In this lesson, we’ll cover 6 basic truths about pain.

It might be tempting to skim

through these quickly, but I would urge you to really take the time and listen all the
way through... because learning in itself is a critical part of the healing process.

incidentally, that brings us to the first of our 6 basic truths about pain.
When it comes to pain, knowledge gives you power.

Knowledge is so powerful, in fact, that education about pain is a medically

recognized form of treatment. Healthcare practitioners call it “therapeutic
neuroscience education,” or TNE, which is a fancy way of saying that someone is
learning about the biological processes of pain. Scientific studies show that this sort
of education is linked with decreases in physical symptoms, improved function,
reduced fear, improved mobility, and a calmer nervous system.

So as you listen to these basic facts about pain, you can feel good knowing that
you’re already doing something scientifically proven to help you.

So with that, let’s move onto our second basic truth about pain:
Pain is designed to protect.

From an evolutionary perspective, pain helps us survive

As humans, we can use pain to learn about our environment and to get better at
avoiding anything that could potentially harm us. It acts as a sort of danger signal,
telling us when we get too close to a hot burner, or teaching us not to pick up a
broken piece of glass. It also motivates us to take it easy when our tissues are
damaged and need rest in order to heal.

There are a few people in the world who experience no pain at all, and it’s no
surprise that this condition comes with a very short life expectancy.
The point is - a life without pain is not ideal. So keep in mind that pain is actually
designed to be a helpful experience that allows you survive by alerting you to
danger.

So pain is designed to keep you safe. Which is why an injury will usually hurt. But in
some scenarios, pain can be suppressed even if there IS an injury. And other times,
pain can be produced when there’s no injury at all.

This mystery brings us to our third basic truth about pain:

Pain is not just a physical experience.
Old models of pain, which most of us were taught growing up, show that pain is only
caused by physical damage to the body. In recent decades, those models have
been proven wrong.

We now know that physical damage to the body is one of many factors that make up
how much pain we experience in any given moment. But it’s actually one of the
least influential factors.

Consider this example:

Imagine you are sitting on the couch with a sprained ankle. Picture yourself trying to
get up off the couch onto the injured ankle, and feeling a throbbing pain the moment
your foot hits the ground.

Now, imagine you are sitting on the same couch with the same sprained ankle. Only
this time, a lion is in the room with you. Now, when you try to stand up, you feel no
pain at all. You begin to run as fast as you can on the injured ankle, relatively pain-
free, until you reach safety. Then, and only then, does your ankle begin to hurt
again.

In each scenario, we see the same physical injury, yet a drastically different
response from the pain system. You can probably think of a time in your life where
something like this has happened to you.

So how does this happen?

It happens because our pain system is sophisticated, and it takes all of the
information that’s important to us into account when deciding whether or not to
produce pain. And the reason it’s able to make this high-level decision is because
your pain system has a command central, located in the most advanced computer
that exists: your brain.

And that’s our fourth basic truth about pain:

All pain originates in the brain.

This is true for every single type of pain you will ever experience - regardless of how
it started, how severe it is, or how long it’s lasted. Pain does not exist until the brain
says that it does.

Think of a broken arm. Your arm is the part that’s injured, and your arm is the part
that feels the pain. So you may think it logical that the arm created the pain. But
that’s not true. The nociceptors in your arm alerted your brain that there’s a
potential threat. Then, the command central in your brain decided how much pain
should be produced in order to protect you from that threat. And then, in a matter of
nanoseconds, your arm began to hurt.

The same is true for all types of pain - whether they are associated with a physical
injury or not. Your brain produces pain in response to all sorts of potential threats,
not just physical injuries. And no matter what the threat is or what the symptom
shows up as, your brain is always the one calling the shots, deciding what amount
of pain will best protect you in this moment.

Sometimes people worry that this means the pain is “all in their head,” as if their
brain has imagined it. And that is simply not true. All pain is equally real, and all of it
is created in the brain. If anything, this fact helps to explain WHY people can
experience such severe symptoms in the absence of any tissue damage.

So while pain can be felt in any area of the body, the decision to create it lies with
the brain. And understanding that fact is absolutely critical to reducing your pain
symptoms… because once we understand HOW the brain makes its decision, we
can start to influence the outcome.

This all brings us to our fifth basic truth about pain:

Pain is an opinion, not a fact.

Specifically, it’s you BRAIN’s opinion of how much pain you should feel at that exact
moment in order to survive and be protected.

Your brain reaches this opinion by answering a whole series of questions. It doesn’t
just assess whether or not there’s tissue damage and create pain based on that
information alone.

It looks at whether you’re able to focus on this pain or not, how afraid you are of
pain in general, how well-equipped your body is to heal itself, what it might cost you
in your life to deal with this pain, and more.

We’ll cover these factors more in-depth in another lesson, but for now, just
remember this: pain is your brain’s opinion, and that opinion does not always reflect
reality.

Your brain can decide that you need to be protected when you don’t.
Your brain can decide that you are in grave danger when you’re not.

As we saw our lion example earlier, the brain can also decide that even though you
ARE in danger and there IS damage to your body, creating pain is not the best
survival strategy.

So your brain is always making judgment calls on what it thinks you need to pay
attention to.

I asked Dr. Tor Wager, Director of the Cognitive and Affective Neuroscience Lab at
CU Boulder, to give a real-life example of this. Here’s what he had to say.

Dr. Wager: "A good friend of my brother’s was rock climbing with his friend one day.
Justin was belaying the friend, which means he was holding the rope in order to
catch the climber if he falls.

"The climber, who Justin was belaying for, got just about to the top of the climb,
then slipped and fell. And he slipped and fell at a moment when they were changing
over the ropes, so Justin did not have his hand on the rope to catch him. So the
rope is spinning, and this guy is free-falling off the cliff.
"Justin grabs the rope, and he catches it and stops the rope. What you have to
realize is that these ropes are made of nylon, so there is incredible friction… you
can’t really just ‘grab a rope.’ But he did, and he caught it, and he felt no pain.

"Then, he looked down at his hands, and the rope had burned all the way through to
the bone. He still has the scars. But in those first moments, he felt no pain. That’s
one example of really strong control of pain and pain processing based on what’s
happening in the environment."
Host: "Does that have anything to do with adrenaline, or is that an urban myth?"

Dr. Wager: "Adrenaline can certainly have many effects on the body, but in this
case, it’s too fast. There’s no way that he could release adrenaline through the
sympathomedullary access, into the blood stream, have that circulate, and have
some kind of effect.

"What’s likely is the brain stem has basic circuits that regulate your heart rate, blood
pressure, how much your blood vessels dilate, whether you feel nauseous, whether
you breathe in and out, AND pain (at least the pain that’s coming up from your
spinal cord). There’s a part of that brain stem that sends projections back down to
the spinal cord that can amplify pain or decrease it - sometimes very dramatically.
That may contain some of the clues to what happens with chronic pain.

"In some models, there’s a number of rodent models of chronic pain, they can do a
partial nerve injury and create a chronic pain state in an animal. Even after the
injury is healed, the animal will exhibit pain behavior. In some cases, this is because
that part of the brain stem is turning pain on all the time - it’s facilitating pain.

"If you look at that system in humans and what that connects to, it’s integrated with
the higher brain centers in your prefrontal cortex and your so-called “reward system”
that have a lot to do with how you think about a situation. Where is your attention,
but also, what does the signal coming in from your body mean to you? And what
else is happening in the environment that you need to respond to?

"We have a lot to learn about that system, but I think that for many of us, it has a lot
to do with how you interpret those pain signals and what they mean for you."

What Dr. Wager said is true…the experience of pain you end up having has a lot to
do with how your brain interprets those signals and what they mean for you.

This leads us to our sixth and final basic truth about pain:
To get rid of the pain, you have to treat the brain.

Even when physical factors are present, they are not whole story… and in most
cases of chronic pain, even the cases that started out with an injury or surgery or
some sort of tissue damage, the contribution of the physical component to the
overall experience of pain is quite small.
Leading neuroscientists, physicians, physical therapists, and other healthcare
practitioners are starting to approach pain this way. They look at it through a
biopsychosocial lens… one that takes ALL contextual factors into account, not just
the physical changes happening in the body.

I asked Dr. Tim Flynn, a board-certified physical therapist and widely published
author, to explain how our understanding of pain has evolved:

Dr. Flynn: "The biopsychosocial model is a relatively recent event. Most of medicine
during the 20th century was based on a Descartes model of a very linear approach
to disease. In other words, we use medical imaging, and if we see something amiss,
we assume that is the problem and we cut it out, burn it out, inject it, etc. That’s a
really old model of pain, and that’s really the model of disease that many physicians
carry to this day, especially when we look at musculoskeletal pain.

"A biopsychosocial model is one that incorporates the biology of the human, the
psychology of that individual, and the social framework and constructs where that
individual is at. We can have the very nearly the same biology, and suffer similar
injury, but depending on our psychological and social frameworks at the time, a very
different outcome. We may have a different capacity for whether we are able to
resist that trauma. If we are just getting by day to day and one more event tips us
over what our body and mind are capable of, we may go on to a persistent
condition.

"The biopsychosocial model encompasses what it truly means to be human. So

when we come with some complaint of pain, we really need to take all of those
factors into consideration, not just the biology at that moment in time."

This may all seem pretty straightforward, but it’s a lot of information to take in… so
take a deep breath and let’s review the 6 basic truths about pain.

1. Knowledge gives you power.

2. Pain is designed to protect.
3. Pain is not just a physical experience.
4. All pain originates in the brain.
5. Pain is an opinion, not a fact.
6. To get rid of the pain, you have to treat the brain.
As a society, we tend to over-attribute pain to structural damage or injury…. even when we
know that an injury healed long ago, or that the level of damage couldn’t possibly account
for the level of pain.

But in reality, there are millions of people with severe chronic pain who show absolutely no
signs of tissue damage in the body. Migraine, fibromyalgia, sciatica, and nerve pain all fall
into this category.

Just like any other type of pain, the symptoms of these conditions are processed in the
brain. They are just as real and severe, and can often be even more frustrating since they
don’t leave many physical clues behind.

But we do know a bit more than we used to about this type of pain. For instance, brain
imaging studies have shown significant differences in brain activity while these pain states
occur. So there are DEFINITELY physical changes happening in the body, they’re just
changes we are not as familiar with.

These sorts of changes are what we call a “physiological change” in the body. They include
temporary, reversible states like changes in muscle tension, nerve-firing patterns, brain
activity, and blood flow. Despite the fact that these are hard to identify in medical imaging,
physiological changes can create real, severe pain. But the most important thing to
remember about this type of change, is that it is reversible and temporary. And even though
it creates very intense pain, it does not cause permanent tissue damage.

A wide array of factors can cause a physiological change to take place in the body, so let’s
start by looking at a simple example: stress.

We all acknowledge that stress can come along with some physical reactions, like tense
shoulders, feelings of nausea, or headaches. Just like with pain, these lower-level physical
responses are happening because of your brain. As we know, the brain is constantly
processing contextual information, including what kind of stress is going on in your life.

Whether you realize it or not, your brain is unconsciously and automatically transmitting this
information to the rest of your body all the time…

It does this through a chemical network that's kind of like a very fast paper route.

Think of the brain as the publisher. It writes and prints out the newspaper, which contains
all of the latest information that it wants the body to know about… in this case, the
newspaper might say that you have a huge deadline coming up, or that you’re in the middle
of a fight with your significant other.
Then, your brain creates its own paper boys, called ligands, who travel through the body,
delivering the newspaper cell to cell.
Tiny mailboxes, called receptors, are sitting on each cell, waiting to receive the paper
As soon as the paper comes, these receptors pass it along to the cell so the cell can read it
and decide what to do next

All of this is happening automatically and pretty much instantly… so our cells are constantly
receiving these updates and deciding whether they should do anything about it.
Based on the information they get, a cell can choose to do all kinds of stuff… divide itself,
create extra proteins, pretty much whatever it wants
In short, that means that contextual information, like a strong emotion or a stressful
situation, can physically alter what’s happening in our cells
Multiply that across a whole bunch of cells, and you see how this can really start to affect
our bodies
This chemical network of information explains how these lower-level stress responses
occur, but it's also capable of triggering much bigger physical responses from our cells
It can make us feel pain in places where there’s no injury, tense up our muscles, redirect
blood flow, or even trigger a migraine

On the other hand, this network is also capable of reversing those same symptoms… just
like when your shoulders relax as soon as you remove yourself from a stressful situation.

So these messages sent out by the brain play a very critical role in both pain creation and
pain relief.

The placebo effect is a great example of how powerful the brain’s influence can be, and
how it can physically alter what’s happening in the body based on contextual information
alone. When a sham medication is taken, the brain believes that relief is on the way, which
leads the body to relax, and in many cases activates the body’s natural ability to heal itself.

Here’s Dr. Tor Wager explaining exactly how the placebo effect works inside of the body:

Dr. Tor Wager: “Some of the most dramatic results that we’ve seen in our lab are that if you
take a sham medication, your brain releases opioids. The brain has its own internal
pharmacy.

"We take morphine, or fentanyl, oxycodone, hydromorphone, or any of those, and those are
external drugs the act on receptors in our brain that are intimately linked with pain relief,
and also with feeling good and engaging in a positive way in life events. The reason that we
HAVE those receptors is because your brain makes its own. Your brain has its own internal
pharmacy that you can engage.

"The reason that this internal pharmacy exists is to translate your knowledge about where
you are, what’s happening to you, and what’s the bigger picture into lower-level changes in
your brain. That’s where the brain is asking ‘How much pain should I be feeling right now?
Should it be more or less, given what I have to do and where I am?’

"Opioids help to implement that. So getting a sham treatment, like a skin cream, can cause
endogenous opioid release."

Host: “So the brain is taking in the information ‘something that’s supposed to help is here,’
and then making the decision to create or experience less pain?"

Dr. Tor Wager: “Exactly, that’s right. And a lot of work in neuroscience has fleshed out the
idea that what you’re engaging in, in terms of your life matters. So, in other words, what
does the pain mean to you? Are you in the midst of a fight, or a social standoff? Are you
able to focus and stew on the pain to amplify it and heal? Or do you have to do something
else that’s very demanding, where feeling pain would be distracting and harmful for you?
So based on those things - what we call the ‘environmental context’ - your brain has the
capacity to turn up and turn down pain, sometimes quite dramatically."

It’s amazing to think about how drastically the brain can change what’s happening in the
rest of the body, both by creating severe symptoms and by relieving them.

Let’s do a quick recap of all these concepts:

People think that pain is associated with tissue damage, but a large portion of chronic pain
doesn’t involve tissue damage in the body at all
Even so, there are still physiological changes happening to create pain, like differences in
brain activity and neural pathways.
Stress is an everyday example of something that can cause physiological changes in the
body… the brain sends out the message about what’s going on to all of the cells in the
body, and they respond accordingly
This chemical network of information can account for much bigger physical responses in
the body as well, like migraines or nerve pain
But luckily, it also has the power to unlock your body’s internal pharmacy, and help to
reverse or heal symptoms

How pain becomes chronic

Regardless of how pain begins, the transition from acute to chronic comes with some big
changes.

It’s believed that the brain has a memory for pain pathways. The more often a certain type
of pain is triggered, the easier it becomes for the brain to replicate that experience,
regardless of whether there’s a reason to create pain or not.

We see this kind of pain memory show up in phantom limb pain - a condition where
amputees report excruciating pain in a limb that no longer exists. There is obviously no
physical damage triggering the pain, so there’s nothing we can do to apply physical
treatments to an arm or a leg that’s not there anymore.

However, it is possible to relieve this kind of pain by changing the brain’s perception of the
situation. That’s why “mirror therapy" is often used in phantom limb cases.The patient puts
a mirror up to their healthy limb, creating a reflection that looks like the missing limb. Then,
the patient moves the healthy limb around, performing small tasks like clenching and
unclenching their fist. When looking in the mirror, it seems as if the missing limb suddenly
present, and moving with ease. This visual is enough to convince the brain that there is no
danger in the missing limb after all, and the pain disappears.

So whether it’s pain in a missing limb, or pain from an old football injury, the brain never
forgets how to create a certain sensation.

When pain becomes chronic, most people also experience a “sensitivity adjustment.” This
is sort of like that fire alarm that used to work perfectly fine, but now goes off every time
you light a candle. Over time, your brain keeps track of everything that could possibly be
related to your pain. It starts to become more fearful of anything it thinks might be a threat,
and eventually, the threshold for the brain’s danger signal to go off becomes pretty low.

This hypersensitivity is almost universal in chronic pain sufferers. And it’s usually a big part
of the reason why things that used to feel enjoyable, like sitting in a chair or going for a run,
may now feel unbearable to you.

Your brain learns to fear physical activities, weather patterns, and certain foods the same
way that it learns to fear everything else. First, through experience, and second, through a
protective overreaction.
Think about how a little boy learns to be afraid of dogs

Perhaps he likes dogs at first, and enjoys playing with them

But then one day, an excited dog chases him down the street, sending the boy into a panic.
Next time he sees the dog, he starts to run away before the dog even moves.
Thinking that he’s playing, the dog chases him again.
After a full year of being chased down the street every single day, the boy will become
more and more afraid of dogs, even though the dog is friendly and there’s no real danger.
But because he feels threatened by dogs, he becomes overly sensitive to them. He might
even become so sensitive that he doesn't even like seeing dogs on TV

This is similar to what happens when you spend a long time in pain. Things that used to
feel safe now feel very threatening to your brain. It starts to perceive these activities as
dangerous, and actually creates more pain in an effort to help you avoid them. And,
because your brain remembers how to create the same pain it’s created before, this pain
can feel identical to a physical injury.

But just like a fear of dogs, your brain can be trained to unlearn this fear. And as you slowly
reintroduce those activities into your life, your brain will start to notice that they're actually
safe.

I asked Alan Gordon, Director of the Pain Psychology Center in LA, to explain exactly how
this works in simple terms:

Alan: “A lot of research is finding that the majority of chronic pain is not caused by physical
problems in the body, but learned neural pathways in the brain. Your brain is giving you the
message that there is some sort physical damage in the body when there actually isn’t. So
our goal, what we’re essentially doing, is taking these people with pain and helping to teach
their brain that the sensation they are interpreting as dangerous is actually safe. And when
you’re able to teach the brain that over and over and over, you can develop some new
neural pathways so that the brain has a new interpretation of the same sensation, and the
pain goes away."

When pain becomes chronic, we also start to attend to it more. It starts to creep into your
exercises habits, ability to focus on work, relationships, parenting, and even sometimes
hygiene. As this happens, your thoughts and feelings about the pain typically become more
frequent, negative, and intense.

And of course they do… it’s hard not to think about pain all the time when it’s affecting
every area of your life. But studies have shown focusing your thoughts and attention on the
pain can make things considerably worse.

Dr. Wager explains how:

Dr. Wager: “Your brain is always learning. Your brain is incredibly plastic. Chronic pain
itself has effects on the brain which are probably harmful. I think a lot of that boils down to
the kinds of things that you habitually pay attention to and think become stamped in with
time.

“So if you have a back injury and moving elicits pain, and that elicits fear, then the more
that happens over time, the more easily your brain wires to do that automatically. It also
wires to attend to the pain so that over time, you become hypervigilant. You’re always sort
of looking out for those signals. And this doesn’t mean it’s your fault if you’re a patient! This
is a natural process: the things you do become more and more automatic over time,
including thoughts.

“One thing that’s helpful for many people is to unwind that. To use your conscious mind and
will to replace those thoughts with other, more beneficial thoughts, and replace avoidance
with positive engagement.

“One of the goals of therapies that can really work for people is to unwind this negative
spiral of avoidance. That has physical effects and it has effects on your brain. Another
strategy that works is to fill your life with positive things. One of the predictions of
neuroscientific theory, especially a theory by a researcher named Howard Fields who is
very influential, is that when you engage in these other kinds of activities, your brain
suppresses the pain. And on top of suppressing the pain, the pain is less important to you,
because you’re doing something else that you value. So you’re engaging the brain’s natural
mechanisms for turning down the pain when you engage in positive things."

It may seem impossible to you right now that you could go an hour without thinking about
your pain… but with the proper tools and techniques, this CAN become easier to do.

But for now, let’s just focus on soaking all of this information in. Remember, knowledge
alone can help you on the road to recovery. Here are the key concepts we just covered:

Your brain remembers pain pathways, and because of this, it can trigger pain that FEELS
like an injury long after the body has healed
When pain becomes chronic, the brain becomes more sensitive, and wires to send danger
signals more easily. That’s why so many things that used to feel enjoyable may now be
very painful.
Finally, as the pain starts to creep into every area of your life, your thoughts and feelings
about pain might become more frequent and negative. But since the types of things you
habitually think and pay attention to become stamped in with time, this makes it difficult for
your brain to hop out of the pain-fear spin cycle.

What pain means to me?

When you’re trying to figure out how to reduce chronic pain, there’s not a one-size fits all
solution for everyone. The contents of your brain are unique to you, and therefore, so is
your experience of pain. However, there IS one question you can ask to figure out your own
road to recovery: What does the pain mean to you?

That’s the question that describes the biopsychosocial approach in a nutshell. To figure out
how to reverse pain, you have to become aware of all of the filters your brain is using to
create and interpret it in the first place.

We know from several studies that thoughts and feelings play a critical role in chronic pain.
You may have heard the phrase “your thoughts become your feelings, and your feelings
become your actions.” This holds true inside of your body, too. Your thoughts, both
conscious and unconscious, produce how you feel about a situation. And your physiology
takes its cues from your feelings, whether they are rational or not.

Let’s take a look at all of the filters your brain uses to determine your thoughts, then
feelings, and eventually physiology:

First, we have your thoughts about the pain itself. When you live with chronic pain, it’s hard
not to think about it, and it’s perfectly natural to worry about how long it will last, or whether
you’ll ever be able to go back to the life you had before. That being said, persistent
negative thought patterns about your pain can do you much more harm than good.

Physicians and scientists have long studied the process of “pain catastrophizing” - a
pattern of thinking that gives constant worry and attention to pain and jumps to worst-case
scenarios. Across conditions, pain catastrophizing has been shown to predict pain intensity,
disability, and psychological distress about the pain.

There’s a questionnaire researchers use to determine how much of a “pain catastrophizer”

each subject is. It was developed and validated in the mid-90s by Sullivan, Bishop, and
Pivik. I’ll read the questions for you now, and you can decide for yourself whether these
statements feel true for you. Be as honest as you can in your assessment.

Here are the statements:

When I am in pain, I worry all the time about whether the pain will end
When I am in pain, I feel I can’t go on.
When I am in pain, it’s terrible, and I never think it’s going to get any better
When I am in pain, it’s awful and I feel that it overwhelms me.
When I am in pain, I feel that I can’t stand it anymore.
When I am in pain, I become afraid that the pain will get worse.
When I am in pain, I keep thinking of other painful events.
When I am in pain, I anxiously want the pain to go away.
When I am in pain, I can’t seem to keep it out of my mind.
When I am in pain, I keep thinking about how much it hurts.
When I am in pain, I keep thinking about how badly I want to pain to stop.
When I am in pain, there’s nothing I can do to reduce the intensity of the pain.
When I am in pain, I wonder whether something serious may happen.

If many of these statements sound familiar, that’s okay. It simply means your brain is using
these thought patterns in its decisions about pain. And luckily, with some tools and
patience, you can work to change that.

In addition to pain catastrophizing patterns, your thoughts and feelings about coping with
pain can also play a role.

You may have heard of the term “locus of control” before. Someone with a strong internal
locus of control has a strong belief in their own ability to influence the events and outcomes
in their life. Someone with a strong external locus of control tends to view the events and
outcomes in their life as a result of luck, fate, and the actions of others.

Controlling for all other variables, it’s been shown that patients who have a stronger
internal locus of control report lower pain intensities and less frequent pain. They also tend
to be more engaged in multidisciplinary treatment approaches, which require patients to do
a lot of exercises and introspection on their own time. As a result, these approaches tend to
be more effective for them than for those who believe they have no control over their pain.
This pattern holds true for other forms of treatment as well... your beliefs about your own
ability to handle the treatment and whether it will work can impact the actual efficacy.

But it’s not just your thoughts and feelings about PAIN that make a difference. It’s also the
thought patterns that make up your usual mindset…

Your brain filters the experience of pain through the very same personality tendencies and
biases that it filters everything else through… each social interaction, stressful life event,
and minute detail of your everyday life.

It’s long been thought that your general style of thinking and coping is correlated with how
likely it is that your pain will become chronic. That’s not to say that any of this is your fault,
just that how you think about things matters.
Just like having negative thoughts about pain can lead to increased pain, so can a general
pessimistic outlook.

But there are some other, less obvious personality tendencies that are thought to
perpetuate, and sometimes even be the cause of severe physical symptoms. Think about
whether you identify with more than one of these.

Perfectionism: holding yourself to an almost impossible standard of quality in everything

you do
Goodism: an intense desire to be well-liked, often resulting in overextending yourself for
others and putting your own needs last
Serial caretaking: constantly putting yourself in situations where you’re depended upon for
someone else’s wellbeing
Low self esteem: never truly feeling like you are inherently enough
Strong inner critic: having an inner voice that’s constantly critiquing or tearing down
everything you do
Bottling up emotions: a tendency to push down or power through any strong feelings, for
fear they may make you appear weak or out of control
Hypervigilence: any sort of neurotic or obsessive tendencies, and a strong desire to feel in
control at all times

I should mention that some of these tendencies are not inherently good or bad… I’m simply
pointing out that your brain is using the thought patterns of these biases to create your
experience of pain.

The reason these tendencies are all considered “risk factors” is because they contribute to
the brain’s perception of stress. Stress is not an event or stimulus that happens in your life,
it’s your brain’s judgment that what’s happening exceeds your resources…. perhaps that
means it exceeds your time constraints, your emotional capacity, or even your coping
ability. When the brain feels that it is under stress, physiologcial changes take place,
Sometimes, that means creating pain out of nowhere. Sometimes, it means activating a
trusty old pain pathway that your brain is already familiar with.

Here one example of how this works with the personality traits I just listed:

If you hold yourself to an unrealistically high standard of perfectionism at work, your brain
will constantly make the judgment that the demands placed on you are greater than the
resources you have to accomplish them at the level of perfection you require. Eventually,
this wires your brain to be in a constant state of stress, which has serious physioloigical
consequences.

Okay… so your thoughts about pain, and your general personality biases both play a role in
shaping your experience of pain. Another filter you might not have considered is past
stress.

Your whole perception of reality is filtered through your own personal lens of past
experiences. So it makes sense that your brain would take these into account when
deciding whether it feels safe.
There’s a lot of evidence that this filter is actually one of the most influential when it comes
to pain. Any formative experience that shapes your way of thinking can be roped into this
category… but it’s particularly important for those who have experienced serious trauma or
adverse childhood events.

This includes physical, sexual, or emotional abuse, physical or emotional neglect, violence,
substance abuse, or mental illness in the household, parental divorce, or the incarceration
of someone in the household.

There is a significant overlap between people who have experienced these kinds of events,
and people who develop chronic pain, and studies have shown that adverse childhood
events can lead an increased risk of developing conditions like migraine or fibromyalgia. It’s
been shown that trauma can physically alter your brain, which is why it makes sense that
these past events would factor into how you experience pain today.

It’s also very common for serious pain conditions to appear out of the blue, or worsen right
around the same time as a stressful life event… like a death in the family, the loss of a job,
or the loss of an important relationship.

Dr. Howard Schubiner has been helping his patients connect the dots between emotional
experiences and physical pain for years. Here’s how he explains what’s happening:

Dr. Schubiner: "The studies clearly show that when people have an emotionally upsetting
even, the parts of the brain that are activated are the exact same ones that are activated by
a physical injury. So that shows us the mechanism by which emotional pain can create
physical pain. And so all of those things are happening, and then the pain becomes learned
and that vicious cycle ensues. Over time, the pain just gets worse rather than getting
better."

If you experienced trauma and now experience chronic pain, that doesn’t mean that you are
doomed to be in pain forever. It just means means that this experience may have changed
the way your brain works a little bit. It’s possible that these past experiences now make
your brain feel unsafe a great deal of the time, and those changes could be perpetuating
your pain.

Again, there are tools to help you reduce this effect. And in fact, awareness is one of them.
Simply acknowledging that there may be a connection between past events and current
pain levels sometimes be helpful to unlinking the two.

There’s still one more filter the brain uses in creating your experience of pain that I want to
cover, and that's social context.
Chronic pain can feel incredibly disruptive to the course of your life.

It can make it hard to focus at work, or even make it impossible for you to keep your job.
This might mean you’re now in a very different financial position than you once were.
The pressure of constant pain and the search for answers can create extreme tension in
your social relationships, too, especially a spousal relationship.
You may lose the ability to do things you once loved doing, like going for a run or playing
with your kids.
You may even lose the ability to perform simple tasks, like carrying a bag of groceries.

All of that combined with a fruitless search for relief can lead to symptoms of depression,
anxiety, panic attacks. It’s been estimated that chronic pain takes a similar emotional toll to
a cancer diagnosis.

This enormous sense of loss is like a huge weight, and it’s completely natural to feel this
weight. Even so, overfocusing on these perceived losses is linked with increased pain
intensity, frequency, and duration.

More troublingly, this sense of victimhood can sometimes seep into your core sense of
identity. That can lead to all sorts of changes in your core beliefs and thought patterns, and
fuel the intense cycle of pain right back up.

So…. back to our original question. What does the pain mean to you?

The answer to that question goes through a bunch of filters before your brain makes a
decision.
Part of that answer is influenced by your thoughts about the pain… like “I’m worried that it
will never go away."
Part of it is influenced by your personality tendencies… and how much it takes for your
brain to perceive that the demands on you are greater than the resources you have to
manage them
It could also be influenced by your past experiences and trauma
And finally, the social context… how the pain shapes your relationships, career, and social
identity.

Tips for the healing journey

So now that you know a lot more about how pain works, and the role of the brain, what can
you do about it?

The first step, as you already know, is to continue your education. The more you know
about what’s happening in your body, the better.

The second step is awareness. Start thinking about which elements of your life might be
contributing to your pain, and how. See if you can find any connections between the onset
of your pain and a life event that was meaningful to you. Take a look at the filters your
thoughts go through every day.... notice whether you tend to be overly fearful or
pessimistic, and how much pressure you put on yourself. Finding connections between
these elements and your physical symptoms doesn’t mean that the symptoms are your
fault. You’re simply trying to notice patterns that it might be helpful to unwind.

Finally, once you become aware of which factors may be at play, start retraining your brain
in those areas of your life.

If you’re a little lost on how to do all of this, that’s okay. That’s exactly what the full Curable
program is for.
It contains more educational lessons about specific stressors, and the proper tools and
techniques to help you identify what’s contributing to your pain, and learn how to slowly
reverse the pattern your body has fallen into.

This isn't a miracle cure or an instant fix - this approach requires your commitment and
participation. But whatever you choose to do, and however long it may take, know that you
are not alone, and there IS hope for recovery.

How To: Brain Training

One of the key components to getting better on this mind-body journey is to start
truly believing that even though you're in a large amount of pain, you're not broken
or unfixable. Your body is simply creating these neurological responses to the
subconscious thoughts and feelings floating around in your brain.

Now, if you do continue to believe that you're doomed to suffer for the rest of your
life, these mindbody techniques just can't really help you. They are designed to
unlock the power of your mind to reverse physical symptoms. And if your mind
doesn't believe that that's possible it won't actually work.

There's nothing I can do for you to flip that switch. It really has to come from you. So
before we go any further just really check in with yourself on where you're at. Do
you really want to believe that this can work for you? Do you really want to believe
that you could be in less pain a month from now and a month from then you might
not have any pain at all?

If the answer is yes, then this series of exercises could be a real game changer for
you. It'll help you build a case against these pain signals that your mind can really
believe. So let's get started on that right now.

Word Swapping:

This might be one of the simplest tools that we have to offer you. It's as easy as
swapping out what words you're using to describe your pain and symptoms.

You may be wondering: "how could the words I use to describe my pain possibly
matter?"; but they do matter quite a bit. Whenever you say (or think) a word, it
paints a mental image in your brain. That image has an impact on how the brain
responds to the world around you.
So think about it: if you are thinking (or saying) "there is a stabbing pain in my back
that just won't go away," what's the mental image that comes to your mind? It's
probably an image of a knife that's repeatedly stabbing into your back and won't let
up. That's not a great image to keep around. It's not helping you calm down your
amygdala, and it's certainly not helping to release any of the tension in your back. In
fact, it's probably activating your brain's fear centers, which can send more pain
signals down to your back.

So the exercise we are going to try today is simple: swap out any pain-related
language that might be conjuring up negative mental images and replace it with
something more positive. For instance, you might replace "This really hurts. This is
a lot of pain. My pain is flaring up." with "I feel less comfortable than I would like to
right now." Even though you're admitting that you're not comfortable, saying the
word "comfortable" can be really calming and soothing to the brain.

You might even want to stop using the word "pain" for a day altogether. So instead
of talking about the "pain in your back," maybe just call it a "sensation" - a sensation
that is less comfortable than you would like it to be. You could also try "pressure."
Anything that isn't going to set your amygdala off and send your brain into a fear
cycle is going to be a lot better than the word "pain.".

Paying attention to your language will change the way that your neural circuitry is
programmed to respond to pain signals. If you're no longer processing them as pain,
but now just processing them as a "sensation" or "pressure" or "something that is
not giving you comfort," you will create a really different experience for your brain
and your body.

So let's take this one step further: if you often use specific descriptors for your pain
(like "this pain is burning"), you can try using the opposite (like "this sensation isn't
quite as cooling as I'd like it to be"). If you think that your pain is "stabbing," try
picturing it being cushioned. If it feels like it's "aching," maybe try picturing that it's
not quite as "soothed" as you'd like it to be. If it feels like it's "squeezing or
tightening," just imagine that it's not quite as "loose" as you'd like it.

And that's it. It really is just that simple. Have fun playing around with this exercise!

Somatic Tracking

In most cases of chronic pain, the brain is getting safe, normal signals from the
brain, but it's interpreting them as dangerous.To turn off the false alarm, you need
to teach your brain how to interpret these signals properly.

In this exercise, Alan Gordon guides you through Somatic Tracking. By paying
attention to your pain through a lens of safety, you can gradually rewire your brain
and turn off the pain.

Exercise:

Close your eyes and slow your breath down for just a sec.

Breathe in a couple of times, just to center yourself. Oftentimes just slowing down
your breath and focusing on the breath coming in and out is a good way to center
yourself and ground yourself.

I want you to see if you could bring your attention to the dominant physical
sensation in your body right now, whether it's in your back, whether it's in your
chest, whether it's in your arms, or wherever you feel it most, right now, just let your
attention go there. And if you're feeling a sensation in more than one place, just
choose one.

And I want you to see if you can focus on the physical sensation itself. Breathe into
that physical sensation, wherever it is, whatever it feels like, give it a little air. Give a
little space.

Oftentimes, when we feel a physical sensation that isn't particularly pleasant, we

have the tendency to try to distract ourselves from it or focus on something else. But
I want you to see if you can do the opposite.

Focus on the physical sensation and just assess it, just see if you can watch it.
You're not trying to do anything to it, you're not trying to get rid of it, you're not trying
to change it, you're just familiarizing yourself with it. You're just exploring it.
So as you breathe in, and you attend to this physical sensation, just notice. Is it
pleasant? Is it unpleasant? Is it neutral? You're just gathering information. One isn't
any better than the other, you're just assessing.

And just notice, is it widespread? Or is it more localized?

Again, you're just kind of assessing the characteristics and really practicing seeing if
you can watch this sensation from a place of truly detached curiosity or interest.
Just notice it. It's a safe sensation. It's not dangerous at all, it's perfectly safe. And
all you're doing is you're paying attention to it and noticing it. You don't need to get
rid of it. You don't need to change it. You're just getting to know it.

And just check in and notice: what does this sensation feel like? What are the
characteristics of this sensation? Is there a tightness? Is there a clenching? Is it
squeezing? Is it a warm feeling? Is it a pulsing feeling? Is it a tingling feeling? Is it a
fluttery feeling? You're just gathering information, you're just noticing, you're
assessing, you're paying attention. And actually see if you could even appreciate
just looking in mindfully, gathering information about the sensation and just noticing
what's going on.

Really just see if you could be curious as you pay attention to the sensation, how
interesting it is that your body is capable of generating these really interesting,
unique sensations.

And as you pay attention to the sensation, just see if you can notice what happens,
knowing that whatever happens is okay. Does it intensify? Does it subside? Does it
move around? Does it change in consistency? Does it stay exactly the same?
You're just gathering information. You're just noticing what happens as you attend to
this sensation. Knowing that as you pay attention to this physical sensation, you're
actually communicating to your brain that this really interesting, unique sensation is
safe. That it’s okay, and you're just getting to know it. Right now at this very
moment, you're developing the neural pathways to pay attention to this physical
sensation, without fear, without any judgment, without any ulterior motive or any
goals. You're just watching. You're just noticing you're just taking in the show.

And as you breathe into the sensation, just notice what happens. If it intensifies,
that's fine. Just follow it, just ride that wave. If it subsides, that's okay too. You're
just getting to know it. It doesn't matter what it does. You’re outcome independent

If it moves around, if it stays exactly the same, that's okay. You're just strengthening
those brain muscles, you're learning to pay attention mindfully. And whatever it
does, it doesn't matter. The only thing that matters is that you watch it. And notice it.

And as it moves, just see if you could really almost enjoy, not the sensations
themselves, but even just the act, or the process of paying attention, mindfully and
communicating such a nice loving message to your body in your brain, that these
sensations are safe.

Enjoy the show. It's like you're lying back in a field, watching the clouds pass by just
kind of noticing the shapes they make. And just attending, just watching, just feeling
it out.

And take a couple more moments to breathe in to this sensation. Following it

wherever it goes. If it goes, just lean into it if it changes or moves in any direction.

And in a moment, I'm going to have you open your eyes. But before you do, just
take a couple more breaths to reconnect with yourself to re ground yourself to just
stabilize. Take a breath. Feel the physical sensation of the breath coming in and
out. One more time.

And when you're ready, open your eyes and stop the exercise for now.

Talking to Your Pain

Today, I'm going to introduce you to a technique that might sound a little silly at first.
It's all about controlling yourself talk, which means talking to your body, talking to
your fear, maybe even talking to your migraine. And it can help unlock the power of
the mind and calm down the amygdala.

So let me paint you a little picture of why this is important. Typically, when we start
to feel pain coming on, it's really easy to panic and most of us instinctively jump into
a really scary inner dialogue of, "Oh no, the pain's coming. What do I do? Where is
the dark room, how do I get away? Oh my gosh, please cancel all my plans. I'm not
gonna be able to come in to work tomorrow, I'm gonna be out for at least 24 hours,
please get me some peppermint oil and some pills."

As you can probably imagine this kind of inner dialogue doesn't do wonders for
calming the nervous system down. In fact, it does quite the opposite. It triggers our
fear responses, sets the amygdala off, and actually amplifies the pain itself. To
change the response of our nervous system, we need to change the narrative, and
that starts with changing what we tell ourselves. Instead of letting the pain take total
control and acting like we have none, we have to try to stand up for ourselves,
telling the pain who's really in charge here.

Try and think of your pain like a bully on the playground demanding your lunch
money. If you get scared and immediately hand it over, the bully's just gonna keep
coming back day after day, stealing your money. But if you stand up to the bully and
tell them no, you might just have a chance to keep it. There's more than one way to
do this and we'll try a bunch of different things in the next exercise, but here's an
example. You could talk to your body and just kind of tell it that the jig is up, "Hey, I
see what you're trying to do here. It's not going to work. You're trying to send me a
message about this thing that's stressing me out, I promise I will deal with this on
my own terms. I do not need to go lie down right now. We are going to do this my
way, not yours, so stop it."

Or, if an aggressive approach isn't really your style, you can try something a little
softer. Maybe try talking directly to your inner child for example, "Hey, I know you're
feeling really triggered right now and you just wanna freak out. I know you think
creating pain is helpful, but it's not. I can handle whatever emotions are bubbling up,
I don't need to be distracted from them with physical pain. So, just calm down. It's
okay, I can handle it, I'm right here."

Alright, I think you are pretty good to go for the next exercise, which will give you a
few more ideas for other kinds of dialogues that you can have with yourself when
you feel the pain starting to bubble up. Feel free to mix and match until you find the
one that works best for you. I'll see you back here soon.