain Psychology at the American Academy of Pain Medicine. And this is just a reflection of the growing interest in psychology within the field of pain medicine and the world that psychology plays. We’re particularly interested in broadening access to low cost, high quality pain psychology care. Other resources I want to make you aware about. I write a column for Psychology Today online. So if you’re interested in learning more about psychology and pain and the interface, you can go online and see some of the postings that I have there. And along those lines, in 2014 I wrote this book that I found myself working in clinic with people with chronic pain. And I found myself saying the same things over and over again. So I decided to put it into a book so that people could access the information. Not everyone can come to clinic and work with me.

And so that’s what this book is about. I’m really interested in helping people need as little medication as possible. Not that medication is a bad thing, but I think we can all agree that if we can need the less of it, that’s a good thing. Right now I am working on the next book and working furiously as we speak. And this will be coming out soon. And some of the information that you’ll be hearing from me tonight is going to be in this next project. OK, so let’s talk about pain. If you have chronic pain, if you experience pain on a regular basis, then you’re probably your own pain expert, and not necessarily in terms of treatments, but in terms of your own experience.

And every single person in this room or people who are watching over the internet, wherever you experience pain in your body, no matter what your medical condition is, your diagnosis, no matter what treatments you have tried, the pain that you experience is processed in your brain. And so that is just a basic foundation for how psychology fits into the experience of pain. Everything is processed in your brain. So think of your brain as your pain computer of sorts. So if I were to prick my finger right now with a needle, well those signals would be– the nerves in my hand would feel that. It would transmit signals ultimately through my arm and ultimately to my spinal cord and into my brain. And so then that would register as ouch. That hurts. I want to get away from that. And that’s sort of intuitive. That’s how we think about pain. But once we have chronic pain, it gets a little more complex.

Because when we feel pain, and we want to get away from it, we feel that ouch, it’s not so easy to do when we have chronic pain. We can’t get away from something that we’re experiencing from inside of ourselves. The other thing to know about the experience of pain in that example where I prick myself on the finger and those signals travel up to my brain, whatever is going on with me in this moment emotionally is going to influence my experience of pain in the moment. So whatever I might be experiencing in my life emotionally is going to influence my experience of pain. And then, how I respond to that prick is also going to influence how I experience that pin prick, the level of pain that I have and my suffering around it. So there’s a big, big role for psychology in pain. And let’s just talk about the definition of pain now. Because we think about pain, like yeah, I know what pain is. It hurts. It’s the thing I want to get away from. Nobody wants more pain.

This is the actual definition of pain. This is from the International Association for the Study of Pain. Pain is an unpleasant sensory and emotional experience. And so this is where I really want to draw your attention to that word emotional. So believe it or not, psychology is built into the definition of pain. We just don’t tend to think about it all the time. We tend to think about the pain as being the sensory experience. What we feel in our body. And it’s not intuitive for us to think about the emotional aspects of pain and how important they are. But it’s half of the definition here. And in my opinion, OK, I admit. I’m biased. I’m a pain psychologist. But if we pay more attention to that aspect of the definition, we can gain better control over our experience.

And that’s really what this is all about. How do we put you in the driver’s seat of your experience? How do we allow you to have more control over your pain so that you need fewer doctor visits, and you need less medication, and you’re just better able to control your experience? So even if you don’t have chronic pain, what I’m going to say today will be relevant to you. This emotional experience is a part of the definition of pain.

We were just talking about that. But then when we experience pain, we’re going to have an emotional reaction to it. And that reaction feeds right back into our pain experience and can determine how much we suffer. So it’s hard to think about pain as being anything other than bad. Isn’t it? Because pain is, by its very nature, is– think of it as your harm alarm. Pain is there to warn you. It’s the danger signal. It’s there to motivate you to get away from whatever is threatening. Pain is threatening. And so it really motivates us to change our behavior to want to get away from it. But again, that works really well when it’s just a needle, or a pin prick, but once we have chronic pain, how do we get away from something that’s coming from inside of us? Whether that’s migraines or fibromyalgia, or maybe you have back pain.

It’s hard to just escape that, right? And so we really can’t. We can’t just escape it. But those signals and these processes are still happening. We’re still getting the same sense of, I want to get away from this. This is bad. It’s, of course, it’s going to be there. And if we don’t learn skills and techniques to manage this automatic process, then we can be left feeling– the process can lead to a lot of confusion, and some helplessness, and hopelessness. So pain is there for a reason. And it’s very adaptive, and it helps us survive. It’s a good thing. But once we have chronic pain, it’s a different story. And that’s when we really need to learn more and learn how to control it. So I’m going to take what will appear to be a little side trip, but it’s not. I want to talk about something related to pain. This is the experience of dread.

Dread is to anticipate with great apprehension or fear. And sometimes people– we all dread something in our lives, right? I mean we all do. You could think about dread as being painful. So let’s talk about things that are– where we use in our language. We use pain to describe really what we dread. So uh, traffic, traffic getting here tonight, it was painful. Taxes. Most people dread taxes. I don’t know if you do, but I do. And I’ll tell you, this one. This is really funny. Math is painful for some people, not everyone, but for some people. And it was for me years ago when I was in school. And it’s interesting. So in our everyday language, we use dread to almost to describe what’s painful for us. And there’s actually a scientific basis for this. It’s not just linguistics. And so there’s interesting research that was done on people who dread math. And so these researchers, Doctors Blaylock and Lions, did a study on people who had math anxiety. But they really characterized them as math dreaders. And this was a study where they used FMRI technology.

So they scanned people’s brains and were able to see in real-time what was happening in their brains as they were thinking about math and as they were approaching math tasks. And remember, math was painful for these math dreaders. And so what they found was that people who really dread math, when they look at their brains, it’s activating the same regions of the brain that’s associated with pain processing. That’s associated with physical pain and physical threats. And so literally, the things that we describe as painful, or when we are dreading something, it’s lighting up those same areas. It’s activating regions of our brain that indeed are associated with the experience of pain. And so it sets a stage for us to begin to understand how some of those things in our daily lives, that maybe we dread or are particularly stressful, it has implications for how that might impact our pain. If you have chronic pain, a lot of people notice an association between stress and pain.

And there are clear connections for this. And what I’m putting forward here is how this idea of the experience of dread relates to pain. So what’s worse than physical pain? The dread of physical pain is worse than pain itself. And this was shown recently in a series of different studies. This is a field of neural economics. And this field of neural economics is concerned with the value that we ascribe to things because the value that we ascribe to things determines the decisions that we make around it. And so this is studied in the marketplace. So the field of neuroeconomics, there’s classes on it. There’s degrees in this area. There’s books on the topic.

I just pulled a few of these off the internet. This one, How the New Science of Neuroeconomics Can Help Make You Rich. So there’s a lot on the topic. But what’s interesting is that some researchers were really interested in understanding how dread influences decision making. How does dread influence decision making? And they do this in experiments where they use pain. And so they bring people into the laboratory. And I don’t know if you’re familiar with pain research. But we do bring people into the laboratory, and we do inflict pain. And I promise it’s not severe. But you do experience some pain. And then we study reactions to pain. And we study what happens in the brain when you experience pain. And in this particular set of experiments, people came into the lab. And they put them into an FMRI scanner to study the brain.

And they had them experience foot shocks. So that was the paradigm, little shocks on the foot. And they’re low voltage. So nobody was harmed in these experiments. But people experienced low voltage foot shocks. Now, classical theory of decision making would hold that we would want to put off tomorrow things that are painful or things that we don’t want to do. And what we will choose to do what are the things that are more rewarding and comforting. And so we want pleasure now, and we’ll put off the things that are painful. That’s why we delay on our taxes and so forth. So that’s a basic logic for it. But what they found in this experiment was that when they set people up to experience various foot shocks, they were concerned with the amount of time that people had before they experienced the foot shocks.

So they gave people choices. And they said, you can experience this moderate level of pain now, or you can delay, and you can experience that same amount of pain later. And so while we would suspect that people would want to delay and not experience that pain. In fact, people preferred to experience the pain now to get it out of the way because the delaying the pain, it just engendered dread about it. Then they’re thinking about it and worrying about it and dreading it. And so that was actually worse than experiencing the pain sooner. So that was the idea. People would rather experience pain sooner to get it out of the way. Another set of scientists studied it further, this concept of dread and pain and how they relate. And in this next experiment, they were also playing with time and decision making. And they gave people a choice. They said, you can experience this moderate level of pain in the future, or you can experience it now, but it’s going to be more painful if you experience it now. So the choice was pain in the future or more pain now.

And what they found was is these people particularly high on dread, they’ll take more pain now because that period of dread is more painful than pain itself. And so this, again, allows us to begin understanding how our perceptions and our experience, or emotional experience, really characterizes our pain experience. They took it even one step further where they studied how framing the pain changed people’s choices around pain. And what they found was when they used language where they talked about, OK, you’re going to experience a shock soon, it’s about 30% less than that one you had earlier. When they framed it as a reduction in pain, people were much more likely to experience the pain, even the same amount of pain, than when they framed it, either in a neutral way, or in a way that made people– where it cued them that somehow it was an increase in pain.

So even the language and the framing around pain is very powerful. This is just further evidence about how our psychology influences our experience. Now there’s other factors, of course, that influence pain. I’m going to talk about a lot of them. Some of them we can change, and some of them we can’t. If you are female, you’re more likely to have pain than men. You’re more likely to acquire chronic pain. And once you have it, it’s more likely to be more severe. You’re more likely to have more frequent episodes of pain and for them to be more painful. And there’s different reasons for that. There’s a lot of reasons for that. And what it boils down to is that in a lot of ways, female physiology is more primed for pain. And it just makes it that much more important that we learn various skills and techniques so that we can ensure we have control over our experience.

Now other factors emotions. Anger is, of course, an emotion that we’ve all experienced at least from time to time. Well, it turns out that persistent anger is particularly problematic in the context of pain. And a lot of research has been converging in this area. A lot of it done by Dr. John Burns. And what his work and what the work of other people is showing is that the experience of anger is associated with more severe pain.

And not only just more severe pain, but it’s also linked to our ability to function, how much are we able to do and our quality of life. And so this has been shown in different ways. In our own lab, at the Neuroscience and Pain Lab, there is a colleague, Chloe Taub, who has been looking at the role of anger and how it influences the emotional experience of people who have a history of trauma. Now we know that when we experience trauma in childhood, or even at any point in our lifespan, but particularly in childhood, it’s well studied, that this history of trauma sets us up to develop chronic pain later in life.

It’s almost like it creates a vulnerability. We’re more likely to experience it. And one of the things that Chloe’s work is showing is that anger has a particular role in people who have experienced trauma in terms of how they will respond to pain later on. So again, really identifying anger as an important therapeutic target. This next study, we actually treated anger in an intervention, compassion meditation intervention study. So this compassion intervention was developed at Stanford at a CCARE at Stanford. And we studied how this compassion meditation intervention would help people with chronic pain.

And so what we found is that when people took this nine-week compassion course, that not only did their pain intensity reduce, but also they had concomitant reductions in anger. And this is really important because when we have chronic pain, often anger can be a common experience. It can be a common experience for people to even feel angry at their own bodies. My body’s not allowing me to do what I want to do, to be frustrated, to be angry, or maybe we’re angry at other people from time to time. But it is important to identify if you have those persistent emotions and to know that it’s important to treat it specifically because it will help your pain. Related to this is a concept of injustice. Injustice and anger also combined to be a very potent influencer of pain outcomes. They basically serve to make pain worse.

And this is important in the context of chronic pain. How many people ask for chronic pain? Nobody asked for it. Nobody signed up for it. It’s not fair. And then on top of it, sometimes people have chronic pain because they were involved in an accident. Let’s say you were in a rear-ended on the 101, and you had whiplash, and then, you developed chronic pain. Certainly, there’s injustice there. Let’s be real. I mean nothing is fair here. But if we harbor feelings of injustice, if we feel victimized by a circumstance, that turns out to work against us. The data are really clear, that when we have feelings of injustice, that they impede our ability to focus on what we can do to help ourselves.

And that’s really important to be mindful of. The idea is that sure, there’s a lack of justice, and I have been a victim of a circumstance. But really holding on to that will not serve you well. And so the idea is to address that and treat it, so that your pain can improve. This was a study that I conducted with Dr. Halawa at Oregon Health and Science University back when I was there. And this was interesting. It really gives us a snapshot into how our beliefs about pain and pain treatments influence our experience. And in this study, we were interested in looking at people in the Middle East compared to people in the United States. And we were studying people with lung cancer. And people with lung cancer who have pain and their willingness to engage in treatments. And what we found was that people, Americans, are fine with taking medication, especially in the context of cancer. If they have pain, they will take the opioid medication to reduce it. But in Saudi Arabia, people do not take opioid medication, even if they’re offered it, because they perceive pain as being a test of God.

And it’s a sign of strength and endurance for them to experience pain. And so they do that. And it’s very difficult to get people to engage around pain treatments because of their beliefs around the meaning of pain in the context of their culture and in their religion. When we have surgery, we’re generally given pain medication. We take it for a period of time. Some people take it for longer periods of time than others. Even if all of the other factors are the same. Some people need more pain medication than other people.

We’ve been looking at some of the reasons why some people need medication longer. This was a study that was conducted by Dr. Jennifer Hah and Dr. Shawn Mackey here at Stanford and colleagues. There’s a big list of colleagues involved in this study. But what they were interested in was what are some of the factors that predict how much medication we need after surgery. And what they found, the punchline on this one is that when we have certain factors, some depressive symptoms, when we don’t feel good about ourselves, there’s a sub-scale in depression that’s related to self-loathing. When we don’t feel good about ourselves. When we feel worthless. That was a strong predictor of whether someone goes on to continue to need more medication over time.

Again, testament to how are psychological experience influences pain and also our response to pain treatments. So I’m going to give you a second to take a look at this comic. And I’ll just read it. “The pain starts in my husband’s lower back. Travels up his spine to his neck. Then it comes out of his mouth and into my ears. And that’s why I get these headaches. And we’re poking some fun here. I’m poking some fun here. We can all relate in some aspect of this at different times in our lives. But at the core, what this is illustrating is that there are social dimensions to pain.

Pain can be transmitted in various ways, and we’re learning more and more about the impact of social factors on the pain experience. There is a researcher down south in California, Naomi Eisenberger. And she’s been studying the concept of social rejection and how it relates to pain. And we’re making less of a distinction between social pain and physical pain, frankly, because what we’re finding is that social pain primes us to experience physical pain. So what’s the antidote to all of that? Well, it turns out that romantic love is an analgesic. That love does kill pain. It is a natural painkiller. This was shown right here at Stanford. This is another one of Dr. Shawn Mackey’s studies. And this was a fun one because a lot of the pain studies are like we’re going into the vortex and studying negative emotions. And this one was studying love. And so they recruited people, students right here at Stanford, who were in an intensely loving, romantic relationship.

So they’re like deeply in love. They sign up for this study. And you bring them into the pain lab, and we’d do some pain testing on them. And then, part of the experiment was they would look at a picture of their beloved. And then, we would see how that would influence their pain testing while they’re viewing a picture of their beloved, compared to a picture of a stranger who was theoretically equally attractive. And what they found was that when people are looking at a picture of their beloved, they feel less pain.

It is your body’s natural painkiller. So you can almost think of it as an androgynous opioid. That they didn’t really test for opioids, but we do know for a fact that there’s some mechanism to explain that romantic love, and just even viewing a picture of your beloved, does reduce pain. So we could prescribe that for every one as a painkiller. So going further and taking a look at some of the social factors. How social factors influence pain? This is another study done here at Stanford. This is spearheaded by my colleague, Dr. Drew Sturgeon. And he was really interested in how social factors influence pain intensity and also emotional distress. And it’s more typical that we think about well, yeah, I have pain, and then I can’t do the things I want to do. And that’s why I feel this way. That’s why I have emotional distress. I can’t do the things I want to do. But what Drew was actually showing in this study was that it wasn’t so much what you could or couldn’t do that explained how much emotional distress you had.

He found that the extent to which you had this reduction in your ability to engage socially that that is what made pain lead to emotional distress. So it’s coming more into our awareness. It’s appreciating the influence of social factors, how important it is for treating pain and reducing our pain. So this gentleman says, “I keep getting pins and needles in my arms.” And this is one of my favorites of all time. And why I love this cartoon– it’s so human. I mean we all do this. But really, it’s such an eloquent metaphor, in my opinion, for psychology. It’s in the background.

And if we’re not aware of our thoughts and our emotions, if we’re not aware of our feelings and what’s triggering us in feeling a certain way, then, unwittingly, unbeknownst to us, we’re probably contributing to some of our pain and suffering. Because our brains and our bodies are designed in a way where it’s going to bring up some of these emotions, some of these thoughts that can trigger more pain, some of these emotions that can trigger more pain or prime us to feel more pain. So if we’re not aware of what’s happening, we might be this guy from time to time. And that’s the whole purpose of bringing more awareness to how these pieces fit together, how psychology fits into this picture. Oops. OK, so the underlying idea, no matter what kind of pain you have, no matter what your diagnosis is, no matter what kind of treatments you have had, you are participating with your pain, with your thoughts, with your emotional experiences, and with your choices.

This does not mean that it’s all in your head, or that you’re making it up, or that it’s all psychological. You have a medical condition, and you have pain. And your psychological experience will influence how much pain you have, how much you suffer from pain. So it’s almost like you have the ability to dial it up or dial it down. And by paying attention to these psychological pieces and learning skills and tools and information, you can harness some potential that’s available to you to turn that dial down. So pain catastrophizing, this is something that I spend a lot of time studying, researching, and even treating in the pain clinic. So you may have heard this term before. Pain catastrophizing is when we focus on our pain and have a hard time focusing on anything but the pain.

It really grabs our attention and holds it there. And so we might be thinking, uh, my pain, it’s awful. I might be thinking there’s nothing I can do about my pain, focusing on how helpless I am about my pain. And I might be ruminating about my pain. So it’s when we magnify pain, ruminate about it, and feel helpless about it, sort of a trifecta there. And we all catastrophize from time to time. Maybe we catastrophize finances or relationships or different things. But in the context of pain, it’s particularly toxic to overfocus on pain and feel very negatively about it. And hopefully some of those previous slides are setting the stage for you to understand how that all fits together. So how do know if you’re catastrophizing or not? Well, we measure it with, typically, there’s different questionnaires. But one of the easiest to access is just online. You can Google it, the pain catastrophizing scale. You can take this measurer, and you can see where you fall on the spectrum. You can take this scale even if you don’t have chronic pain because it will reference– think about when you do have pain.

Maybe going to a dentist office or if you had a medical procedure, how do you tend to think and feel in the context of pain? Well, it turns out that this is a really important factor to pay attention to. Pain catastrophizing has been studied for more than three decades now. And the research is really clear, that the idea being, that when we catastrophize our pain, well, there’s overlap in the neural circuitry between what is activated when we catastrophize and what happens when we experience sensory pain, physical pain, in the laboratory. So think of it as that it shares real estate in your brain, basically.

And as it turns out, catastrophizing is when we– that’s how we respond to pain. I feel pain, and then I can’t stop thinking about it. And then I start thinking about how terrible it is. And it’s probably not going to get any better, and what’s going to happen as a consequence of it not getting any better. That’s catastrophizing. That’s how I’m responding to pain. It turns out that how you respond to pain, if you’re catastrophizing, it shapes your brain patterns. And we can see this in the scanner.

We could put you in the scanner and see how your brain is activated while you’re catastrophizing. That’s easy. But here’s the interesting thing, that people who catastrophize, their neural patterns look different even at rest, even at rest. And so it shapes your neural patterns, and it primes you to feel more pain. So the more we get on this track, the more we stay on that track, and the deeper the track gets.

Now, but just like the gentlemen with the tattoos, we can learn to not get tattoos. And you can learn how to stop this process. But the important things to know, it does prime your nervous system for pain. And it sets the stage for you to have a poorer response to any of the treatments that your doctors will try. So this is the way I explain it to the people that I work with, and I teach classes on catastrophizing.

And I say, imagine that this is your pain, this campfire, and it’s contained, and you know it, and you live with it. And there it is. When we catastrophize, it’s the equivalent to picking up a can of gasoline and pouring it on that fire. And so we can learn how to stop catastrophizing. It’s not going to take the pain away though. But we can get you back here. And this is the goal. This is the idea with pain psychology and learning how to use some of these skills and information. It doesn’t take it away. But if we can get you back here where it’s manageable, that is gold. That is a huge win, and hopefully, you would agree with that. OK, so how does catastrophizing impact pain? All kinds of bad stuff, more pain intensity, worse function. It’s associated with disability.

It actually predicts the development of chronic pain. So let’s say none of us have pain in this room, and we take this catastrophizing scale. And then we go a whole year out into the future. And then we see, well, who in the past year developed chronic pain? The people who scored high on that questionnaire are significantly more likely to develop chronic pain later on. This has been shown in prospective studies. It’s fascinating. That’s how powerful your mind is. So what predicts treatment response? What predicts who gets better after surgery and how quickly people get better after surgery? It’s an interesting question because lots of people get the same treatments, and we respond differently. What makes the difference? Well, it turns out that catastrophizing is one of the most potent, prognostic indicators of recovery after surgery. And so people who score high on this questionnaire before surgery are more likely to need higher doses of opioids after surgery and to take them for a longer period of time, more likely to develop ongoing pain after surgery, more likely to stay in the hospital longer, to have a poorer rehabilitation, poorer functioning.

So it delays recovery. And it can lead to pain lasting for a much longer period of time. That’s how powerful your mind is. And so the idea is that our doctors can try lots of interesting things. And we have some good medical tools available. But if we’re not addressing how we’re responding to pain and some of these other factors, we might not have a solid enough foundation. And I want to be very careful here. This is not to place blame on us as patients. We’re all patients at some point or another.

It’s not to place the blame on us. It’s to highlight that there are opportunities for us to optimize our response to medical treatments. And I think it’s in all of our best interest that we do that. So I have dedicated a significant amount of my career to studying this thing called catastrophizing. This is so powerful, so potent. It exerts a huge negative influence. Can’t we just treat it? And of course we do in pain psychology, in health psychology. We do identify catastrophizing, and we do treat it. And we typically treat it individually. You work with a psychologist over a period of time, or you attend these group pain psychology classes, cognitive behavioral therapy. And it’s typically eight sessions, two hours at a time. So over a course of a couple of months, this is treated. But it’s treated within the context of a lot of different factors that we look at with pain. So we might be focusing on pacing and how our mind and our mood influence pain.

And catastrophizing is one aspect of that treatment. But there wasn’t any quick way to address and treat catastrophizing. So I was inspired by this study here. This was conducted– the second author here, Katie Martucci, is now at Stanford in our pain lab. And she and Fadel Zeidan, and colleagues conducted a really cool study in 2011. And in this study, they took people who did not meditate, did not meditate, brought them into the lab, and they did some pain testing on them.

And then they taught them some brief meditation techniques. And I mean brief, 20 minutes, but 20 minutes for over the course of four days, so a total of 80 minutes. 20 minutes, each day, quick coaching on meditation techniques. And then they had them do the pain testing again inside of a scanner, an FMRI scanner. And what they found was that when people learned these meditation techniques very quickly– remember, it was only 80 minutes that they invested in this– they were able to reduce their pain by 40%. And they were able to reduce the bothersomeness, the unpleasantness, of pain by almost 60%. So this is amazing, that something that’s basically free can really modulate, really reduce, pain so quickly. So I was thinking, how can we apply this to catastrophizing? So in 2013, I developed a two-hour class. It’s a single session class that focuses only on catastrophizing. What is it? Why you should care about it? And what you can do to reduce it? So it’s information, and it’s skills-based. One of the foundations is learning how to calm your nervous system in the context of pain and stress.

This is what happens automatically when the harm alarm goes off. And this is what happens when we learn the relaxation response. So this is a clear skill that is taught, and it’s used regularly. And there’s other components in the class as well, different information where people identify what are the triggers for catastrophizing? And they put together a personalized plan to treat it. And so what we found is that people really enjoyed the class. They found that it was acceptable and were satisfied with it. But more importantly than that, what we found is that their catastrophizing scores reduced significantly. And this was really interesting to us, that in two hours, you can teach people how to gain control over their mind-body connection, reduce catastrophizing. And this potentially could then lead to very important improvements and health outcomes for pain and also for surgery.

And we found that even if you were depressed or anxious, that you still got a nice result from the class. So we found very large effects. And this is just a highlight, that the majority of people in the class experienced either a moderately important reduction or a substantially important reduction in catastrophizing just from this two-hour class. And we submitted a grant to the NIH. And fortunately, they agreed with us. And we were given a multimillion dollar award to study this class in more detail to better understand what are the mechanisms by which this treatment works? And how psychology works, and how can we use that to help people? Because we can simply take medications, or we can also learn various skills that help us need a little bit less of that.

Not that medication is bad, but we do want to optimize everything we can do to gain control. And so this is a topic that I speak about frequently is empowering people to reduce their own pain as much as possible. OK, so how do you open the medicine box in your mind? One way we could think about it is how do we empower ourselves, each and every one of us, to change our pain, to change our brain, and also to change our behavior? And so self-regulation of cognition, emotion and arousal is paramount. Let me put that in English.

Learning how to better control our thoughts, our feelings, and the amount of stress that we feel in our body and in our nervous system is the key. And we can learn how to do this. Ultimately, developing confidence in your ability to calm your own nervous system is the key to success, to gaining as much control as possible over your pain experience. OK, so let’s open your medicine box. What are Beth’s tips for doing this? I do have a list of tips for you. Number one, and these are based on the science, learn mindfulness-based stress reduction, if you haven’t already. Because there’s great data to support that it works. For improving, it helps reduce pain. But when we think about everything that I’ve been talking about, it helps put a container around our responses to all of those emotions and factors in our life.

The stress, or anger, or catastrophizing, all of these things that amplify pain processing in our nervous system, these are skills and techniques that help dampen that processing. So meditation is great. Work with a pain psychologist, a psychologist who works with people with chronic pain, has very specific training in treating chronic pain, who is a cognitive behavioral therapist. Work with someone one-on-one to make sure that you’re really optimizing everything you can from a psychological perspective. Determine if you’re catastrophizing and get it treated if you are. If you happen to be a patient at the Stanford Pain Management Center, I teach free classes on how to stop catastrophizing, how to treat it. And so you can ask about that. You’re more than welcome to come. The trick is to use the skills daily because what we’re doing is we’re conditioning our nervous system away from pain. So if you just use them every once in awhile, it’s not going to do the trick.

That’ll help you have a little bit of comfort in the moment, but it’s not going to alter the way you are processing pain. It’s not going to alter some of these patterns of thinking and feeling. So you want to use the skills daily and really cultivate this belief. This is critical that you’re changing your brain and your experience because you are. Exercise regularly. Well, that’s a funny one for me to put up there because I haven’t said anything about exercise so far, however, exercise is known to be some of the best medicine for pain.

It’s great pain management. It also improves your mood. And when our mood is better, it improves our pain. So there’s different pathways by which exercise is excellent mind-body medicine. And if you’re not sure, if you feel like it might be unsafe, work with a physical therapist, get checked out, find exercise program that’s appropriate for you. And there’s lots of professionals who can help with that.

If you have sleep problems, learn about sleep hygiene. One of the best predictors of pain intensity on any given day is the quality of your sleep the night before. Lots of people with pain have sleep problems. There’s a great sleep clinic at Stanford. There are lots of experts who can help with this. I encourage you to seek out that help. There’s even professionals here who are sleep psychologists. And they help unravel some of the stressors or anxieties or how our psychology might be interfacing to work against us in the realm of sleep. And so there are professionals who can help with that.

Nurture positive and supportive relationships because we know how important these social factors are. Ah and this one, learn to nurture yourself. And we talked about how love, intense love, romantic love, is analgesic. What if we learned to love ourselves and learned to be kinder to ourselves? And so if you know that you’re struggling with that, that’s where the compassion training can be so effective. If you have any anger take the compassion course to foster release and forgiveness. These are taught right here at Stanford.

Every day focus on what you can do. So critical, so critical. And lastly, source gratitude because it will help you shift your mindset away from some of those factors, feelings of also anger, injustice, some of the factors that we know worse than pain. And it helps shift us into a state of expansiveness. So sometimes people will say, Yeah, Beth, that sounds great, like the exercise, or go take a course, or be more social. But I have chronic pain, and I need to feel better before I can do those things. And we get into this chicken or egg dilemma with this. Know that you’re not going to feel like doing these things. You’re not going to wake up wanting to exercise. Or sometimes you’re just not going to want to get out and see people. We have to encourage ourselves to do it anyway because that is the medicine that helps us get better. But if we just know, expect that you’re not going to want to. If you wait for the day, when you want to do some of these things, you’re going to be waiting a really long time.

So the way to take control is just to know, yup, I’m not going to want to, and I’m doing it anyway. Because I am going forward, and I am determined to have a better quality of life. And this is how I see each and every one of you. And I just want to say thank you for your time and attention. I also want to say thanks to my colleagues and collaborators, people who are doing some really amazing work.

And I’m just lucky to get to work with them. So thanks again. [AUDIENCE CLAPPING] I think we have some time for questions. Is that right? Any questions? Yes? One thing you didn’t mention was the power of laughter and positive thinking and seeing the glass half full versus half empty. But laughter alone, you talked about romantic relationship, and that’s if you’re lucky enough to have one, of a meaningful one, is the endorphin that your body, your chemical– your own chemicals that are working on your pain receptors. And I think laughter is a lot more– so much endorphin release and [INAUDIBLE] exercise. Those two are very [INAUDIBLE]. Absolutely. Great point, great, great point. And for those of you who couldn’t hear, she was saying that laughter is excellent medicine for pain and absolutely. A really nice basic way to think about it, if we want to be really reductionistic here, things that bring us joy are analgesic.

They’re painkillers. And the things that when they don’t feel good, that we would describe them as being kind of painful in the way, they are painful. They do prime us to have more pain. And so it’s an opportunity for all of us to put our lives and our relationships and our choices under the microscope and to determine is this bringing us joy or not? And do we want to maybe make some different choices? Or how can we steer ourselves more in the direction of joy and laughter and love? Yeah, absolutely.

Question? Yeah, is anybody doing research on the notion that there are forms of chronic pain that are analogous to tinnitus, which is something that nobody understands? But my understanding that I have of it is that it’s psychological. Perhaps. And you’re a psychologist. Is [? somebody ?] working on this notion that chronic pain someplace else in the body is literally the same kind of process but just involving different nerves and auditory nerves? Yeah, so it’s an interesting question and really hitting on the idea of something like tinnitus, which is the persistent ringing in the ears, that they don’t have good understanding of the mechanisms or why that’s there, but that there is overlap, actually, with chronic pain indeed.

And we find that there’s overlap as well with other types of conditions where there’s something of a stuckness in the brain and the body. So an example of that is post traumatic stress disorder. Well, we experience a trauma, a horrific trauma. The whole nervous system goes into high alert, and it never goes away. And so maybe I had a car accident 10 years ago, but I’m still living every day as if the accident just happened. It’s stuck in the nervous system, and why is that? And the same with pain. Those pain signals are no longer serving a useful function, and yet they’re there. And so some of the treatments are similar. I mean we look for ways at a minimum to manage these– the flares associated with it or the bothersomeness around it. So for tinnitus, for example, and even for chronic pain, some of the best treatments involve learning how to harness the mind-body connection, how to de-escalate and dampen some of the high alert that your system is experiencing.

Another question? Yes, Did I understand in the beginning of your talk, you said when they do functional MRI, the part of the brain that lights up is same as perceived kind of a pain? What did you say exactly? I had a little difficulty with that. So I’m not exactly sure what you’re referencing. Was it about the dread part? Or was it– When you first talked about when they looked at functional MRI, the part of the brain that lights up actually with physical pain, actually same as.

Got it. Yes. So I think the part that you’re referring to is that there are many different studies that look at how the brain is activated during pain. And when we experience certain negative emotions, for instance, there’s a lot of overlap between what we’re experiencing emotionally and this map of what we experience from pure sensory pain. My difficulty was when, my understanding was there’s psychosomatic pain and then there’s truly mechanical, physical pain.

A bulging disc pain is a bulging disc pain. There’s nothing perceived. Yes, yes. Because you’re upset, it’s just daunting is there, and nothing is going to relieve it until you get the adequate pain relief. But with the emotions, that’s the difficulty I have. I’m sure the part of the brain that is lighting up is different. Oh it’s a great point that I want to spend a little more time on. And thank you for bringing it up. So the idea that yes, you could have pain in your spine, the bulging disk. We can image that and point at it and say, Yeah, that’s what hurts, and that’s why that hurts. But even so, even with all of that said, our psychology, the overlay of psychology, can either make it worse or make it better. Now we can do all of the treatments in the world to help you dampen the pain processing. It’s not going to fix the bulging disc. There is a level of pain that will be there, if you have that medical pathology. There’s definitely there’s an emotional psychosomatic part of it also, even with the bulging disc.

[INAUDIBLE] The definition of pain, no matter what the cause of the pain, is that it is a negative sensory and an emotional experience. And it’s all in this spectrum to what extent this is really influencing your pain experience. But the exciting thing for me is that there’s beautiful, wonderful opportunity for us to take a look at where those opportunities lie to gain more control. And to me that’s really exciting because it puts you in the driver’s seat of helping make things better for yourself. It’s not going to take away the bulging disc.

Nobody’s saying that. But also, I’m not putting forward that all pain is psychological or just in your mind. What this is about is recognizing that there is power in psychology to alter our experience either for the better or for the worse. And of course, we want to make it better. So we use some of these skills, techniques, and formulas to help ourselves suffer less and to get more out of life. Question over here and then over here. Yeah. So you [INAUDIBLE] about pain catatrophizing and how that can actually magnify your experience of pain. What are the potential benefits and risks of potentially prompting that pain catatrophizing by asking about to monitor it at different doctor’s appointments. So you’re trying to monitor it to make sure your pain goes away. Could that potentially influence the way they experience the pain? Do you mean what is the potential downside of monitoring pain or of monitoring pain catastrophizing? Could the potential– so by trying to monitor pain, could you actually be sparking this pain catastrophizing? Even if you’re trying to help.

No, it’s a great question. Yeah, yes, so the question is you know now that every time you go to the doctor, they ask us about our pain. And so we’re constantly bringing our attention to it. And you hit on a really great question because it’s one that we actually struggle with in pain research. Because how do we study it without asking people about it a lot? And we don’t want to be asking them all the time because that’s a negative intervention, just asking people to think about it. What we really want is for people not to think about it. But it’s a catch-22 in pain. We were literally talking about this this week in the lab. It’s like how do we study it without priming people to pay attention to the negative aspects of it. So my personal belief is yeah, it can play a role.

It can. And we just need to be very mindful of it. And there’s no great solutions that we have right now. Ask about it along with everything else. What’s that? Ask about it along with everything else. Yeah, well, and now that you mention it. When you come to a pain clinic, when you’re working with people who really only work with pain, whether that’s a psychologist or a physician, often they won’t even say, they won’t even ask about your pain. They’ll just say, how are you doing? How are you doing? And just ask it open-endedly. Because usually when people hear that they might think Oh, I had a great week. Or today, blah, blah, blah, blah, blah.

So not asking about pain, ultimately, we want to be in that direction. Yeah. And then there was a question here. I just want to know if it’s possible to see the web addresses again. I wasn’t fast enough to copy them down. Absolutely. Let me see if I can get to the first slide. So we have the first– here we go.

This is the one. Let’s see if I can get it to work. I might need tech support to help me get it up at this point. Sorry. So let me do this. Let me just give you the address or the name of the lab. So it said Stanford– There’s one in the one with the back pain. The back pain. That one. OK, so what you’ll want to do is you want to go to the Stanford Systems Neuroscience and Pain Lab. So if you just go to that website, you will then find the tab for the Center for Back Pain. So it’s housed under the Neuroscience and Pain Lab– the Systems Neuroscience and Pain Lab. That’s where you find the Center for Back Pain.

So Stanford Systems Pain– Neuroscience and Pain Lab. I can write it down for you. Come see me afterwards. I’ll write it down for you. I’ll make sure you get it. It’s long. It is long. It is long. You’re right. You’re right. And also the Stanford Center for Back Pain, that will get you there. And you fill out an online form. And we can automatically see if you’re eligible for this free treatment study. And even if you’re not available for that one, we have other cool studies coming up all the time. We do a lot of different things. And so you will be contacted when there is a study that it appears that you qualify for. Then we bring you into the lab, and we’ll do ask more questions to find out what’s appropriate and what’s interesting to you. Yeah, another question. So you had mentioned that there’s a cultural difference in the way that people perceive pain within cancer populations.

In your experience, or perhaps there’s research on this, is there a difference in different cultures and how people experience pain in general? It’s a great question. And did you want to chime in there? Yes, yes. I’m from Iran, Persian, and my father, of course, very much pers– wants to be perceived. So he had done some woodwork, he’s retired now, so his shoulder was aching and very much, I think, because he stopped doing it. And I said, Dad, well, you need to stop. You’re doing too much. I’m going to show it. It has no right to hurt.

I’m going to show it. He basically, he does not take any pain medication. And yes, very much, I think cultures and men especially, they don’t– But it’s interesting because there’s also a gender effect there. And sometimes there can be an age effect too. I mean back in the day, people would just be like suck it up, and they would just suffer or get through it. And so there’s many different factors. So culture, age, sex, gender, it all plays a role. The one thing that I will say without being a cross-cultural expert on the topic is that many studies have looked to see well, do we just have more pain here? Is there something about our culture where we’re more sensitive to it? And the answer is no.

The answer is no. That we had this surprising statistic that 100 million Americans experience pain on an ongoing basis. That’s almost one in three adults. But really, when you look at the data for the other countries in the world, it’s all similar. It’s all similar. So I think there’s pockets of differences from here and there. But actually, the prevalence of pain is– it’s pretty standard across the globe. We’re just less patient with the pain. We want a pill right away. A pill. A pill. Just give me a pill. I’m hurting, give me a pill. I just want to cure it quickly. Yeah, yeah. Question back here. I just want to clarify something. You had said that anger is a therapeutic target and that also that catastrophizing is this therapeutic target. Is the compassion training the treatment on both of those targets? So interestingly, well, that is a great question because I have not seen any data for a study that has looked at compassion training as a treatment for catastrophizing.

Our study looked at compassion cultivation training and found that it reduced pain and anger concomitantly. And so it’s very useful for that. Now I would suspect that it would be useful for catastrophizing as well. And what we’re really focusing on now is briefer treatment, specifically, for catastrophizing. The idea that well, gosh, if this is such a powerful negative factor, what if we identify people early on and rapidly treat them, so that they can have an– optimize your response to whatever treatments your doctors will try with you? So I have this fantasy in the future that when you set foot in the pain clinic, or maybe even in primary care, that they could screen you and give you a link to a video, where you could get all of the information and start self-treating. And in fact, here at Stanford, we adapted the class that I developed. We put it on video and adapted it so that it’s appropriate for people who are about to have surgery.

Because remember one of the big indicators of how well you do after surgery is whether or not you’re a catastrophizer. So what if we treat catastrophizing before surgery? And that leads to quicker recovery, less medication, better function. So that’s the hypothesis. We’re studying this right now. We’re doing a randomized controlled trial in women who are undergoing surgery for breast cancer. Some of them are getting a mastectomy, but some of them are not– it’s not mastectomy, but they are undergoing a surgical procedure. And so we’re looking to see can we help people remotely? Because they’re just watching this online and going through the treatment online. But I think now because we know that pain is so prevalent in this country, and we’ve all seen the stories on pain treatments. And we need solutions that can help people. And we have to find ways to treat big masses of people efficiently and in a manner that’s cost effective. And so part of what we’re trying to do here at Stanford is develop these innovative treatments that can be part of the solution. Yeah. How many of these treatments then get to a surgeon, for example, out in the real world, not in this academia setting, so that his breast cancer patients would be aware that they could take a video or that they could– who does that? When you say we, who does that? Who delivers that? Totally, no, it’s a great question.

So first we study it in an academic environment. And the end goal is just to have these free on the internet and available. That is the goal. One excruciating aspect of science and research is that we have to study it for a period of time before we can just make it free and widely available. And there’s ways that we get around it. I mean I put this information in my book, for instance. But when we just develop it, we have to learn how it works and for whom, so that we can basically give people more information about it.

But I will share with you that my goal is to get it out and for it to be completely free. And it won’t be this year, and it probably won’t be next year. But sometime in the near future, that is absolutely the goal. So that you, or any of us, could just Google that. Download it. Download the app. The app will be free. The video is free. Everything, all of it, widely accessible. Because there’s no point in just developing things in our lab, and then we help 30 people. The point is to help transform pain care and to give people the tools and the resources, so you can self-treat at home.

But my point is that information is out there, much of that’s out there right now. But how would many patients who have surgery, would their surgeon, for example, be alert enough to this to say go to this website, or here’s some research– Well, it’s a good question. And we’re moving things in the direction of educating more on this topic. So just this month I had an article published. It’s basically in a journal read by surgeons.

It’s a surgical journal. So it starts there with really educating medical providers who don’t live in this world of psychology. I mean they just– no fault, no harm. But it’s a new concept for them. We’re working to introduce the concept, draw attention to the importance of treating it and also to connect to them with resources. Because as you mentioned, even though, for instance, this whole video package isn’t available now, there are things that are available today that people can use. So those are the things that I write about. Yeah, another question? I just thought about something. It goes to your question of dreading. Have they done a study to, perhaps, choose two groups. One, preoperatively, you tell them, oh, this operation, this is really intense. It’s going to hurt. It’s going to hurt a lot. We’ll do as much as we can. And then see what happen. versus tell people, oh this doesn’t hurt at all. When you wake up, there’s going to be no pain. Don’t worry about it. And then have they done something like that? Not exactly that, but something that I think will be equally interesting is that they have done studies, actually do studies where they perform fake surgeries on people, sham surgery.

And so you either get real surgery or fake surgery. But you don’t know the difference. And people get better from fake surgery. People get better from taking placebo pills, fake pills. And we talk about placebo. It’s pejorative. Oh, that just shows that it’s all in their mind. To the contrary, placebo is a fascinating concept. And it really illustrates the power of our mind and what we believe and its capacity to either heal us or harm us. And it’s really great you brought that up because that’s exactly– I’m so excited about this topic. And that’s exactly what I’m writing about right now in this second book is exactly this.

This idea, the way that it’s like a pejorative concept. Oh, placebo. We need to be focusing on that. That’s the coolest thing ever. And we’re focusing on something like the big story is on the pharmaceutical. But the big story is really on how people just believing that they’ll get better, get better. It’s fascinating, fascinating. Well, unfortunately, physicians, in general want to give you the worse scenario usually because afterwards they don’t want to be responsible in case things don’t– so we do that often, I think. So one of the things that’s really interesting is that the power of suggestion is so potent that it often can call into question the idea of informed consent because we’re listing all of these negative things that could happen. And then we start focusing on them and searching for evidence. And we can actually start to create some of those symptoms.

This is exactly what I’m writing about right now. And so this effect is so particularly powerful in cancer that some doctors– I mean there’s actually been medical literature where they say where they’re having debates about whether it’s ethical or not to inform patients about some of the side effects and to get them thinking on it because they can create them. So there’s a debate on that actually. Yeah, yeah. Kathleen. [? You can’t use morphine and a lot of ?] things like cortisol and [INAUDIBLE] in some of your studies. I didn’t really see that in any of these. You’re right. I didn’t put that up. So Kathleen’s raising a great point. I have done prior research looking at how catastrophizing influences the immune system. And this was a pilot study I did back in Oregon. And it was a bit of a painful study for me because I brought people into the lab. And we placed a catheter in their arm because we were drawing blood samples over the course of hours. And what I had them do was I had them catastrophize.

I actually asked them to catastrophize. So focus on your pain, how bad it is, and imagine it worsening. And then I want you to talk for 10 minutes about the worst parts of it, what you see unfolding if your pain gets worse. So I actually guided people to catastrophize. And this was really hard because it goes against my fiber of my being. And I want to help people. But sometimes we have to study the negative stuff so that we can better help people. And this was that study. And so then we drew blood at various time points and measured the cytokine response. Cytokines are a marker of the immune system.

We were trying to measure the amount of inflammation that would be expressed in the blood as a consequence of catastrophizing. And what I found were a couple of things. One is that women got a pretty good response, whereas men did not. And we could interpret that. And we could say, well, it’s more stressful for women or all of these things. Well it’s true that the immune system is often a little more overactive in women. They’re more likely to acquire inflammatory conditions, for instance, we are as women. But there was some scientific confounds. I mean I was in the room as the experimenter, so it might have been a gender effect, that men were less comfortable emoting. What I found was that the women who had an inflammatory response were the women who not only experienced this negative emotion, but it was visible. There was expression of negative emotion. So it wasn’t just enough to picture it in your mind, like, yeah, that would be awful. They had to affectively display their emotion, and that was correlated with this inflammatory response, which we could measure in the blood.

And so that has some implications, then, when we think about health and how stress can impact our bodies and our physiology and inflammation. This was a study that was done in people who had chronic pain. We know that inflammation isn’t good for pain. I mean that’s pretty commonly known. We often take anti-inflammatory medication for that reason. So we don’t know the full consequences and implications of this research. But it offered some clues about how we direct our thoughts. And the emotions that we experience as a result of how we direct our thoughts directly influences our immune system. And that there are implications for pain, possibly, as a consequence of that. So thank you for bringing that up, Kathleen. Question. Has there been any studies on just visual observations of people with pain and then linking that with their experience of pain, like their pain scores and everything, with a measure of catastrophizing? So it seems like you hear providers talk about, well, they entered 10 out of 10 pain, but they’re walking and talking and laughing, all this kind of stuff.

I’m wondering if those types of observations are hinting at catastrophizing. If somebody, like you said, their affect is negative. They’re– Oh interesting. –grimacing, things like that. I wonder if that’s what you’re actually looking at. Is that correlated with their measure of catastrophizing? Yeah, so what’s interesting in this specific experiment, we didn’t find that their measure of catastrophizing correlated with how much affect they were displaying in the moment. But it was the intensity of the induction that correlated with their experience of inflammation. I think what you might be asking is in just everyday people, are there more objective ways to either measure pain or to observe catastrophizing? Am I– Yes, the observation, I was just interested, I’m interested in your thoughts on the observation of catastrophizing, aside from the measures and the scores and stuff like that. Interesting. It’s definitely something we– clinically, we see it.

Sometimes even when people are less willing to endorse it, but you see it, and you hear it. And then you look at their score, and it’s like something’s not connecting there. So sometimes people will underreport for whatever reason, for whatever reason. And there’s no blame there. It’s just sometimes people score lower. They just tend to. But when you’re working with them, you identify, no, this is actually happening.

This is something that we need to address clinically. So that does happen absolutely. Any other questions? One in the back. This is out-of-the-box and on the other side, but with people that are very mindful and that are very in control of their pain, and then stepping into an emergency room or in a doctor’s office, and you have pain, but you’re not very sure of what that pain is. And most recently, a lot of people with cardiovascular diseases, it’s on the rise, and those are probably most things that are undetected and feel very flu-oriented more than feeling like heart attack. I mean especially if you’ve never been sick, you don’t know what those things feel like.

Going in with controlled pain, you feel like bad. You always make it more. OK, because you look normal, you feel normal, and you could control your pain, and you’re just going through so many tests. And by that time, it’s just too late. By that time, they diagnose and it’s almost too late. Right, right, so she raises an interesting point, sort of at its core, is if we’re very mindful of our pain and mindfully controlling it and really have a nice container around it, that it might in some ways impede access to care.

I think– I feel like through a– for instance, I’m a very perceptive person, so I’m very in tune with my body. I’m very in tune. So I can control pain. I can divert it. I can do yoga. I can do all these things. But then when you step in after you’re going through something very serious, it’s almost– it takes a long time for someone to be like, are you really in pain? To be believed. You look really healthy.

Right, to be believed, because yeah– By that time it’s like they couldn’t diagnose someone earlier and [INAUDIBLE]. Yeah, it’s a good point. And that’s one of the issues with chronic pain is that you don’t see it, and so people assume that it’s not there. They’ll just assume that you’re healthy or that you feel good. And people have no idea what’s happening, and that can be a component of the suffering and isolation of pain. And so we actually talk about that, when we’re working with people that– letting people know that you have pain without it becoming the focus of the relationship.

But letting people know that you have it can be important. And also, know that people will forget. And so having to bring it up or remind them or have productive conversations so that the relationship can move in a way where you feel like you’re being heard and also seen. Because it is hidden, and people won’t– they won’t remember. They won’t, and so it can be in the background and, especially, for folks who are younger, in particular. Yeah. I was wondering if there are studies out there with actual doctors that when patients are going through this kinds of things what they’re actually looking at, compared to someone that’s coming in– I’m more talking about cardiovascular health because it’s so undetected.

You know that you’re going in– because they ask you questions, like, what’s the pain? And do you felt that. You don’t know what a heart attack feels like. [INAUDIBLE] you’re breathless. It could be asthma. It can be like, you’ve been exercising. It can be a lot of things. Absolutely. I’m not familiar with that specific literature and, in particular, this aspect of what are physicians perceptions of a patient’s symptoms in the moment of like cardiac symptoms and whatnot. But I think that that’s an interesting literature, I’m sure.

I think what she’s describing as acute pain in the chest is emergency right away. I mean when you walk into ER, if you say my chest hurts, they usually are not going to ignore you. And you said acute, you’ll know. Believe it or not, people that are even relaxed in general, the cardiovascular disease, when they have chest, they also describe having this impending doom, the feeling of impending doom. And they’re not doomy people. They’re very happy, joyous, but when it comes to the chest and the heart pain, they have that sense of impending doom. I agree. [INAUDIBLE] You have to be the very assertive client. When you walk into the ER, you have to say, I have history of heart disease, and my chest hurts.

Believe me, you’ll be the first one to be seen. So any other questions? Does it feel complete? OK, well, thank you all for your attention and time. Thank you..

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