The Truth About Managing Chronic Pain (w/Dr. Rachel Zoffness)

– ♪ I try to ♪ ♪ Say goodbye and I choke ♪ ♪ I try to walk away and I stumble ♪ ♪ When I try to hid it ♪ ♪ It’s clear ♪ ♪ I got Rachel Zoffness up in here ♪

– [Zubin] What’s up, Rachel? How are you?

– [Rachel] That was amazing.

– [Zubin] Do you like my intro? We weren’t even planning on doing an intro.

– [Rachel] Do you sing only in the shower or outside of the shower too?

– [Zubin] Well, I should only sing in the shower according to all who’ve heard.

– [Rachel] Disagree.

– [Zubin] Oh yeah?

– [Rachel] You sing on your show.

– [Zubin] I do, but that’s purely, talk about denial, repression, projection. Like I deny that I can’t sing so I project a terrible voice to the world. Everybody doctor, Dr. Rachel Zoffness, PhD is back on the show. One of my most requested return guests.

– [Rachel] Wow.

– [Zubin] She is UCSF faculty. She’s a pain psychologist, specializing in chronic pain and illness. And you are on the, you’re a pain educator faculty at Dartmouth. So you teach other healthcare professionals about pain, particularly the aspects of pain that are biopsychosocial, which are all aspects of pain.

– [Rachel] Totally. And that word sounds really complicated and scary most, most of the time for most people.

– [Zubin] Make it less scary for me. Explain what you mean when you say that.

– [Rachel] Okay, let’s talk about it. So we are under the impression that most health conditions, including pain, are purely biomedical, or purely biological. And by that, I mean, all pain is of the body is this impression that we have. So if your back is hurting, it’s easy to believe that your pain lives exclusively in your back. By the way, I’m going to answer your question in a roundabout way, but I promise you, I will answer it.

– [Zubin] Typical PhD psychologist, always up in my face with the, with the nuance and the, and the details because you can’t, you cannot discuss this complex subject without that.

– [Rachel] So I, right, and I am a nerd and I am committed to science. And I want to make sure that when we’re talking about complicated things, we do it in a way that is A, scientific, B, factual, and C, at least for me, as easily digestible by people as possible. Because I think a lot of people think of pain as this really complicated thing that’s really hard to understand, but it’s, it’s not, it’s not out of anyone’s wheelhouse. So in general, we think about health as often as like a biological thing. Like it’s something that’s just happening to your body, but as you said, pain and all health is actually biopsychosocial. So what that means is, again, we tend to believe that pain lives exclusively in our body. Your back hurts. You go to the back doctor. You have procedures and medications to help your back. What science tells us is that that actually is not true. Pain does not live exclusively in your back. Pain is not purely a biological problem. One reason we know this is because of this thing called phantom limb pain.

– [Zubin] Do tell.

– [Rachel] I’m going to tell. Phantom limb pain is this condition where an accident survivor or trauma victim loses a limb, like an arm or a leg, and they continue to have terrible pain in the missing body part. So you can have no leg and continue to have terrible leg pain. And what the tells us is pain must be constructed somewhere else, right? Because if pain were constructed in the leg, no leg should mean no pain. And the fact that you continue to have pain in the body part that isn’t there means that pain is actually constructed by this part of the body called the brain. And the really cool thing about the brain is that it’s comprised of all these different parts that are always working in unison, working together. So what we know about pain is there’s no one single pain center in the brain. There’s lots of parts of the brain that process pain. One of the parts of the brain that processes pain is your limbic system. Doctor, what is the limbic system?

– [Zubin] I’m on the spot? The limbic system is our more primitive part of the brain that manages emotions–

– [Rachel] You got it.

– [Zubin] And unconscious things can sort of thing. I call it the, if we’re going to use this analogy, it’s the elephant, the, oh, I actually locked my focus. It’s the elephant, this unconscious, huge ancient part of our brain.

– [Rachel] Yeah. Your limbic system, exactly right, is your brain’s emotion center. So what that means about pain, according to neuroscience, is that pain is both physical and emotional 100% of the time. And I’m going to say that again because it’s so important. All pain that you have in your body that you think of as physical pain is also emotional 100% of the time. So the emotions you feel affect the sensations in your body, always. If you’re stressed or anxious, or if you’re depressed, or if you’re angry, or if you’ve experienced trauma, your pain is going to be amplified. Yeah, I know, there’s so many things to say. You go.

– [Zubin] Oh.

– [Rachel] I know, it’s rich, it’s rich.

– [Zubin] Okay. So already, we violated the prime directive, which is all pain is medical, treated with a molecule or an agent. There’s a physical cause for all pain, exclusively. And the mind is just responding to that physical cause. Well, if you take the physical cause away in the form of an amputation, there’s still pain and not only pain, but the suffering around pain with phantom limb.

– [Rachel] Yes.

– [Zubin] Then you mentioned things like trauma, anxiety, you know, fear, those kinds of the emotional state, the limit part, the limit brain. And that is a perfect segue into the, the topics we’re going to talk about because we want to talk about things that are uncomfortable to talk about for many doctors, because they don’t, they can’t wrap their mind around it in a reductionist way, like fibromyalgia, or complex regional pain syndrome, or PTSD, or heaven forbid anxiety and depression.

– [Rachel] Totally.

– [Zubin] So we’ve kind of framed what we want to kind of dive into.

– [Rachel] Yeah.

– [Zubin] So if things are, if things are biological, psychological, limbic, emotional.

– [Rachel] Yeah.

– [Zubin] Remind us again, we talked about this last time, the social component.

– [Rachel] Totally. So I’m so glad you circled back around. I was going to do the same. So this biopsychosocial model of health, pain, but also all health tells us that there’s three domains of health we need to look at at all times. And that the health condition, whether it’s depression or pain or trauma or diabetes, it doesn’t matter, lives in the messy middle of those three domains. So there’s bio, the biological domain of health. So that system damage and tissue dysfunction, other way around. Tissue damage, system dysfunction. I knew I would get that right eventually. Immune function, it’s diet and sleep and exercise, all those physical things that are very, very, of course, important to health. But then there’s the psychological domain, which has so much stigma around it. Drives me crazy as a pain psychologist. We can talk about that all day.

– [Zubin] Oh yeah.

– [Rachel] And then there’s the social, or the sociological domain. And if you think about it as these three bubbles, there’s bio, there’s psych, there’s social. It’s like if you’re only focusing on the biological bubble of health, you’re missing two thirds of the pain problem or you’re, you’re missing two thirds of the human experience of health. So in the psychological domain, there’s a lot of different things and unpacking it sort of could take us 17 episodes. But there’s thoughts. So how you think about your body and just any thoughts you have actually amazingly, immediately affect your physical body. So if you start thinking, for example, panicky scared thoughts, your entire sympathetic nervous system will go into fight or flight and you will feel the physical cascade of things that happen when you think a thought. Your thoughts affect your body 100% of the time. Also in the psych bubble, we have coping behaviors. So if you ask 10 different people living with chronic pain, how they’re managing their pain, they’ll give you 10 different answers. And how you act, of course, how you behave, affects the pain you feel. If you’re inside all day, not moving, that’s going to affect your body a certain way. And then also we have, there’s so many things, right. And then there’s the social or sociological domain, which is the one you asked about. So the social domain includes social behaviors. So family, friends, if you’re a kid, school, media and social media, work. And then there’s socioeconomic. So your access to care, your ability to afford treatment, culture, religion, your environment around you, your, of course we know environment affects health. Lifestyle, there’s a whole domain of medicine called lifestyle medicine.

– [Zubin] It seems like your socioeconomic domain would also put you in the, on the locomotive railway tracks to be hit by the train of trauma more likely in some ways.

– [Rachel] Yeah.

– [Zubin] And so it, there it is. It’s this complex web with, by the way, I forgot to mention this. This is Rachel’s book and you can find it on Amazon. I’ll put a link. It’s outstanding. And it outlines a lot of this stuff so that you don’t have to, you know, remember it for the test.

– [Rachel] Yeah. No, there’s not going to be a test today.

– [Zubin] Good, that’s good.

– [Rachel] Yeah.

– [Zubin] So bio-psychosocial. Now you said a few things that I want to dig into. One of them is this idea of the psychological stigma component of pain. So how many doctors have said things like, oh, you know, this is all in your head or this is mind generated, this somatization of what’s going on. So you just need to take an antidepressant and chill. Cause I can’t find anything wrong with you. Or off the record, when doctors are talking to each other or scribbling notes to each other. Oh such and such is crazy. It’s crazy pain. It’s not real. It’s status hystericus, right.

– [Rachel] Yeah.

– [Zubin] How do you think about that?

– [Rachel] I think that’s a massive problem with chronic pain. A lot of people with fibromyalgia and other chronic pain conditions have gotten that message. Like, oh, you’re just anxious or this is all just in your head, or really this is just depression. And I think it’s so, not only is it stigmatizing, but it’s dismissive. It’s the sense that this experience that you’re having doesn’t matter and you should just be lumped into the pile of crazy people.

– [Zubin] Crazy people.

– [Rachel] And I think what that does is it further separates out this idea that either you have physical pain and you see a physician or you have emotional pain and you see a psychologist like me, but that’s not how pain works at all. Pain is always both physical and emotional. So if you actually want to treat pain, you need to be targeting all the things you’re feeling, all the things you’re thinking, all the ways you’re behaving or managing your pain, and of course your physical body. But in Western medicine, we separate these two out. And so the message we give to our patients, and by the way to physicians in training is if you have a patient who is anxious and depressed, which happens to a lot of people, then just lump them in the mentally ill category. And maybe that will explain away this physical stuff that’s happening, but it’s always altogether.

– [Zubin] It’s a, it’s a reductionistic approach where we reduce a complex problem to one of its components.

– [Rachel] Yeah.

– [Zubin] And so, you know, I like to think of it in a, in a, in a, in a four square. It’s a Ken Wilber thing. Like you have, I, internal experience. You have we, inner subjective experience. You have it, the body, and you have its the bodies and the technical and socioeconomic stuff around us. And those four quadrants comprise all of reality, every single aspect of reality. But in medicine, we tend to go it as the only quadrant, and ignore the internal. We ignore the inner subjective and we ignore the socio-economic. I think it’s partially because of how we’re trained, partially because we don’t have resources, partially because we’re not paid to do it, partially because we’re not trained to do it, all those other things, right. Is that been your sort of vibe on it?

– [Rachel] Are you a philosopher?

– [Zubin] I would, I play one on TV and I did sleep at a Holiday Inn Express last night, so.

– [Rachel] Good answer. Good answer.

– [Zubin] Why do you ask?

– [Rachel] Cause you sound like one. And it’s impressive.

– [Zubin] They talk, they talk like that. It’s all obfuscation cause they don’t really know what they’re doing.

– [Rachel] Stop.

– [Zubin] So you terms like, well, our inner subjective we space that we’ve generated Rachel. You would just say, yeah, that’s called the doctor patient relationship or the therapeutic alliance or yeah.

– [Rachel] I think at the end of the day, we’re both saying exactly the same thing, which is health is this really complicated thing that has been distilled down to this biomedical model where we only look at body parts and then we only treat those body parts, oftentimes exclusively, but primarily with pills and procedures. And actually if we want our patients to get well, what we need to be doing is looking at the whole person, and whole people are complicated. But the thing about the whole person is no matter where in your body the pain is, your brain is connected to your body 100% of the time. So whether it’s fibromyalgia and you have like 18 points of pain or 22, you know, or whether it’s complex regional pain syndrome, or whether you’re one of those people who’s living with chronic daily stomach aches. And we should talk about that too. The brain is connected to the body 100%, everything affects everything. So if you are someone living with pain and you feel like you’re a physician is only focusing on this biomedical stuff. One thing that we can do is start opening that up and try and reduce the stigma around that by talking about the role of the brain and pain, and sort of weave in these other treatments that we know are effective for pain. Like what I do, which is cognitive behavioral therapy. Or treatments like biofeedback, which we can talk about, which connects the brain and the body and helps you navigate the physical sensations that come about when we’re thinking stressful thoughts.

– [Zubin] You know, what’s interesting about all this too, these therapies is that they do change a locus of control too, don’t they?

– [Rachel] 100%.

– [Zubin] Yeah. I mean, cause normally our locus of control with pain is external and out of our control. I’m the victim of this pain. I, you know, and, and the thought, what you mentioned about thought inflecting with pain, they’re one continuum. Our thoughts generate a lot of the anxiety, projection, future component of pain. Like is this pain ever going to go away? How’s this going to affect me? I’m going on vacation. What’s going to happen? Will my spouse or partner leave me with this pain? And those projections then add in a feedback, as you mentioned, by a feedback in a malpractice way. So you’re saying there are ways to actually hack that by looking at thought, cognitive behavioral therapy, intervening that way and looking at bio feedback loops and saying, oh, you know what, actually, we can change the locus of control to here and actually do something beneficial for pain.

– [Rachel] And I love the word hacking, especially in like the bay area. I feel like everyone’s trying to hack everything.

– [Zubin] Like we’re all neuro hacking.

– [Rachel] Yeah, we’re like, yeah. We’re like hacking health and meals.

– [Zubin] Oh yes, Soylent.

– [Rachel] Orgasms.

– [Zubin] Can you hack an orgasm?

– [Rachel] Oh, I don’t even want, there’s a, there was a cult that was attempting to. It went south. We can talk about that another time.

– [Zubin] No, I think we need to, this is one of those things where I need, I need, it’s like I learn by doing.

– [Rachel] Oh my god.

– [Zubin] But no, no that’s so, but, but it does, it does actually points to this. There’s a reductionist component in the bay where it’s like, well, I can just neuro hack my way through.

– [Rachel] Right.

– [Zubin] Anything.

– [Rachel] Right. Well, the interesting thing is the hack for pain is undoing the miss messaging that has happened, right. The hack for pain is undoing this stigmatized separation between emotions and body, physical and emotional and merging it into one thing again. That actually is the hack cause what happens and what research shows is when you target the catastrophic and terrified thoughts that understandably accompany chronic pain, so many people with chronic pain and chronic illness are suffering and struggling, understandably, and are scared about the future and are scared about their bodies, and are scared of their partners leaving them, like you said, because of their pain and their, they’re scared about losing work and income. They’re scared about, you know, not being able to play with their kids, losing their sex life. There’s so many things that unders, naturally and normally come along with living with chronic pain. But when you merge the two and you treat the thoughts and you treat the emotions, shockingly, or not shockingly, what happens is that, and this is shown across neuroscience, is that pain volume goes down too. So if we actually want to hack pain, we have to treat the whole person. We have to treat the thoughts. We have to treat the emotions. We have to treat coping behaviors. We cannot just treat the back or the arm. It will not work.

– [Zubin] Yeah. I mean. And so, and by the way you said pain volume.

– [Rachel] Yeah.

– [Zubin] Remind me what that is.

– [Rachel] Yeah, yeah. So there’s a metaphor that I have for talking about how pain works. And again, I’m this neuroscience nerd because science makes the world make sense to me. And I was a kid with chronic pain and I’ve had bouts of chronic pain as an adult. And I think it’s so important and so empowering for people to understand pain. And it is not beyond any of us. So the metaphor is this. If you imagine in your central nervous system, which is your brain and your spinal cord, that you have what I’m going to call a pain dial and the pain dial is like the volume knob on your car stereo. You can turn it up and you can turn it down. And there’s lots of things that adjust pain volume. So one thing that can change pain volume, this is not going to shock you, is stress and anxiety changes pain volume. Another thing that changes pain volume is mood and emotions, negative emotions in particular, but also positive emotions change your pain value. And three is attention, or what you’re focusing on, and this maps onto pain neuroscience. So I’m going to tell you how.

– [Zubin] Can I ask, can I ask one question though?

– [Rachel] You can ask as many, as many as you want.

– [Zubin] When you say attention, it’s interesting because there’s distraction and then there’s immersion in the actual field of pain. Can you speak to that a little bit?

– [Rachel] I can, but only after I finished.

– [Zubin] Then I’m writing it down that we’re going to come back to that.

– [Rachel] Take copious notes.

– [Zubin] Yes, copious.

– [Rachel] We’ll circle back around.

– [Zubin] I’ve got my ZDoggMD hands off my pen available at supportertribe4lyfe.com.

– [Rachel] I have a question.

– [Zubin] Yes?

– [Rachel] Can I, can I get a free one for being on the show?

– [Zubin] Yes you can. Remind me, I have Health 3.0 flask. I have a ZDoggMD flask. Show ’em your flask. This thing, this thing sounds like a pack of dolphins that are communicating by sonar.

– [Rachel] It’s true. I’m not doing it.

– [Zubin] You’re not going to demonstrate?

– [Rachel] No.

– [Zubin] All right, well, I would demonstrate, but then we’ll give each other COVID. Yes, remind me of this.

– [Rachel] You should’ve disclosed that up front. I’ve been vaccinated.

– [Zubin] I’m triple vaccinated. I went and got the Sinovac just for fun, you know, just to see, see if I’d understand Mandarin after getting it.

– [Rachel] You cannot drink .

– [Zubin] So we were on, we were on a roll and we got–

– [Rachel] Pain volume.

– [Zubin] Pain volume. Yes.

– [Rachel] Right. Volume knob. Like a car stereo and it lives into your central nervous system. I can’t tell if this is like a good thing or a bad thing.

– [Zubin] Laughter, does laughter turn your pain volume down?

– [Rachel] Laughter, yes.

– [Zubin] It does.

– [Rachel] Laughter turns pain volume down.

– [Zubin] I feel good laughing.

– [Rachel] There is a scientific American article that’s so great about how laughter is medicine for pain.

– [Zubin] And cursing as well, I understand, has an analgesic effect.

– [Rachel] Cursing has an analgesic effect and I can tell you why. You get to express and release negative emotion. And when you release negative emotion, negative emotion goes down. And when negative emotion goes down, it turns down pain volume. It’s just cathartic to release. I call it teakettling. Can I, I’ll tell you why and then we’re going to go back to pain volume.

– [Zubin] Yes, but then I’m going to interrupt you one more time because this is, this is, this is important. Go, teakettling. This sounds like a sexual thing that happens on a crazy website that you don’t want to subscribe to with actual money. You use Bitcoin so it’s untraceable.

– [Rachel] I’m going to ask the audience to question where your mind is at at any given moment. There’s absolutely tea kettles in my mind are absolutely not even remotely sexual, but that’s fine. That’s good.

– [Zubin] Okay.

– [Rachel] This is good for me.

– [Zubin] All right, all right.

– [Rachel] Good.

– [Zubin] We will agree to disagree on that.

– [Rachel] That’s good. I like it. Okay, so, so do you know what would happen to a teakettle if it didn’t have a hole for the steam to come out?

– [Zubin] It would become a bomb.

– [Rachel] It would, correct, it would explode. And human beings are the same. And we all know that because we have all seen people explode with emotion that they have not expressed. So everyone, we all carry around lots of negative emotion and it needs to come out of your body because emotions are somatic. By that I mean, emotions are physical. Emotions don’t just live in your head. They come out in your body. If you’ve ever had butterflies in your stomach or sweaty palms like me before speaking on a podcast, you know that your emotions come out in your body. However, a lot of us walk around in life suppressing, or holding in our negative emotions. Turns out science shows that’s bad for your health. Your negative emotions need to come out. They live in your body. They can come out as pain, and stomach aches, and sweaty palms, and vomiting, and trigger migraines and all the things we we’ve all experienced that, right. So teakettling is a word I just made up. I use it with my patients and the concept of teakettling is it whistles, there’s a release for the steam to come out and humans are the same. We need to release our negative emotions and we need to find safe, controlled ways of doing that. So talking to someone like a therapist is a way of teakettling. Going for a run, taking a hot shower, cursing really out loud, screaming in your car is teakettling. We have all done things like this, yelling into a pillow. There’s a million ways to teakettle. I know you have questions. Can I go back to the pain volume before I forget?

– [Zubin] Yes. And then we’re going to go back to emotion because I love this.

– [Rachel] I know. It’s, it’s, there’s so much to talk about. And what’s interesting is that we started with pain and now it’s a direct line to like releasing your emotions.

– [Zubin] It’s all connected. Yeah, yeah. Teakettling, I love that. So next time I do a live show on Instagram. For some reason, Instagram triggers teakettling for me in the form of cursing.

– [Rachel] Yeah.

– [Zubin] So I’ll just tell a story real quick, the other day, and this idea of feeling emotion, inhabiting emotion, and letting it pass through you is something we are never trained to do. In fact, we’re trained to do the opposite.

– [Rachel] That’s right.

– [Zubin] Don’t cry, don’t do this. Don’t do that, don’t scream. Don’t punch things that aren’t human. You can punch humans cause apparently that’s socially okay. So I had, I was meditating in the morning and you know, very open and unguarded. And then so emotions happen when that happens. Then I went right outside and did a show for Instagram and I was gonna talk about masks and I was going to talk about COVID, you know, I was gonna talk about this. And I find myself going and the other thing, and the other thing. And people are like, yeah, all the emojis. Yeah. And I’m like, why does this feel so good? And afterwards I was like, floating, just so happy. And then I realized, I probably ruined my career just by doing the show, but I don’t care cause I don’t have a career. So I’m back to you and your, and your pain volume.

– [Rachel] Right, but you teakettled. You felt better afterwards.

– [Zubin] I still feel dirty because the word teakettle still sounds so. But yes, yes.

– [Rachel] You must know things that I just don’t know.

– [Zubin] No, I just project. So, so, so, so thank you for bringing that up and back to pain volume.

– [Rachel] Right, okay. So we have this volume knob. It’s controlled by lots of things, stress and anxiety, negative emotions, and attention or what you’re focusing on. So specifically, specifically, when stress and anxiety are high and your body is tense and tight because that’s what happens when we’re stressed and anxious, and your thoughts are worried. If you think about the pandemic, all of those things are what, what was happening for all of us. What happens is your brain’s limbic system, again, the emotion center in your brain, sends a message to this pain knob, this pain, and it turns up pain volume. So when stress and anxiety or high, pain volume is turned up by your brain. The second thing is mood and negative emotions. So when your mood is low and you’re miserable and depressed, when your thoughts are really negative. And of course, this is a thing that often happens when we have chronic pain or illness, your brain, limbic system, sends a message to your pain dial raising pain volume. So again, pain is amplified and feels worse when emotions are negative. And the third thing is attention. So when you are in bed at home, missing out on life, not going to work, not seeing your friends, and you’re focusing on your pain, your prefrontal cortex, which is another part of the brain that processes pain, sends a message to your pain dial raising pain volume. So pain feels worse when you’re stressed and anxious, when emotions are negative and you’re sad and miserable, and when you are focusing and thinking about your pain. But the reason this is good for all of us is that the opposite is also true. So when stress and anxiety are low, which by the way is why relaxation strategies and biofeedback and mindfulness can be so effective for pain management even though those are stigmatized and everybody rolls their eyes, including me, at one point in my life. The reason those are effective is because what they do is they lower stress and anxiety, which turns down your pain volume, same with mood and emotions. When you are engaged in pleasurable activities, when your emotions are positive, you’re feeling grateful. You’re feeling happy. You’re experiencing joy. Your limbic system turns down pain volume. So pain feels less bad. And same with attention, when you are engaged and absorbed in activities. Like I often ask my clients, tell me about a time you were so absorbed in some activity you briefly forgot about your pain. That’s not magic, but we’ve all had that experience. And what that is is that’s your prefrontal cortex sending a message to your pain dial lowering pain volume. So there are all these ways that we can manage our pain beyond medications, beyond surgeries. They’re all in the pain management work book, actually. So I’m glad you brought it up. I took everything that I was doing in my practice. I’m one of those people that gets very angry about the lack of affordability and accessibility of healthcare. What I do is not affordable to most people. I think that’s bullshit. Insurance does not reimburse things like biofeedback and cognitive behavioral therapy and pain psychology in general. I think that’s actually like completely unacceptable.

– [Zubin] Backwards, totally backwards.

– [Rachel] Completely backwards.

– [Zubin] But they’ll pay for the pill. Yeah.

– [Rachel] And they’ll, and they’ll pay for many, many expensive surgeries and you can have like eight back surgeries and that’s all covered. So I stuck everything I did in a book cause I want people to be able to afford it.

– [Zubin] And, and I’ve read the book and it’s fantastic.

– [Rachel] Thank you, Z.

– [Zubin] And we will just going to keep pitching this book because it’s awesome. And I’ve got the link in here, so, okay. So let’s bring this back now to, so let’s do some case examples of, of syndromes that are classically stigmatized by Western medicine. So let’s start with fibromyalgia because this is one, and I’ve done a couple shows on this and I’ll say some things that seem controversial until you actually look at it as a biopsychosocial disease, which all diseases are.

– [Rachel] Exactly.

– [Zubin] So I’ll say that a lot of patients with fibromyalgia have absolutely real symptoms that you can actually diagnose using criteria. So that the first instinct of a lot of healthcare professionals is this is a fake disease, right. Okay. Stigma one, let’s just get rid of that. The second thing is it seems that a lot of people who suffer from fibromyalgia have suffered trauma at some point.

– [Rachel] Yeah.

– [Zubin] How does that relate to this web that you’re describing of pain volume, negative emotion, thought, attention, all this kind of stuff.

– [Rachel] Yep. So first things first, just want to zoom out for a second and say, fibromyalgia is what’s called a chronic pain condition and any type of condition that’s considered chronic is when you’ve had pain, believe it or not, for three or more months, that is then officially considered chronic pain. Chronic pain has lots of different definitions. And it depends on who you ask, but it’s three or more months or beyond expected healing time is the standard definition. And fibromyalgia, as people know, usually lasts many years for a lot of people. And it’s this mysterious illness. People don’t exactly know what causes it. People don’t know the treatment. There’s like a lot of, and like you said, there’s a lot of stigma around it too. So people will often see physician after physician and get lots of different prescriptions or recommendations. And the pain remains. And it used to be the diagnosing fibromyalgia was required that you had pain, I think in 11 out of 18.

– [Zubin] Right, there’s–

– [Rachel] Points.

– [Zubin] Points. And there’s other things you can throw in as like minor criteria, like sleep disturbance.

– [Rachel] And fatigue.

– [Zubin] Brain fog.

– [Rachel] Exactly.

– [Zubin] Right.

– [Rachel] And, and thankfully that has changed because as anyone with pain knows, you have different pain on different days. So, you know, on Tuesday you might have pain in 22 body parts, but you know, by Thursday you might only have pain and eight body parts. Does that mean you don’t have fibromyalgia? I mean, it’s just like, it’s not a great criteria for diagnosing a chronic condition.

– [Zubin] And it seems like the traumatic component, if it’s present.

– [Rachel] Right, back to, yeah.

– [Zubin] Yeah. It seems like that might relate to something you’ve talked about before, which is the nature of pain as an alarm signal. Can you speak to that?

– [Rachel] Yes.

– [Zubin] Yeah.

– [Rachel] I’m going to answer that question by asking you a question.

– [Zubin] Oh dear.

– [Rachel] Yeah. I want you to think of a skill that you practiced over time. You were bad at it. You practiced it and you got good at it. And let me back up and just say, what I’m going to do with this analogy is explain why pain becomes chronic. And simultaneously if we get there, how trauma and chronic pain are best friends. That’s my goal. Oh, and I’m also going to throw in some neuroscience.

– [Zubin] Oh, even better.

– [Rachel] Oh yeah. So we’re going to start with a metaphor because I really like them.

– [Zubin] Okay.

– [Rachel] A skill, you were bad at it.

– [Zubin] Yeah.

– [Rachel] You practice it over time.

– [Zubin] Yeah.

– [Rachel] You got good at it.

– [Zubin] Do I have to be good at it? Or can I just have been better at it than I was?

– [Rachel] Yeah.

– [Zubin] Okay.

– [Rachel] Improvements acceptable.

– [Zubin] Then I’ll say singing because I was always bad at it. Now I’m slightly less bad at it. And I had to put a lot of work into being slightly less bad at it.

– [Rachel] Okay.

– [Zubin] Yeah.

– [Rachel] That will work. Are there any physical activities that you were bad at and you practiced and got good at?

– [Zubin] Sure. So let’s say running.

– [Rachel] Running, okay. I can use either of those.

– [Zubin] Okay.

– [Rachel] Okay, but I’m going to use running for our sake. Good.

– [Zubin] Perfect.

– [Rachel] Here’s how I’m going to say this to you. The pathways in your brain are like the muscles in your body. The more you use the pathways in your brain, the bigger and stronger they get. Right? That’s just straight up neuroscience. It’s called neurons that fire together wire together.

– [Zubin] Wire together.

– [Rachel] Yes.

– [Zubin] So I’ll say my homunculus in my brain, which maps out my motor. It’s all perineum. I don’t know why. I hardly use my perineum.

– [Rachel] Way TMI everybody. TMI.

– [Zubin] I’m just trying to throw you off your game.

– [Rachel] That’s TMI.

– [Zubin] Because you’re so good at it.

– [Rachel] You didn’t do it, you didn’t.

– [Zubin] Yeah, I can’t.

– [Rachel] Yeah.

– [Zubin] All right, I’ll keep trying.

– [Rachel] Ready?

– [Zubin] Go for it.

– [Rachel] Good, great, great. So if you said to me, Zoffness, I want really huge biceps. I would say–

– [Zubin] Bro.

– [Rachel] Bruh.

– [Zubin] You don’t need to want, all right. There’s nothing to want here.

– [Rachel] I would say, those are okay, Zubin. But if you want big biceps, go to the gym and lift weights. And over time with repetition, the more you use the muscle, the bigger and stronger, stronger they will get. It’s the same with the pathways in your, in your brain. The more you use those pathways, the bigger and stronger that pathway gets. So when you practice singing over time, at first you’re not good at it. But over time, the singing pathway in your brain gets very big and strong. Because singing is a lot of things, by the way. It’s your auditory cortex. It’s using your vocal cords. It’s reading sheet music, if that’s something you do, but I don’t want to make any assumptions here.

– [Zubin] Please don’t.

– [Rachel] And same with running, right. Running is also requires a lot of different parts of your body and brain working together. So over time, the more you sing or the more you run, the bigger the singing pathway in your brain gets, the bigger the running pathway in your brain gets. Of course your body is changing along with your brain. Guess what happens when after many weeks and months and years, you inadvertently accidentally practice pain? The pain pathway in your brain gets really big and strong. And when that happens, we say that your brain has become sensitive to pain. What does that mean? That took me a long time to be able to explain. So when we say a dog is sensitive to smell, what that means is a dog would come in here and sniff around. It would pick up on scents that you and I don’t even detect. Cause small bits of sensory input to a dog’s brain are very big. Same, same when the brain becomes sensitive to pain, small bits of sensory input from the body are amplified. So to your brain, when you have a big and strong pain pathway, those small bits of some sensory input are amplified. And to you, they seem and feel very big. Make sense?

– [Zubin] Wow.

– [Rachel] Yeah.

– [Zubin] I have never thought of it that way.

– [Rachel] It’s called, so it’s called central sensitization.

– [Zubin] Yes.

– [Rachel] It’s this well-known–

– [Zubin] I’ve heard the term, but I’ve never heard it described like that.

– [Rachel] That’s right. But everybody, and I mean every body with chronic pain has experienced some form of brain sensitization in some form or another. That’s just how experience and time work, whether we like it or not. So central sensitization, which again is just this phenomenon by which the brain becomes sensitive to pain over time, underlies chronic pain conditions, which is why when we’re treating pain, it’s really important to desensitize the brain. How do you desensitize the brain? Can I give you a quick metaphor?

– [Zubin] Yeah, please.

– [Rachel] Great. So if you imagine being in a very dark room, like you’ve been in a movie theater and it’s pitch black, and then someone turns on the lights and you’re like ah, my eyes, I can’t see. Turn ’em off. Because your brain over time has become accustomed to the dark, right. Your pupils.

– [Zubin] Rods, cones, living together, mass hysteria.

– [Rachel] Right, you’re eyes have adapted to the dark. So to desensitize a sensitive brain, it’s like being in a very dark room and opening up, if you imagine like blinds opening up just a crack. So at first the light is jarring. It hurts. You’re like, ah, turn, close that. And then if you just keep it open after like what 15 minutes your eyes have adopted, your brain has adjusted, cause it’s not your eyes actually it’s your brain, has adjusted and you’re okay. And then you open the blinds just a little bit more, a little bit more light comes in. It’s jarring, it hurts. 15 minutes go by. You desensitize. You can handle the light and gradually very slowly over time, you’re in a light-filled room and you’re okay. And it’s the exact same with treating chronic pain. So little bits of stimulation are exactly what a sensitive brain needs. So it’s a small, gradual return to physical activity, which, which sounds so scary, understandably. It’s a gradual return to social activity. And some people, of course can’t. There are some conditions where you’re–

– [Zubin] Just can’t do it.

– [Rachel] Right. You can’t. But in general, the treatment for chronic pain is completely counterintuitive. It’s the opposite of what you think. It’s the opposite of what your brain is telling you to do. Your brain is telling you to stay in the dark room because it feels safe and your brain is sensitive. And to desensitize a sensitive brain, you need to let the light in, but a little bit at a time.

– [Zubin] I mean, and that, that seems to have applicability to a lot of related conditions, whether it’s PTSD, anxiety.

– [Rachel] I know.

– [Zubin] It’s real interesting. But now I could feel if, if, if I’m a chronic pain suffer, which I, which I am actually technically, because I have chronic neck pain for now three, four years.

– [Rachel] That’s chronic pain.

– [Zubin] And a lot better, by the way, you know why?

– [Rachel] Why?

– [Zubin] Because I do posture exercises and stretching and those little back rollers and it’s vastly better. And even now when I sit with you, you’ll notice how every now and again, I’ll do this kind of thing. Cause I’m like, so it’s adjusting lifestyle, but it’s it wasn’t, you know, it wasn’t avoidance of the pain. It was going, okay, well what does, what can I do to try to, and when I feel it, I kind of, it’s, it’s complicated, but I’ve not taken a pill for it. I got a PT referral that I haven’t filled out yet. But it’s a thing. So the question though that I can see some chronic pain suffers saying is, well, if practicing pain builds those circuits, then shouldn’t I just be on narcotics very early on to prevent any pain practice, and why doesn’t that fix it?

– [Rachel] So I want to say upfront, I am not anti-medication, and I want to be very clear about that. I think all medications have a place and God bless medications, especially for acute pain, like post-surgical pain. And there are medications that are appropriate for pain. So I do not mean to suggest that. I more just want to put the power back into the hands of people living with pain and say, there are things beyond medications that we can do for pain. And I think we just need to stop focusing on that as the exclusive or primary goal when it comes to pain management, because it’s focusing just on this tiny little piece and there’s like a rainbow of things that we can do. So it’s more just that. But so what research has shown, medications do not desensitize a brain to pain. In fact, there’s very controversial research that shows that actually over time, what opioids do specifically is they sensitize the brain to pain. And I didn’t make that up. It’s not my research. So don’t get mad at me.

– [Zubin] No, I’ve seen that, I’ve seen that research. I’ve cited that research, yeah.

– [Rachel] But, but what they do is your brain gets sensitive over time anyway, because you’re inadvertently accidentally using over and over again this pain pathway and you’re strengthening. And when you take opioids, actually what they’re doing is they’re making your brain more sensitive to the sensory input from your body, not less. And so it blankets, you, you feel nothing when you’re on opioids, right, cause they block all of your, what I’m going to call pain receptors, just to simplify an overly complex phenomenon.

– [Zubin] None of this mu nonsense. Yeah, exactly.

– [Rachel] It is very complicated, but you know, they block all the receptors that make you feel these terrible things. So while you’re on them, you feel a lot better. But over time what’s happening is your brain is actually getting more sensitive to pain. And I say that because a lot of people are never told that information upfront. So yes, medication for acute pain, opioids for acute pain. Great. But for long-term chronic pain, we need to be doing other things too.

– [Zubin] Which, which is part of the tragedy of yanking away opioids suddenly on someone who’s had chronic pain and has been on them.

– [Rachel] It’s horrifying.

– [Zubin] Yeah. And you’d hear it on the, on the forums and stuff. People are terrified. Yeah.

– [Rachel] And it’s horrifying.

– [Zubin] Yeah, yeah.

– [Rachel] It’s unethical because you’re not providing people with other pain management tools.

– [Zubin] Yeah, exactly.

– [Rachel] And now their brain is extra sensitive and you’re just like throwing them to the wolves.

– [Zubin] Right.

– [Rachel] But.

– [Zubin] It’s as unethical as starting down that path without exploring the other paths as well simultaneously.

– [Rachel] Totally, totally. Back to your original question cause I haven’t forgotten.

– [Zubin] Oh, I have. What was my original question?

– [Rachel] Trauma.

– [Zubin] Oh yeah. Thank you.

– [Rachel] But first I feel like we have to understand the science and the neuroscience before we can talk about this over, this complex overlapping thing. So–

– [Zubin] I’m gonna interrupt you one more time.

– [Rachel] Yeah, no, do it.

– [Zubin] What I love about you, Rachel, and this is a pure compliment, is that you won’t let your, your experience, knowledge and understanding of things be reduced to soundbites. So you’ll take something I ask and you’ll say, let me take you on a journey that will explain this in a way that you will understand it better. And I love that. So every time you do that, I get a little burst of dopamine. All right, so back to trauma.

– [Rachel] I appreciate that. I mean, for me, I just feel like science should be in the hands of the people. Like I love being a nerd and I’m glad I went to school for 500 years, but pain is a ubiquitous human phenomenon and what human being doesn’t deserve to understand their pain. So, or to connect it with all these emotional experiences that we all have as humans. So, so that is what I want to do. I just want to like go on these journeys and just bring it back around.

– [Zubin] I love it.

– [Rachel] So I’m glad. That’s nice feedback. So trauma, so PTSD is a formal diagnosis that’s given to people who have experienced profound trauma where either their life was in danger or they witnessed someone else’s life in danger. And there’s a lot of things that happen when you have PTSD. It’s post-traumatic stress response and stress in my mind is a really key word there because what happens after you experience a trauma is that your nervous system goes into overdrive. And by that, I mean your sympathetic nervous system is your fight or flight system. Can I, can I say the nerdy science of that?

– [Zubin] Please do. I want to hear about all kinds of, you know, sympathetic, vagus nerve, parasympathetic. I mean go deep.

– [Rachel] Yeah. I actually want to hear how you explain this too, cause I think you and I are two sides of the same coin. So I want to hear your thoughts on it too. So sympathetic nervous system, back in the day, humans were food. We were hunted. So when we were out on the plains with our spears and our loincloths, yours was decorated with tea kettles.

– [Zubin] It was. And it did not cover the perineum. That’s why it’s so hyper-stimulated.

– [Rachel] So TMI. So much TMI.

– [Zubin] Teakettling.

– [Rachel] Animals were hunting us. So our brains did us this phenomenal favor where they evolved a mechanism to protect us in case of extreme danger. And that is your fight or flight system. So when a lion was approaching, you could either sit down on the ground and start thinking, what should I do now? You know, should I call Bobby? Should I–

– [Zubin] Do some math?

– [Rachel] Dig a hole?

– [Zubin] Get your abacus out, right. Yeah.

– [Rachel] Right. Instead your body gives you a cascade, a biological cascade. So hormones, neurotransmitters get released into your bloodstream. Adrenaline starts bumping, a lot of things happen, and we’ve all experienced this when we go into fight or flight, when we’re nervous. So sweaty palms, dry mouth, your pupils open to collect more light. Your heart starts racing, your blood rushes away from your extremities to your core because your core is the most important part of your body. Digestion halts. All of these things happen because the energy is required to either flight, which has run for your life, or fight, which is you take your spear and you try and, you know, get that line before it gets you. And then of course, there’s the freeze response also, which is like you play dead. Fight flight freeze. So with PTSD, we see an abundance of sympathetic nervous activation. We also see this change in the brain where the brain tries to protect you from any future threat. So people who have experienced trauma have a symptom called hyper-vigilance. And hyper-vigilance is you’re extra vigilant all of the time. By vigilant, I mean, aware and hyper aware of your environment and on edge. So if you tap someone on the shoulder when they’re hypervigilant, they’ll startle, they’ll jump.

– [Zubin] It’s almost like stimulation sensitivity, right?

– [Rachel] That is true.

– [Zubin] If you have pain sensitivity that you’ve been practiced.

– [Rachel] Yep.

– [Zubin] It’s stimulating any trigger you’re hypersensitive to. So these all pathways all seem to converge.

– [Rachel] They all converge. And when you’re anxious, your sympathetic nervous system is on overdrive. PTSD is, has historically been categorized under the heading of anxiety and stress disorders. So here’s the relationship, full circle. When you have experienced a trauma, your brain is trying to protect you from future traumas. So it’s on high alert. One could say it is sensitive to input. Your brain has become sensitive after a trauma. Pain, as you said before, is your body’s warning system, your danger detection system. So pain exists to protect you. So if you step on a nail and you keep running, that will be bad for your body. If you break your leg and you keep running and you have no pain, that will be bad for your body. If you put your hand on a burning stove and your skin melts off and you don’t do something about it, that is going to be bad for you. So pain exists to protect you, ultimately. Again, we know with chronic pain that the brain has become hypersensitive over time. Same with trauma. Trauma is a hypersensitive brain trying to protect you from danger. Pain is a hypersensitive brain trying to protect you from danger. They are best friends. And if you look at the research, trauma, especially in veterans, which have been studied extensively, and chronic pain end up being best friends. So people who have had trauma early on in life, childhood trauma, and there’s an abundance of study. They’re called the ACEs studies by Feliti, yes. The ACEs studies show children with early childhood trauma are more likely to develop chronic pain and chronic illness later on in life. That is not a coincidence. That’s not a coincidence. The brain is now sensitized. It’s like a, they call it like a fingerprint. Like it’s like a fingerprint in your brain. You’re more likely to develop these things. And then same with adults with trauma. If you’re an adult with trauma, you are also more likely to develop chronic pain because your brain is in this sensitized state. So chronic pain and trauma are best friends, whether we like it or not.

– [Zubin] Man, that’s awesome. They’re best friends. They’re part of a web. That’s why pain, trauma, PTSD, all this are mingled in this kind of zzz. And yet we want to go doink to one little part of that and expect it to improve. We can’t, we have to look at it. And I think if actually part of, I think part of the problem that people with chronic pain have is they don’t, sometimes they feel there’s no therapeutic alliance with witnessing what they’re suffering. And I think by witnessing all aspects of their suffering, it’s a much more powerful therapeutic alliance too, than just saying, you know what, I got the answer for you. It’s back surgery.

– [Rachel] Right.

– [Zubin] Or, and, and the idea of ACEs, these adverse childhood experiences.

– [Rachel] Thank you.

– [Zubin] So as an internist, I don’t see the kids, right. But I see the adult kid who now has hypertension, diabetes, you know, congestive heart failure. Hypertension in its own thing, I think is fascinating. We call that some physical condition. I don’t think it’s a, I think, I think it’s, biopsychosocial.

– [Rachel] Yeah.

– [Zubin] I think that if you’ve had a traumatic event as a child, that sympathetic undercurrent is firing in a, in a way that is no longer productive as an adult and it drives cardiovascular disease. And it might be that it’s actually further potentiated by, potentiated by stimuli that normally you or I would not mount a hypertension response to. So in so many ways we say, let’s reduce your hypertension to Norvasc or lisinopril. When in fact it’s all, the same things you talked about, biofeedback, cognitive, even cognitive behavioral therapy for hypertension, along with medication when necessary is probably a better answer.

– [Rachel] Right.

– [Zubin] And then of course, if we could prevent ACEs in the first place, we could probably solve this problem in a couple of generations.

– [Rachel] Yeah. And thank you for, yeah, adverse childhood experiences. That’s what ACEs stands for. And there’s a whole, there’s an abundance of studies. It’s just wild to see this relationship between early trauma and physical health conditions later in life. It’s like, again, why are we separating, separating out physical and emotional? You’re one human. Your brain is connected to your body 100% of the time. Like, why are we pretending that we should only treat one or the other?

– [Zubin] You know, and, and I think the best example of that, first of all, the placebo effect.

– [Rachel] Oh boy.

– [Zubin] Like what the heck.

– [Rachel] Oh boy.

– [Zubin] Come on. It’s staring right at us. It’s kind of like, you know, when Galileo is like, you know, you know what, earth goes around the sun. It’s like, well, yeah, it was right in front of us the whole time. We just, we’re looking from the wrong perspective. It’s the same with this kind of thing. I mean, can you, can you kind of speak to that a little bit?

– [Rachel] Can we talk about placebo for a minute?

– [Zubin] Yes, please.

– [Rachel] I, I’m dying actually to hear what you think. And in my mind, placebo is this big missed gift. I remember when I was doing my PhD, we would look at these studies and we would say, oh, well, the placebo did, you know, helped this many people, you know, and this treatment helped only a few people more, so that it’s, it must be a wash. And I, I rolled with that. It’s almost like this brainwashing thing that happens in graduate school. And I was like, oh, placebo. And I would,, I hear what hear myself using that word as like, oh, it’s just placebo. Now having gone down that rabbit hole and being like a health and pain psychologist and thinking about like what actually helps people. Placebo, what it means is when you believe a thing is going to help you, there is a change in your brain and a subsequent change in your body and you get better. It’s called, it’s called self healing.

– [Zubin] And I’ll go a step further and go you don’t even have to believe in the placebo.

– [Rachel] Right.

– [Zubin] There’s some part of your unconscious that gets benefit. It’s a therapeutic alliance with a concept almost.

– [Rachel] Give me the placebo for every one of my conditions all day, every day. It’s no side effects and it’s all the benefits and, and you get better. It’s unbelievable.

– [Zubin] Which is why, and like–

– [Rachel] Give me a placebo pill.

– [Zubin] Dude, they used to, you could prescribe something called Obecalp, which is placebo spelled backwards. And it used to be you could write a prescription for Obecalp, and give it to patients and patients will get better. But now it’s like considered unethical.

– [Rachel] No, no, I want it.

– [Zubin] I want it too.

– [Rachel] I want it. How do we?

– [Zubin] Yeah, how do we do that? Now what’s amazing is so separating the placebo effect. The placebo effects appears to have gotten stronger over time as our collective unconscious believes more strongly in the reductionist medical model. So now you could do the same, like SSRI trials, that back then, if you ran them again, now the placebo would be so strong the SSRI might not succeed against the placebo because we’ve lifted placebo up.

– [Rachel] That makes me happy.

– [Zubin] Doesn’t it?

– [Rachel] Yeah.

– [Zubin] But ah, there was a piece of that that I was going to say. So placebo. Oh. So when something does work against placebo in a profound way, you can be pretty sure that it has a mechanistic success. And a good example I’d give is like like the MRNA vaccines for coronavirus. It’s like, look at those trials.

– [Rachel] Right.

– [Zubin] That’s a placebo controlled, double-blinded randomized trial.

– [Rachel] Right.

– [Zubin] Oh, there’s a huge difference between the groups.

– [Rachel] Right, shit works.

– [Zubin] The shit works.

– [Rachel] Yeah.

– [Zubin] Right. So that’s why I think, you know, whereas other drugs, like, especially in psychiatric medications.

– [Rachel] Let’s go down that rabbit hole.

– [Zubin] Yeah, do it.

– [Rachel] Finish your, finish your thought.

– [Zubin] No, that’s. I, I don’t want to now because of that’s what I want to talk about. Yeah, I know. You know, but this idea that, that, that placebo is powerful means again, mind, body, they’re one field. We don’t, it’s been staring at us and yet we don’t ever harness it or understand it or properly study it. There’s some, Guy Stuart at Harvard who’s good at studying this.

– [Rachel] I know, I know. I want to like replicate him. I just, why don’t we, why aren’t we putting all of our money towards this magic? And by the way, I am a scientist and I am not a woo woo, like why aren’t we putting all of our money toward this scientific process we see happening in every scientific study where people are getting better because you’re telling them they’re going to? There is a self healing mechanism. That literally means there is a self healing mechanism inside all of us that we don’t know how to tap into. That’s what that means. It’s so hopeful for me. It’s like, it’s mind blowing, it’s for mental health. It’s for physical health, it’s for pain. It’s just, how do we dump all of our resources into researching the crap out of that.

– [Zubin] Or, or cut to the chase and just dump all our resources into community connections and therapeutic alliance and.

– [Rachel] Social medicine.

– [Zubin] Social medicine. Cause when I, when I went to my, my doctor just a few weeks ago, I hadn’t seen a doctor in like, you know, tons of years. And I had the, you know, all the usual labs and lipids. By the way, I went to a major health care, you know, integrated center around here that isn’t Kaiser actually. It’s a different center. And when I got my bill, I was just like, my jaw dropped. Nobody tells you what things cost. Like a CBC for $60, really? But anyways, that’s another talk. The dude was one of my contemporaries at UCSF and sat and listened to me and elicited, like with the back pain. And I have some tennis elbow, that another thing. Minor stuff. But it was causing actual a degree of suffering. Like I was avoiding activities like meditation because I couldn’t sit for that long without having severe neck pain. Just the act of him saying, oh yeah, I see what you’re, this must be difficult for you. And here’s, we’ll do a PT referral and we’ll do this. And have you tried this? Have you tried this? Oh, that’s yeah, okay, well, I think it’s this. Examining, laying hands. I already feel a million times better just by having that connection. And I’m a scientist, like I’m again, the woo woo thing is doesn’t come natural for me. I don’t think that’s woo.

– [Rachel] No, it’s not.

– [Zubin] I think that’s the nature of reality.

– [Rachel] Of course, humans are social animals and we need each other to survive.

– [Zubin] Absolutely.

– [Rachel] And the number one trigger for, I mean, if you think about what happened during the pandemic, people were isolated. Depression went up, anxiety went up, chronic pain went through the roof, overdoses.

– [Zubin] Still rising, yeah.

– [Rachel] Went through the roof. So humans are social animals and we need each other to be okay. And I think that’s an important point. And also to your point about anxiety and depression, something that’s that always makes me crazy is sort of this thing that also happened with chronic pain, which is somehow we medicalized these really common human experiences. And I do believe in anxiety and depression. So I don’t want to suggest that I don’t, but somehow big pharma has convinced everybody and depression is a chemical imbalance. And that what that means is you have a mental illness, your brain is broken. And the only thing that can it is, do you want to guess? It’s a pill.

– [Zubin] It ends with a little registered trademark circle around it.

– [Rachel] And you have to buy it from a pharmaceutical company. So what I want to say very clearly and very loudly, but I won’t yell cause it’s just the two of us in a studio.

– [Zubin] You can yell. I have a compressor on.

– [Rachel] And there’s a microphone in front of my face. Depression does not mean your brain is broken. Anxiety does not mean your brain is broken. Neither of those things are exclusively due to chemicals. Both anxiety and depression are this word biopsychosocial, which means yes, there are biological components to the human body, always. And there are psychological components. What I mean is your thoughts affect your mood and your anxiety all the time. If you start thinking, let’s see, what’s a particularly depressing thought. Nobody likes me. I’ll never get better. The world is on fire and it’s ending. And there’s no hope. You think that’s going to affect your mood? You bet your ass it will. Thoughts affect emotion. Of course they do. And, and social behavior. Again, we’ve got bio. We’ve got psych. We’ve got social. Social behavior also affects anxiety and depression. If you are in an abusive or otherwise dysfunctional relationship, you think that might affect your mood and your stress and your anxiety? Yes. If you’ve been abandoned by your family, you think you might feel depressed or anxious? Yes, you will. If you’re cut off from your community, if you’ve lost your job, if God forbid you’re a parent who’s lost a child. So depression is not simply you have too little serotonin and here as a pill to, that is not what depression is. That’s not what anxiety is. Big pharma has sent us all for a ride. And for some reason, we now believe in medicine that we should be sometimes exclusively treating these conditions with a medication. And again, I want to say, I am not anti medication. Medications are very helpful for some people some of the time. Some people will say their lives have been saved because of a medication. And I am totally all about it. I am all about whatever works. What I am not all about is fleecing the public into believing that depression and anxiety means that you have a chemical imbalance and there’s only one way out. There are lots of ways out. And depression lives in the middle of that bio-psychosocial bubble. And so does the anxiety. Can a pill help? Sure, some people some of the time. Is that the only answer? No. Is it a panacea? Definitely not. That’s my soapbox.

– [Zubin] Take them. Hey man, this is amazing. No, I mean, we’re 1,000% aligned on that, you know, and my mother, the psychiatrist, feels the same way.

– [Rachel] Wow.

– [Zubin] And, and, and, and, but, but again, she’ll, she’ll also double down on your emphasis that there are lives that have been saved by these medicines.

– [Rachel] Oh yeah.

– [Zubin] Of course, we know this.

– [Rachel] Yes.

– [Zubin] But that’s fine. That’s the prevailing cultural wisdom that is run by big financial incentives. These aren’t bad human beings, by the way. I don’t like the villainization of pharma. It’s the villainization of the incentive that you make money by doing things to people with pills. What if we made money by actually helping people? Well, then we would probably help people more.

– [Rachel] Right.

– [Zubin] But we don’t. We thought that’s how you help people in the beginning of this kind of scientific revolution of medicine. But now we’re realizing, oh, actually there’s a step beyond that which is this more integral way of thinking. In social discourse and ideology, I call it the ult-middle. It seems everything is true, but partial as part of this web of network. It’s this radical idea that you don’t assume people are evil because they don’t share your idea, but you do listen and you say, okay, well. Ken Wilber and another philosophy reference calls it integral thinking. It’s holistic, everybody’s made of holons. We’re all holes and part of bigger holes. And each of us are those four quadrants. If I, its, it, and we. So if you don’t see the whole thing, okay, and I get it, it’s hard to see the whole thing. And we don’t get paid to see the whole thing. And we don’t get trained to see the whole thing.

– [Rachel] That’s, yeah.

– [Zubin] But if we don’t do it, we get reduced to a pill or the opposite, right. We get reduced to like some new age circles that are like, man, if he just like balance your chakra, like all that hypertension will go away, bro. And it’s like, yeah, yes and? There’s something else. And one other thing I want to say about that, there’s a saying in Zen, that that is thinking is the disease of the human mind. Now what they mean by thinking is they don’t mean like creative thought or planning or strategizing. None of that. They mean the self-referential discursive thought, like your pain, what you’ve described as your pain voice, Mrs. Beasley, the voice that’s like, you’re never going to get better.

– [Rachel] From the last episode?

– [Zubin] From the last episode. And it’s in your book, and so on. Actually Beasley isn’t in the book, is she?

– [Rachel] She is.

– [Zubin] Oh, she is, okay. Yeah, yeah, yeah.

– [Rachel] She is.

– [Zubin] Yeah. This idea that when we identify with those thoughts, when we lose ourselves as feeling we are this, that’s when things go awry and you have tools in the book and elsewhere that say, okay, now we can actually let’s make a little space between us and the thought.

– [Rachel] Yeah.

– [Zubin] And truth test these thoughts.

– [Rachel] Yeah, that’s right.

– [Zubin] Yeah.

– [Rachel] Yeah, there’s like so many things to say about all the things you just said.

– [Zubin] I can tell. I can watch you when I say things like that. And I just see your mind is like , there’s 30,000 things I want to talk about.

– [Rachel] Yeah. So I wanna go back to being problem solvers cause I think you and I are both those things. And it’s one thing to talk about how, you know, it’s important to not just tell everyone that their brains are broken and they need a pill to fix it, first of all. But then it’s also important to offer some alternative solutions. So research shows that there are treatments for anxiety and depression that are equally as helpful as medications, or that can be used in conjunction with medications like cognitive behavioral therapy, like mindfulness based stress reduction, which I know sounds like voodoo, but I have used it myself. It is very, very helpful.

– [Zubin] It works.

– [Rachel] Like biofeedback, which again is this really cool science where you learn to connect the thoughts in your head with the sensations in your body. There’s, there’s a ton of stuff out there, lifestyle medicine. So changing what you eat and how much you exercise and changing sleep hygiene. So there’s a million things we can do for anxiety and depression either in addition to, or besides medication. And it’s just so important to put tools in the hands of the people who need them. That’s like my whole MO, so. Yes, I want to change the story. I think there’s a lot of story around, you know, you know, it’s just a chemical problem. You know, you’re mentally ill. I want to change that story because I really firmly, passionately believe that humans experience anxiety and depression normally and naturally over the course of our lives. I want to de-stigmatize that. I don’t think it’s a sign of mental illness. Of course, yes, extreme depression, extreme anxiety requires extreme intervention, but you know, humans, we are emotional creatures. We all, just because you experienced anxiety during the pandemic, does that mean you have a mental illness? I vote no. I would call that an external or situational trigger that triggered most of us to have higher than normal anxiety. So anxiety is not always a mental illness. Sometimes you’re depressed during a pandemic because you’re cut off from your loved ones and you’re, you can’t go to work and you can’t go to your favorite restaurant. So all these things contribute. All of these things are complex and they’re a biopsychosocial picture. And if we, if any of us want to help our patients, or if any of us want to get well, we need to look at all the parts.

– [Zubin] I’m about to teakettle right now, woman.

– [Rachel] Let me hear it.

– [Zubin] F@#@! this pandemic! You know?

– [Rachel] Yeah, I know.

– [Zubin] It’s a collective kind of, collective kind of suffering that we’ve, that has descended on all of us. And it affects us as individuals. And like you said, it doesn’t mean we’re mentally ill.

– [Rachel] Right.

– [Zubin] It means we’re humans, we’re social creatures, we trigger off the news. We trigger off others, we trigger off getting shamed at a supermarket for either not wearing a mask or wearing a mask, for getting vaccinated or not getting vaccinated, for, you know, and it just becomes this collective thing that, you know, we want to reduce to, oh, well, you know. And then what do we see? Overdoses like up 30% or something in the pandemic.

– [Rachel] Yep.

– [Zubin] Something ridiculous.

– [Rachel] Yeah.

– [Zubin] And they were already bad before. Our life expectancy was already going down before. And then you look at like, say Dan Buettner’s blue zones where people live to be 100 and all this stuff. And like places like, you know, parts of Southern Greece, I think, Southern Italy and you go, wait, what are they doing different? They’re not on a bunch of SSRIs. They’re not taking Norvasc or Lipitor or lisinopril, usually. They have tight communities where people are active until late in life, where they’re supported by each other, where they’re social, where they eat reasonably, and reasonably fresh food where they don’t chase a lot of material acquisition, where their stress levels are modulated by stuff in the community. And where if someone’s feeling–

– [Rachel] They’re swimming in the ocean.

– [Zubin] And they’re swimming in the ocean. They’re active, they’re getting reasonable amounts of natural sunlight. Yeah. But what have we created here? The perfect utopia to make a sick, obese and, and depressed. And then we want someone like you to solve it with a pill. And when you say, oh, it’s actually much more beautifully complex than that. And also within your control, I’m sure people will be like, I’m going to go to the other person who just going to give me the pill.

– [Rachel] And that’s okay. And that’s okay. You know, life is complicated and all these health conditions are complicated. And I think it’s really human to want a quick fix. I know that I have always wanted that too. Like I was a kid with chronic stomach aches and I wanted a quick fix and it turned out that I had social anxiety and it was like, I couldn’t stand up in front of a, let alone give an interview. I couldn’t stand up in front of a class without passing out and getting a stomach ache and getting nauseous and vomiting. So, so everyone wants a quick fix. I think that’s called being human. And I don’t judge. I don’t try, I try not to judge that, but, but I do wanna make sure to say that we’re, we’re all going to get healthier if we’re targeting all the things instead of just one of the things.

– [Zubin] Man, I really feel for you with the stomach ache thing. No, cause I had that too as a kid.

– [Rachel] Really?

– [Zubin] High anxiety kid. Probably had like formal irritable bowel syndrome when I was late teens, early 20s, like in college.

– [Rachel] Will you tell people what that means?

– [Zubin] Well, you know, I don’t really know, but I’ll say what it meant for me is like any time, I didn’t even know I was stressed, but suddenly you’re just like cramping, pain, nausea. You know, have to run to the bathroom. And you feel like something is wrong physically. Like, oh, you’re not, it’s not feel, you’re convinced that this is a physical problem that needs something put up your butt to figure out what it is. I never had that. But if I had access to it, I’ve been like, sure, figure it out. Cause I have cancer. There’s something going on.

– [Rachel] Of course.

– [Zubin] Right.

– [Rachel] Yeah.

– [Zubin] And in fact, the fact that it got better when my anxiety improved just naturally and it’s, it’s pretty much gone now is a testament to a piece of that. And the other testament to this whole mind body thing is that the sense that you said it earlier, you get butterflies in your stomach. It’s a physical sensation of an emotional state. They call them feelings because you feel them in the body.

– [Rachel] That’s right, physical and emotional.

– [Zubin] So tell me, how do you think about these kinds of stomach ailments because I’m sure you take care of kids and stuff who suffer with this?

– [Rachel] Yeah. The speech I give parents is the number one sign of stress and anxiety in kids that I see is stomach aches and headaches. Now I had a neurologist get very angry with me. She said, you’re stigmatizing my patients.

– [Zubin] Oh.

– [Rachel] And I said, I don’t feel any stigma around explaining to parents that physical and emotional are connected. That’s what science says. And I am just a conduit. I’m just reporting. But, but from her perspective, when you say that to a family, you’re suggesting the child is mentally ill, just to be clear, that is not at all what I’m suggesting.

– [Zubin] Dude. And how painful is it when you watch as an objective observer and you see the child suffering with headaches and stomach aches and you go look at the home situation, look at the level of stress. It’s staring you at the face. And you’re sometimes, I’m scared to tell people, you know, there’s a lot going on here. And the million dollar scans and stuff are not going to answer your question.

– [Rachel] That’s right. Well, and the kid has also said to me that they’re anxious, and they’re experiencing social anxiety and they have a number of phobias.

– [Zubin] Oh my gosh.

– [Rachel] Yeah, so, so. The stomach thing is particularly interesting to me on a personal level, but also because stomach aches and abdominal pain are so common, all of us have experienced the butterflies in your stomach or the nausea before a big, you know, performance or something at work. You know, you’ll get stomach aches or headaches. And again, that’s because emotions don’t just live in your head. They also come out in your body. That’s just how the body is built. But specifically with stomach aches, there is something called the enteric nervous system. I had never heard of this before when I was a kid with stomach aches. I wish any doctor had told me about it. Your enteric nervous system is this fascinating combination of neurotransmitters and nerves and tissue in your gut and. Okay, pop quiz. Guess which part of your body, you’ve heard of serotonin, of course.

– [Zubin] Maybe.

– [Rachel] Maybe. I just don’t know if the audience has. So serotonin is a brain chemical, a neurotransmitter, that regulates a lot of things. It does a lot of things like appetite and sleep, but it’s most popularized for regulating mood. So if you’ve heard of an SSRI, that’s a very popular antidepressant and even antianxiety medication. And it regulates this chemical, this brain chemical called serotonin. Serotonin is thought to be this like big regulator of emotion and mood. And people think of it as like this happy medication. So when you take an SSRI, it makes you happy cause it raises serotonin. That’s not exactly how it works, but that is the popular marketing of it. Guess which part of your body has the most serotonin?

– [Zubin] It’s your enteric nervous system.

– [Rachel] It’s your gut.

– [Zubin] Your gut.

– [Rachel] It’s your gut.

– [Zubin] It’s a transmitter.

– [Rachel] It’s not your brain.

– [Zubin] Yeah.

– [Rachel] It’s not your brain. It’s 80 to 90%, 80 to 90% of the body’s serotonin lives in your gut. Your gut is your body’s emotion center, in addition, of course, to your brain. So it’s why you have a gut instinct. You feel something in your gut. Why, why? Oh, well it’s your emotion center. 80 to 90% of your serotonin is in your gut. So there’s a reason why you get stomach aches when you’re nervous. And there’s a reason why you were getting cramping. So I just want to say, if anyone is living with stomach aches or experiences vomiting or diarrhea or constipation or any of those normal and natural things that happen when we’re in a state of stress, and by the way, most of us are in a state of stress most of the time due to family conflict, or pandemics, or work stress or whatever. So there’s a lot of articles on the enteric nervous system. I actually have a really nerdy website, which is just my last name at Zoffness.com. And there’s a ton of resources on the enteric nervous system because I am fascinated by it. There’s scientific articles. Scientific American has articles. But also to say, part two, the science of the stomach ache. We talked before about fight or flight, which is your sympathetic nervous system, which gets activated when you are anxious or stressed. It’s trying to save your life. One of the things that happens when fight or flight occurs is that digestion halts. So before you were rolling along, normally digesting your food and then suddenly digestion halts. So have you ever seen a bird get scared and fly away?

– [Zubin] It usually sharts itself.

– [Rachel] That’s correct. We call it evacuation because when you fight or flight, you want to be as light as possible so you can fly off or run off. Humans do the same thing. When we are in a state of stress, our body oftentimes tries to evacuate. So you vomit or you have diarrhea or whatever. And so you have the urge to go to the bathroom. So it’s again a good sign from your body that you’re experiencing stress. For some of us, we know that we’re stressed and then we notice our body. For others of us, it’s the opposite. Like you said, when you’re a kid, you just feel your body freaking out. We don’t get a lot of emotion education as a child. So you feel your body freaking out and you’re like, why is this happening to me? I don’t know what’s going on. I think I have a disease. And it’s your body telling you that it’s in a state of stress or, or that you’re anxious.

– [Zubin] Oh man, I mean, this is, if we could just educate kids on–

– [Rachel] Oh my god.

– [Zubin] This and their emotions. You said we don’t get a lot of education in emotions. I would, I’m going to respectfully disagree, but not in the way you think. I think we do get plenty of education on emotions, on how to repress them, how to ignore them, how to hide them, how to push them down further into the body. And you know, my, my friend, Angelo DiLullo, who is a big meditator has, has a saying, he says, emotions really want to be experienced for what they are. And when you start to repress them, it’s kind of like goes into the spectrum of your teakettling idea. If you don’t let things inhabit you and pass through you, you continue to obfuscate them with various things. You’re, they’re going to misbehave in ways that come out as in passive ways. And some of those are physical. The stomach ache. The other thing that you said that I thought was very important is this fight or flight thing. And you’ve, and I have talked about this fear of speaking or fear of being on a podcast or fear of whatever it is. Well, it turns out like we evolved in a way, our persuasive skills evolved to convince others in the tribe that whatever our emotional state is is, is valid or whatever our gut instinct is is valid. And when we’re up there trying to convince others, we are in physical peril. Meaning if we fail to persuade the tribe or fail to influence them, we get worse breeding rights, worse eating, worse hunting, et cetera. We could be ex-communicated from the tribe. So in a way, your life’s in danger when you publicly speak, historically. Now we translate that into, I’ve got to give a talk for my company or whatever. I got the slides and I’m shitting myself beforehand or shaking or, you know, sweating or whatever are the physical manifestations. That’s our fight or flight.

– [Rachel] Exactly.

– [Zubin] We’re trying to decide, am I going to die up there? Literally. That’s what comedians say, oh man, I died up there. It’s literal historically. So once you start to realize that there are ways that you can listen to your body and actually short-circuit some of those natural reflexes.

– [Rachel] Agree.

– [Zubin] And some of that’s just practice.

– [Rachel] Oh yeah. It’s exposed, some of it’s exposure.

– [Zubin] Exposure.

– [Rachel] It’s doing the thing you’re scared of. Why do, like that’s like literally the reason I’m here, by the way I almost bailed, I was really nervous. And I was like, I’m just going to cancel.

– [Zubin] You know what? I could feel that through the text thread because it’s, and you know what, and I gave you an out too.

– [Rachel] I know, I love you.

– [Zubin] I was like, you can go. And you braved up and said, you know what? It’ll just, I feel the same way.

– [Rachel] No, I told you I was nervous. So the only treatment, so for people who have performance anxiety, and it can be performance for like speaking, it can be performance for a sport like soccer, or, you know, giving a talk at work. The only way out is through. The only way out is through. And I have to remind myself of that all the time too, because I have these things I really want to talk about. And I’m passionate about changing the way we treat pain and the way we talk about mental illness. And the only way to do that is to get over yourself. And anxiety is real. And the treatment for anxiety by the way, is exposure therapy. What I’m doing is an extreme version of that, but I’ve worked my way up to it. So for me, at first, it was like giving talks to small groups of five and then doing bigger groups. And then speaking at conferences, which took like a lot of, you know, work and nervousness and occasionally vomiting.

– [Zubin] Yeah.

– [Rachel] But, but, but then you get to a point where you’re like, no, this thing I want to do is so important that I’m willing to do the work to make it happen. So I am always committed to not bailing when I feel nervous, but the urge is always there even still after years and years of working on this. It’s so interesting.

– [Zubin] And you know what’s really interesting too, is that you don’t, so it points out how our internal states are our internal states and often are inscrutable to those outside. So I’m betting the audience would never, ever guess that you have an iota of nervousness talking about any of this because you come off as natural, engaged, sincere, all of which are true.

– [Rachel] Yeah.

– [Zubin] But then you’ll tell, you’ll openly say, hey, this is how I felt before this, or this is what happened before this, which means you’ve gotten very good at expressing your inner states externally.

– [Rachel] Yeah.

– [Zubin] But otherwise I would never have known.

– [Rachel] Oh, interesting.

– [Zubin] I just never would have, never would’ve guessed. Last time you told me–

– [Rachel] You picked it up on the text thread.

– [Zubin] What’s that?

– [Rachel] You picked it up on the text thread.

– [Zubin] Well, on the only reason I did is the last time that you came, you mentioned afterwards, you said man, it was stressful for me. I was like, I would never have guessed. I’m not perceptive enough to have picked that up. And, and, but then reframing it like, oh, there were little subtle signs of it, but boy I’d never would have caught it.

– [Rachel] Yeah.

– [Zubin] So again, I think in some way it’s liberating as an exposure to let that come out to others.

– [Rachel] Sure.

– [Zubin] Right?

– [Rachel] I mean, I think people have experiences that they realize in retrospect could be useful for other people. And I think a lot of us do this thing where, and anxiety tells us to, where we avoid the things that trigger anxiety. That’s actually part of fight or flight. Flight is avoidance to be perfectly clear. So when you feel that anxiety response, your brain is telling you that you should avoid the trigger. And that’s useful if it’s a lion that wants to eat you, but it is not useful if it’s things that can take you forward in your life or help other people or further a message, right. So we avoid. So if I forever for the rest of my life, since like early childhood, avoided public speaking, I would never be able to get the word out. I would never be able to help people or treat people. I would never be able to write a book and pitch it to a publisher. You know what I mean? All these things like, you get in your own way at some point. So the treatment, again, the only way out is through. But again, back to the metaphor with like opening the blinds a little light at a time, exposure therapy for anxiety is the same, similar to treating a chronic pain condition where you do little bits of the thing that scare you. You approach teeny bits at a time rather than avoid. So that’s the, that is the treatment for anxiety, by the way.

– [Zubin] Yeah. Which is, which is, you know, again, you know, I understand this idea with like trigger warnings and safe spaces and all that.

– [Rachel] Yeah, yeah, yeah.

– [Zubin] I get the concept because it’s too much stimulus.

– [Rachel] That’s right. You don’t want to flood. Flooding is too much, right.

– [Zubin] But I think it’s easy to take that the wrong way and go, well, then I want to, you must protect me from any stimulus. No, the idea is you slowly but surely in a safe space, a little bit exposure. And maybe for PTSD, maybe for anxiety, definitely for these kind of spectrum of what we’ll, they call disorders, which are really, you know, again.

– [Rachel] Human responses.

– [Zubin] Human responses.

– [Rachel] Well, and the other thing that you mentioned is like part of the reason for nervousness. And I think this is true for many women. I was reading that even for like famous political figures who are in the limelight regularly, there’s something called imposter syndrome. So.

– [Zubin] Oh yeah.

– [Rachel] Which, which a lot of, I think a lot of doctors suffer from, and I’ve read that it’s women in particular and it doesn’t matter, like, like it doesn’t matter if you have like a degree from Brown and Columbia and UCSD, and you’ve done 12 postdocs, it doesn’t matter. Like you can still feel like you’re a phony.

– [Zubin] Oh yeah.

– [Rachel] It’s like message, again, it’s that voice in your head that like BS, Mrs. Beasley, who tells you, like, you don’t know what you’re talking about and you’re imposter. So imposter syndrome is real.

– [Zubin] Oh yeah.

– [Rachel] And I think the more you’re in a position of being able to help people in a public way, the more you feel it or experience it. But I think people experience it at work. And as a parent, people experience like who am I parenting these children or knowing what I’m doing. So that’s, for me, that’s part of my nervousness too.

– [Zubin] It’s really fascinating that you bring up imposter syndrome and, and its association with. And I wonder if it’s associated with more with women statistically, because I know that I suffer from it quite a bit.

– [Rachel] Interesting.

– [Zubin] Oh, quite a bit. I’ve talked about it actually. And in fact, I talk about the Dunning Kruger kind of curve. So in other words, you know, you know nothing, and then all of a sudden you learn a little bit about it. You overestimate what you know, so you think, oh, I studied a little bit about vaccines and now I’m an immunologist. And so you over project confidence. But then the more you learn about something, you enter the valley of the imposter, where you realize what there is to know is vast. And what you know is actually a small proportion of that. And so you now start to know what you don’t know and feel like an imposter. Now, the question is, I think that is such an impediment to good people, great people doing good in the world. So for example, my wife, I keep trying to tell her, there are so many people that want to see you talk. She’s a chest radiologist, academic, wins teaching awards every year at Stanford. Incredible teacher. Everyone wants to know about the COVID findings on chest radiology, CTS, MRIs, et cetera. And she’s like, yeah, I could do that. But you know, I don’t want to make a mistake or like, say something incorrect or, you know, yeah, plus there’s probably somebody better who’d do it for you. I’m like, you’re my wife. There’s nobody better to do it. I have the capacity. And you know, I just not, I’m not comfortable with that. Whereas I’m like, bro, fake it till you make it.

– [Rachel] That’s right.

– [Zubin] Let’s just pushed through. And she’s not even faking it, right.

– [Rachel] She’s the real deal.

– [Zubin] So I wonder if there is a, a little gen–

– [Rachel] Gender.

– [Zubin] Gender difference there, you know. That guys are just kind of a little bit conditioned to, or maybe it’s a testosterone or some hormonal thing where we’re just like, bro, yeah, I can fucking, I can lift that. No problem.

– [Rachel] It maybe–

– [Zubin] On your neck.

– [Rachel] I mean it could be a combination things, but I think you’re right, that it’s like sort of women are socialized in our culture to see men in positions of power and authority. And I think if you’re a little girl and you grow up seeing mostly men who are speaking the things and in positions of authority, you’re like, oh, well maybe I’m not supposed to be the person who knows the things. And maybe I’m not supposed to be the person who’s speaking the things. I think that happens. I can say for, for women and girls, that’s surely a piece of it.

– [Zubin] You know, related to that, I wonder I’ve heard this and I’m curious your thoughts, you know, the sort of pattern of speech with uptalk where you end everything with–

– [Rachel] Vocal fry.

– [Zubin] Vocal fry, uptalk. I’ve heard it understood in some ways that it’s a, when it happens in women because men do it too.

– [Rachel] Men do it too.

– [Zubin] Men do it too, and that’s something that, again, there’s a double standard. When men do it, it’s like, well, you know I’m manly. When women do it, it’s like–

– [Rachel] That’s annoying.

– [Zubin] That’s annoying. And there was some thought that unconsciously or consciously it’s done by women as a kind of like, well, you know, to kind of disarm men who are afraid of women who actually know what the hell they’re talking about.

– [Rachel] Like almost solicitous.

– [Zubin] Exactly.

– [Rachel] Or like apologizing.

– [Zubin] Exactly right. Whereas it’s like, why would you ever apologize for being awesome? But yet our society has conditioned us from young, you said, when you were young.

– [Rachel] It’s pretty wild.

– [Zubin] It’s pretty wild.

– [Rachel] I mean, I think role models matter. So I think that makes it even more important to me to like, be out there. Yeah.

– [Zubin] Yeah.

– [Rachel] Yeah. Women should be saying the things. Women should be saying the things. Yeah.

– [Zubin] That’s a bumper sticker.

– [Rachel] Women should be saying the–

– [Zubin] Women should be saying the things. What things? Doesn’t matter. They need to say the things.

– [Rachel] Just say the things.

– [Zubin] Yeah. I agree.

– [Rachel] Yeah.

– [Zubin] – Sometimes I find I get in patterns of having a lot of men on the show. And we, you know, shout at each other and this and that. And then, and then I’ll get women on the show and it’s like, this kind of, there’s a sense of, I don’t know how to describe this. There, there, see, we try to deny differences between men and women too, I think to our detriment. Like we should celebrate–

– [Rachel] Totally.

– [Zubin] The respective strengths, right.

– [Rachel] You have a chromosome I don’t have.

– [Zubin] And I, and every day I wish I didn’t have it because it causes me grief sometimes.

– [Rachel] Sure.

– [Zubin] Yeah.

– [Rachel] I have a chromosome you don’t have.

– [Zubin] Damn you!

– [Rachel] Two, I have two.

– [Zubin] You have two Xs.

– [Rachel] I know, isn’t that amazing?

– [Zubin] Dude, I know some, I know some people with three. Klinefelter.

– [Rachel] Me too, I treated.

– [Zubin] Jealous.

– [Rachel] I wouldn’t.

– [Zubin] Like one more?

– [Rachel] It was challenging. Yeah.

– [Zubin] It is challenging. Yeah.

– [Rachel] A lot of.

– [Zubin] Yeah, extra chromosomes at any time are generally challenging.

– [Rachel] Yes.

– [Zubin] But also can be beautiful. But yeah, generally challenging. Diversity, right. Neurodiversity. But the open sense of emotional connection with women, I find, triggers a part of me that is that feminine piece to open. And I think it’s easy to repress that. In fact, it’s quite easy. And that’s something that’s often worth exploring, I think in our own relationships, the connection with, like you actually have, and again, I’m going to say this is just purely observational. You have a masculine component to your communication style that actually makes it very direct and very assertive. So you’ll say, okay, yeah, but let me, let me ask you this, or let me bring it back to this. And that’s very powerful too.

– [Rachel] I’ll tell you why that’s not masculine.

– [Zubin] Ah?

– [Rachel] I am a New Yorker.

– [Zubin] There it is.

– [Rachel] I am a New Yorker. Direct, assertive communication is how I was raised. I was steeped in it. It was like bath water.

– [Zubin] Yeah.

– [Rachel] But it’s interesting that I, I do think you hit on something important, which is like, that is the perception of masculine versus feminine communication. But I think–

– [Zubin] Energies, yeah.

– [Rachel] I think New York women, and I don’t, I hate overgeneralizing, but I think women who grew up in New York or just are used to this communication style. And I have to say moving to California was a shock to the system. People didn’t know what, like I’m sarcastic, I’m direct, I’m assertive. And some people interpret that in a way that I don’t intend, but I also embody that that’s how I am and that’s how I talk. And I, I find myself wishing that people would talk to me that way too. I appreciate it. I like authenticity. I like directness. It like helps me make sense of the world.

– [Zubin] Yeah, from a sense-making standpoint, it’s crucial, authenticity. And–

– [Rachel] And you’re a Jersey.

– [Zubin] I’m a Jersey. That’s why I think we get along so well. It’s kind of like, oh finally, someone speaking my language.

– [Rachel] That’s right.

– [Zubin] You’re right. California is a different vibe.

– [Rachel] It’s a different animal.

– [Zubin] It’s a different animal. And you know, if you’re born here, raised here, that’s how you are then you’re authentically that.

– [Rachel] Yeah.

– [Zubin] So you celebrate it too, right. It just can’t be that that east west divide can really manifest if you don’t, if you’re not perceptive about it in ways that are that generate misunderstanding. It’s kinda like, oh. And then of course, again, with the gender assumptions, it’s like oh, assertive women are bitches.

– [Rachel] Oh yeah.

– [Zubin] And feminine men that are, that are more emotionally connected are pussies.

– [Rachel] Oh, I hate that.

– [Zubin] Yeah, right.

– [Rachel] I hate that. And I do wish we had more emotion education, like starting at a young age to talk to kids about how emotions manifest physically, the connection between the stomach and the headache and the body pain and the trauma and the emotions. And then also what to do with your emotions. Like, let’s talk about teakettling in kindergarten. Like let’s help people manage their emotions early on so they don’t get all bottled up and become these other monsters, you know.

– [Zubin] It’s, it’s really powerful when you allow yourself to feel an unfiltered emotion without a lot of conceptual overlay. So in other words, and that’s a practice.

– [Rachel] Say what you mean.

– [Zubin] So it’s a meditative practice where you say, oh, you know, I’m angry about something or, or let’s make it even more complicated to make it simple. So let’s say you say something that triggers some response in me. And I happened to be that day, perceptive enough to recognize I’m having a response. And it’s an annoyance response. Like I’m annoyed. Okay. Why am I annoyed? So you leave. And then I, I feel into what’s going on. Okay, annoyed. What’s going on? Where do I feel that in my body? It’s here. What happens when I strip away annoyance and these labels? Oh, it feels like this energy pattern, and oh, you know what it feels like. It actually feels like, like shame, like it’s a different emotion than I thought it was. I was putting all this complexity on it. It was really just shame. Why would that be? Well, she said this, which made me feel unworthy about this. And then I felt ashamed. Oh, well, let me just feel that.

– [Rachel] That’s so high. Dr. Z. That’s really high level shit you’re talking about right now. It’s and it’s awesome.

– [Zubin] I read it in, on the toilet in a book. Like my friend, Angelo…

– [Rachel] But that’s high level. No, that is high level. It’s like recognizing that you’re having an emotional experience and then looking inside your body to see where that emotional experience is occurring. And then like looking underneath that physical somatic experience and trying to figure out well what’s underneath that. That is, that takes a lot of work. That’s rad. I’m glad you’re doing that. Let’s have everybody do that.

– [Zubin] So we can train that.

– [Rachel] Great.

– [Zubin] That’s trainable.

– [Rachel] Let’s have a class, you wanna do it?

– [Zubin] I would love to do that.

– [Rachel] Let’s do it.

– [Zubin] Even just like let’s name a bunch of different obscure emotions and learn to recognize and drill deeper and drill deeper.

– [Rachel] Yeah.

– [Zubin] That’s the intellectual stuff.

– [Rachel] It would help so, it would help with physical health. It would help with pain.

– [Zubin] Oh my gosh. If we, if we could get rid of emotional repression, or at least modulate it, I think we’d see a 50% reduction in disease burden in the United States.

– [Rachel] There is a guy I know in Berkeley who is researching that.

– [Zubin] Really?

– [Rachel] Yes. The role of emotional suppression and physical pain. He’s also researching racism and pain because it turns out that when you experience stressors like racism, your pain feels worse. Because remember of the pain dial?

– [Zubin] Oh yeah.

– [Rachel] It’s amplified by all the things.

– [Zubin] By unworthiness and–

– [Rachel] All the things.

– [Zubin] Yeah, oh my gosh.

– [Rachel] Fascinating.

– [Zubin] Really fascinating. And then, you know, so this is something again I’ve mused about before, but I don’t know. Again, you’d have to really study it, but the fact that African-Americans suffer more hypertension, diabetes, heart failure, et cetera, at younger ages, strokes, et cetera. Why, why would that be? You live your entire life with this undercurrent of stuff that generates a sympathetic undercurrent of response.

– [Rachel] And not even an undercurrent.

– [Zubin] Right.

– [Rachel] Like in your face.

– [Zubin] I’m being conservative, right. Exactly.

– [Rachel] In your face. Stress, racism.

– [Zubin] Pulled over by a cop, whatever it is. Yeah.

– [Rachel] All day long.

– [Zubin] All day long.

– [Rachel] Oh yeah.

– [Zubin] Right.

– [Rachel] It’s a massive humongous stressor.

– [Zubin] Right.

– [Rachel] Right.

– [Zubin] Right. Yeah, you need to stop microaggressing against me with words, like humongous, okay.

– [Rachel] I’m sorry.

– [Zubin] I’m a short, five foot five man. And that’s a microaggression. And now my blood pressure went from 120 to 121.

– [Rachel] We couldn’t measure it.

– [Zubin] We could measure it. We’ll put an art line in and just measure it in real time.

– [Rachel] That’s what happened when I first went to biofeedback. I’ve been mentioning biofeedback as this treatment for chronic pain. It’s also a really helpful treatment for anxiety. So biofeedback, someone said to me, oh, you treat chronic pain. You should be sending your patients to biofeedback. And I said, I don’t send my patients to any treatment that I don’t understand. So I went to a biofeedback provider. His name happens to be Dr. Pepper. Which is delightful.

– [Zubin] Delightful, already.

– [Rachel] He’s a professor at the University of San Francisco. He is brilliant. And I adore him.

– [Zubin] I think I know Dr. Pepper.

– [Rachel] Seriously?

– [Zubin] I know of Dr. Pepper.

– [Rachel] Eric Pepper?

– [Zubin] Because–

– [Rachel] He’s written all the books.

– [Zubin] Yeah, because when I was a student there, they were, hey, have you talked to Dr. Pepper.

– [Rachel] Stop.

– [Zubin] Right. No, no joke.

– [Rachel] So.

– [Zubin] Yeah.

– [Rachel] I went to Dr. Pepper.

– [Zubin] Amazing.

– [Rachel] and I sat in his biofeedback chair and he said, I am going to teach you to warm your hands to 90 degrees. I am a chronically cold handed person. And I was like, I do not believe in voodoo. I’m a scientist. And he said, okay, doubter, you know, close your eyes, lay back in this chair. And he connected me using this machine to a variety of sensors on my fingers and on my chest and my arms, my shoulders. And what it did, it did. It was measuring a bunch of different things. It was measuring skin temperature, and galvanic skin response, and muscle tension, and heart rate, and a couple of other things. So I was looking at this machine and it’s reading these biological processes and it’s giving me feedback about these biological processes. So I laid back in the chair, I’m connected to the machine. He’s doing a bunch of things with me. He starts with relaxation training. So I’m relaxing my body. I’m relaxing my muscles. I’m using diaphragmatic breathing. He’s using guided imagery and the guided imagery includes, and I know this sounds wonky. It did, to me. The guided imagery included. Remember his goal is to help me warm my hands to 90 degrees. The imagery includes imagining hot air flowing from my shoulders down into my fingertips and then hot soup on the inside of my arms. I know I was like, what is this? Weird.

– [Zubin] Yeah. This sounds like teakettling to me.

– [Rachel] And then imagining the feeling of your hands over a hot campfire. You can actually, if you search your brain, you can find that feeling. We can talk about the neuroscience of that too.

– [Zubin] Oh my.

– [Rachel] Right. And I’m doing all these relaxation things simultaneously. And then we’re using something called autogenic training, which is where you say words to yourself. It’s like self suggestions. My arms and my hands are heavy and warm. My arms and hands are heavy and warm. And by the way, I’ve been doing this for so long. But as soon as I start talking about it–

– [Zubin] It gets warm.

– [Rachel] My hands get sweaty and red and hot.

– [Zubin] Wow.

– [Rachel] Yes, but what happened was over two sessions, my hands very quickly started going up to 90 degrees and you can’t deny it’s happening because you’re looking at the machine. It’s giving you feedback about your biology. And I remember thinking, what else can I do with my mind? I can heat my hands. What other things can I do with my mind?

– [Zubin] Anything.

– [Rachel] And that’s what we, that’s what we want for people living with chronic pain in particular.

– [Zubin] That’s such an awesome story. Oh my gosh.

– [Rachel] Biofeedback.

– [Zubin] And you think about, like, you think about monks that are able to light themselves on fire , and you know, yeah. It’s some crazy stuff that’s done in.

– [Rachel] It sounds like pseudoscience, and it’s real.

– [Zubin] It sounds like pseudoscience, but I’m telling you it’s not. And, and it’s absolutely real. And that story is absolutely beautiful because that power of suggestion, I mean, we do it all day. You can visualize a strawberry in front of you and see a strawberry. You can taste a strawberry if you were, if you remember, I mean.

– [Rachel] Yeah.

– [Zubin] We are these very complex dynamic fields of intelligence that can do these things.

– [Rachel] That’s right.

– [Zubin] But we, even just say, just what I just said, someone’s gonna be like, oh, that sounds like, you know, woo, woo, woo, woo. But yeah, it works. So that’s all I care about.

– [Rachel] Yeah.

– [Zubin] Does it work?

– [Rachel] That’s why I recommend biofeedback to people now. Like, you don’t have to believe my story, but you can go if you want and learn how to warm your hands. And when I teach it to my patients, they say, especially the kids they say, I can make fireballs with my hands. What else can I do with my mind? And I’m like, that’s right. Now, let’s heal your leg, you know.

– [Zubin] Oh, that’s awesome.

– [Rachel] Yeah, that’s right.

– [Zubin] Yeah.

– [Rachel] Totally.

– [Zubin] Biofeedback. I’ve never tried it directly. Now I really wanna go see Pepper.

– [Rachel] Just try it for your neck.

– [Zubin] Maybe we’ll do a show. Yeah, for the neck, yeah.

– [Rachel] Yeah, you can–

– [Zubin] By the way, my neck feels great right now.

– [Rachel] Oh, I’m so glad.

– [Zubin] What is it?

– [Rachel] It’s magic.

– [Zubin] It is magic.

– [Rachel] It’s voodoo.

– [Zubin] It might also be–

– [Rachel] Maybe you’re distracted.

– [Zubin] I got a crazy roller ball with like spikes on it and I’ll like, I get petechiae in my back from using this thing. Like little, little blister, not blisters little under the skin blood things.

– [Rachel] Oh wow.

– [Zubin] Because it’s that intense, but boy, it feels great.

– [Rachel] Good.

– [Zubin] And then the things go away.

– [Rachel] Yeah, I am all, by the way, I am all about PT for chronic pain. PT is like phenomenal. Like the physical therapists that I work with sometimes work magic.

– [Zubin] Yeah. Because again, they’re, they’re working the somatic angle of it.

– [Rachel] I recently was seeing a teenager with complex regional pain syndrome. He had been misdiagnosed. He had been in bed for about two years. He couldn’t really walk. Complex regional pain syndrome is this chronic pain syndrome characterized by a bunch of things. It’s changes in skin temperature. The skin can turn a really hot or cold, and the leg can turn red or purple . It can, it can swell.

– [Zubin] Physical manifestations.

– [Rachel] Correct. And it’s like this chronic pain condition. So pain lasts for many months. He was getting IVIG infusions. He had a number of other underlying medical conditions as well. He had never seen a psychologist because why would you send someone with pain to a psychologist? There’s so much stigma around that. Nobody even thinks of that. But we correctly, correctly diagnosed him with CRPS. He started doing CBT. I sent him to a PT in Sonora because she is amazing. Her name’s Katelyn Fritz. She’s an absolute magician. And within a month we were seeing dramatic changes in his skin. Like the skin color was going back to normal. Motor functioning was returning. Pain level was reducing. And like within two or three months, he was back to life. And he’s now working as a, a lifeguard at a swimming pool. I mean, like what I’m trying to say is it’s remarkable. These chronic pain conditions are real. They’re not, they’re not made up. They’re not emotional. And treatment with PT and CBT can be remarkably effective.

– [Zubin] Remarkable. One thing I’d want to say is some people who’ve tried this and say it doesn’t work for me. You may want to try another provider. Yeah.

– [Rachel] Yeah, that’s right. That’s right. Not all providers. I mean, that’s a major issue that you brought up before. A lot of physicians are not trained in pain. A lot of psychologists, most of us are not trained in pain.

– [Zubin] Right.

– [Rachel] A lot of PTs and OTs, believe it or not, are not trained in pain. Like you’re trained that pain is a biomechanical, biomedical problem. And science and research says that it’s not. So, so what I would say is if you’ve been seeing providers who are seeing it in this sort of like, what you feel is maybe a narrow perspective, go and see if you can find PT, OT, psychologist, who, or physician who sees it in a more holistic or broader capacity.

– [Zubin] Yeah. I think that’s great advice.

– [Rachel] Yeah.

– [Zubin] So I think we did a bunch of things today.

– [Rachel] We did a lot. We covered a lot.

– [Zubin] We did.

– [Rachel] Yeah.

– [Zubin] You’re awesome.

– [Rachel] You’re awesome. We did to cover a lot more, I feel.

– [Zubin] Well that means we’ll have to do another show.

– [Rachel] Great.

– [Zubin] Yeah. If you’re willing to do it.

– [Rachel] I’m going to have to get over my performance anxiety and the urge to cancel, but sure.

– [Zubin] Yeah. I mean, I guess like positive feedback, whatever helps with that, because the last time your episode got so much positive feedback.

– [Rachel] Yeah, that was really, I was really glad to hear that it was helpful for people.

– [Zubin] Yeah. They really, really got a lot, and speaking of which, I’m gonna pitch your book one more time here. “The Pain Management Workbook”. We’ll put a link up there and this thing is great because it really does kind of summarize a lot of the stuff with action items.

– [Rachel] Yeah.

– [Zubin] And it’s a workbook. So you work with it, you actually do stuff. Which is awesome.

– [Rachel] And also, I also wanted to make sure there was something that you could put in the, like if you’re working with somebody who doesn’t know about pain, that’s a solvable problem. Like if you like your therapist, but they don’t know about pain or you like your doctor and they don’t, just hand them the workbook and you can do it with them.

– [Zubin] Like a hare Krishna, just like at an airport. Just hand them this.

– [Rachel] Exactly.

– [Zubin] Go read this.

– [Rachel] Exactly like a Hare Krishna.

– [Zubin] The Krishna. I, you know, I have, my mind doesn’t work right. I just saw “Airplane” too, the original movie again. And the Hare Krishna scenes are hilarious, but.

– [Rachel] It’s just on your mind.

– [Zubin] It’s on my mind.

– [Rachel] Got it.

– [Zubin] By the way, every time you talked about these kind of like, like Dr. Pepper and these guys doing this crazy research with electrodes, I just kept flashing in my mind to Ghostbusters where Dr. Peter Venkman is doing those like ESP experiments on the guy.

– [Rachel] What’s his name? Yeah.

– [Zubin] Yeah, yeah, Rick Moranis.

– [Rachel] Yeah.

– [Zubin] Yeah, yeah, yeah, and he’s, ow. He gets electroshock. And then the, the dean of like the whole institution kicks him out of his lab. And he’s like, Dr. Venkman, your research methods are the worst kind of pseudoscience. You sir are a poor scientist.

– [Rachel] Oh, I remember that scene so well.

– [Zubin] And you know what’s funny, that sent me down the path to exquisite amounts of reductionism in science. I was like, well, anything that, you know, doesn’t clearly isn’t in the Western biomedical model is pseudoscience. And I’m like, he was talking about ESP, okay. That’s a real thing. Or I have no idea if ESP’s real, but biofeedback is.

– [Rachel] Biofeedback is real.

– [Zubin] So we need to be less about you, sir are a poor scientist, except when you are a poor scientist, you know who I’m looking at, everyone on the COVID non-vax side. I had to get that in.

– [Rachel] Oh, no, please get that in.

– [Zubin] Yeah, yeah.

– [Rachel] I support you.

– [Zubin] It’s, two words.

– [Rachel] I just can’t.

– [Zubin] Delta.

– [Rachel] That’s one word.

– [Zubin] Shit. God. Okay, don’t listen to me. Guys, this was so much fun, Rachel, thank you.

– [Rachel] So much fun.

– [Zubin] Thank you, thank you. Share the show. All that other stuff, become a supporter and join our tribe and we do lives and stuff. And, oh, there’s something else. Please subscribe to the channel if you’re on YouTube, because that really just helps us get our word out. Just click the subscription button. It’s free. And the little notification bell so that you get like notified when we do stuff, because we’re going to keep talking about crazy stuff like this cause it’s important. Rachel, Hare Krishna.

– [Rachel] Thank you for having me.

– [Zubin] Namaste.

– [Rachel] So much fun.

– [Rachel] All those languages.

– [Zubin] And we out, peace.