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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