Unpacking: The Psychology of Pain

Holly: 00:00:00

Since you've already set up the definition of pain, we started to look at why we even have to deal with pain, the difference between acute pain and chronic pain, and how chronic pain changes and fluctuates. And you did a great job of defining that for us. So we're kind of in the right playground, if you will.

But now I want to really start getting out that pail and that shovel and start excavating and digging together.

Intro: 00:00:31

Welcome to Unpacking Pain, a podcast dedicated to understanding the complexities of chronic pain, what causes it, how it affects our lives, and what we can do about it.

Join doctor of physical therapy and pain science researcher Dr. Megan Steele and me, Holly Osborne, a chronic pain sufferer, as together we explore the biological, psychological, and social aspects of chronic pain and create community and understanding in the process what is the impact that chronic pain has on our body and or our mind? And I don't just mean at the sight of pain.

So if my shoulder is the ongoing problem, what is happening to the rest of my body as that pain just keeps on going week in and week out and month in and month out? Is my brain changing? I've read that. I want to know all about that. Is my body? Am I causing hurts in other areas?

Does my back hurt because my shoulder hurt? Like, help us understand sort of what goes on when pain becomes chronic and the rest of the system?

Megan: 00:01:50

Sure, absolutely.

And I think that's a really great question, in part because it's so commonly experienced by people in chronic pain and it's more well understood in terms of the biological treatments of chronic pain.

But just like anything, when we find something that is at least partly behind a problem as massive as chronic pain, sometimes it gets kind of distilled and boiled down. And then we say, okay, well, everything is just because of this little thing we like to call central sensitization.

Holly: 00:02:28

Central sensitization, yes.

Megan: 00:02:31

And that is kind of the catch. All term for your nervous system now is at a heightened level, and it encompasses a lot of different things.

The first thing that oftentimes people will notice is that their pain goes from a smaller area to a larger area, or it starts to spread or peripheralize, we call it. So if you had maybe pain in your back, then it starts to maybe go down into your buttocks, then it maybe starts to go down into your leg.

That's a form of peripheralizing or spreading of a pain signal.

Holly: 00:03:09

Okay.

Megan: 00:03:10

And oftentimes are attributed to central sensitization. And part of it is your peripheral nervous system in those situations starts to Become more sensitized. The fact that there are inflammatory.

We call it like an inflammatory soup around things that have had an injury make the nervous system more sensitized.

Because if we remember from episode one that the purpose of pain is to protect us, and if our body is sensing something that we need to be aware of, it's going to sound the warning signal, sound the alarm, and let us know. Right.

And so our nervous system is sounding the alarm, and then over time, it gets better at sounding that alarm, in part because of the way that our nervous system and our brains are designed, which is to learn information.

And even some of that information is associatively learned, not learned on a cognitive level, but it's learned that, you know, I don't touch that hot stove. Right. Because that's going to harm me. Yeah. When.

When certain chemicals are circulating in certain areas of the body, that's our nervous system's signal to sound the alarm. Something's going on here. Something's going on here. And over time, it actually also causes structural changes to the nerve.

So you'll see areas where nerves have been irritated for a long time. They have less myelin, that fatty sheath around the nerve that helps it conduct the nerve signal more quickly.

As that starts to wear down and break down in certain areas, that makes that nerve more sensitized.

And once that inflammatory soup is out of the area and you're not constantly re aggravating or re irritating that nerve, that myelin sheath has the ability to grow back. But as we talked about in chronic pain states, that doesn't always happen. So peripherally, you see changes at the nerve.

You also see changes where that nerve meets your spinal cord.

So we call it the dorsal horn of your spinal cord, where the sensory nerves come into your spinal cord, that actually becomes more sensitized as well. So we see spreading of the ability for these signals to come into the spinal cord.

So it makes it easier for your body to send these sensory information, information signals up through your spinal cord up to your brain.

Holly: 00:05:37

I see.

Megan: 00:05:38

We used to call them pain pathways, but know that they're nerve pathways, but we can't really call them pain pathways because it's not really pain until it gets up to your brain, until it's interpreted by your brain.

Holly: 00:05:54

I see.

Megan: 00:05:55

So I like to give people the example of the tag in the back of your shirt. So if you reach back in your shirt, do you notice if there's a tag in the back of your shirt right now?

Holly: 00:06:07

Yeah.

Megan: 00:06:07

Yeah. Were you aware of it before? I asked you to reach for it. No, no. So you're. That doesn't mean that your brain wasn't getting the signal.

There's a tag in the back of your shirt. There's a tag in the back of your shirt. There's a tag in the back of your shirt.

But your brain has seen and felt that enough times and recognized it as not a threat enough times that your brain is automatically doing the work of don't care. A threat to me. Don't care, not a threat to me. Move on. I have a podcast to do.

Holly: 00:06:35

Right, right.

Megan: 00:06:37

That's not my problem. I don't need that. And that's what we call descending inhibition.

And so I'm constantly getting signals coming up from my body and I'm also having signals that go down from my brain to my body that are saying not my problem, not a threat to me. I don't need to worry about that. And that's where, um, a lot of people with chronic pain also struggle.

They, they lack that descending inhibition or it's not as strong.

And we see this especially in female populations or in women because of the way our brains are a little bit different and the way we process things is a little bit different. Um, and that's probably, we don't know a hundred percent, but more likely why 70% of the people that suffer with chronic pain are women.

Holly: 00:07:28

That is in. Okay, now we're starting to really get into something fascinating because I'm wondering if women are also more in. I know this, guys.

I don't mean to leave you out of the equation, but I think in general studies show and confirm that women are more in tune with their own feelings, their own bodies. They might have a heightened awareness even just about moving through a cycle. You know, if they're still at an age where menstruation is happening.

And so we're, we're sort of trained almost or we train ourselves from a younger age to start noticing, ah, that feels like PMS coming. Oh, I can tell that I'm on the verge of crying and I don't know why. And, and so would you say that that's, that's part of what's happening is we're.

Women are not just in, in our brains wired for, but also socially even sort of encouraged to look after ourselves a little bit that make us more hyper aware than men?

Megan: 00:08:30

Possibly. But we also know that hormones play a role.

Ah, and that was some of the research that was going on with those transgenic mice with was the hormonal component. And so the Research in humans right now is not very clear.

So some of the research is showing us that estrogen increases pain perception, and some of the research is showing us that estrogen decreases pain perception.

Holly: 00:08:57

Okay.

Megan: 00:08:58

It's not really clear, but we do know that women and men, or boys and girls until puberty have similar pain thresholds. And so it's that change at puberty where women start to demonstrate a decrease in pain threshold.

Holly: 00:09:16

Wow.

Megan: 00:09:16

Okay. Most women are diagnosed with a chronic pain condition at or around menopause.

And so we know these two bookends of significant hormonal changes have a large effect on women and their presentation with pain. So really fascinating area of research. It's part of why I chose to do research on women only because there isn't enough of it, number one.

And there is something there. There's. There's a reason why 70% of the people who suffer from chronic pain are women.

And, and maybe it has to do with the fact that we're more in tune with our bodies or we're more aware. There's interesting research. We call that interoception. And that's one of, one of the other areas of research that I work in.

And they're again, kind of the bookends of that. So people who have a super heightened aw of everything that's going on in their body tend more towards chronic pain.

And people who have almost no awareness or have a very difficult time verbalizing or expressing or understanding the things that are going on in their body tend more towards chronic pain.

So it seems that people on either end of the spectrum have a harder time versus people in the middle that, you know, get sensations from their body, interpret them appropriately, have a fair amount of awareness, but aren't hyper vigilant. Those people tend to tend less towards chronic pain.

Holly: 00:10:57

Okay, so there's so much already in our own physiology that's happening whether we want it to or not, in terms of hormone fluctuation. There are all kinds of things that we can't really control.

And it was fascinating to hear you talk about how the nervous system changes and how the actual makeup and quality of a nerve changes over time and kind of loses. Loses some of its ability really to kind of push back on a pain signal. So, okay, that's the nervous system.

What about this idea that my brain is changing? Like what, what is that about? When I read that, I have to say that I saw some part of myself in that, which I'm happy to share about.

But first, just introduce us to notion of what pain is doing to the brain over time when it becomes chronic.

Megan: 00:11:55

Sure, yeah.

So some of the neurochemical changes or the changes in neurotransmitters affect mood and emotion, which we're going to talk about, I think, in our next episode. We also actually see structural changes to our brains. And this has to do with the fact that our brains are plastic and are always changing.

And so with people in chronic pain, what we see is decrease gray matter in certain areas of our brain and decrease connectivity in other areas of our brain. And that's thought to be in part because when I have chronic pain, I'm firing a synapse over and over and over again.

So our brains are made up of billions and billions of synapses, and we're meant to go over here a bit and over here and here and here and here and here. And what happens when I'm in chronic pain is I fire this synapse over and over and over and over and over again. Am I going to have pain?

Is it going to be bad? I feel it. How much do I feel it? Where do I feel it? Where is it going? Where is it coming from? What's it going to be like?

Today I'm really kind of focus, focus, focus, focusing on that pain because I need to, because it's, it's keeping me alive, it's keeping me safe in some cases. And so what happens around that is those other synapses die off. You've probably heard the saying, if you don't use it, you lose it.

Holly: 00:13:21

Yes. Yeah.

Megan: 00:13:22

That has to.

Holly: 00:13:23

Oh, don't tell me. My brain, like, am I losing brain matter because of my, my constant synaptic firing around pain?

Megan: 00:13:32

Well, you may have during the period that you were really suffering.

Holly: 00:13:36

Okay.

Megan: 00:13:37

Like I said, the great news is as long as you're breathing oxygen, your brain can change. So you can start to grow new synapses and connect new areas as you start to come out of that and you have less of a focus on your symptoms.

And so where we do see an increase in activity, so we see a decrease in activity in our frontal lobe, which is executive functioning, Decreased activity in our hippocampus, which is memory and emotion regulation.

Holly: 00:14:09

Okay.

Megan: 00:14:10

And so things like, you know, remembering your exercises that you got from physical therapy. Yeah. Remembering that you have a physical therapy appointment.

Those types of things can be challenging because I'm sort of dealing with this higher level thing that's always got my. A certain level of my attention, which is my physical pain. Right. And so what we find is the area of the Brain in the very center.

It's in our subconscious area of our brain called our amygdala, which we used to think of as the fear center of our brain. But we've learned more about that of late, and now we recognize that to be more of a threat detection center.

Holly: 00:14:54

Is that the part that we call the reptilian brain? Is that the same thing?

Megan: 00:15:00

It is, yeah. So it's. It's more reflexive, it's less conscious.

We don't like, you know, kind of the deeper brain centers we think about as older aspects of our brain and the more, farther out brain centers we think of as newer or the neocortex. And some of that is a misnomer, but it's not terribly important. But it is less. We're less consciously aware of it most often.

And so it's firing in a way that we don't have a conscious awareness of more often than not.

And so, again, this area of our brain that's meant to keep us safe, that's meant to detect threats, is firing, firing, firing, firing more often than somebody without chronic pain. And so that's telling my nervous system to send a signal more often and to interpret more things as threats. Wow.

Holly: 00:16:03

I mean, it's starting to make sense around this vicious cycle that it's, It's. It's tough for a lot of people living with chronic pain to get out of it because you can't help but anticipate the pain.

Megan: 00:16:18

You.

Holly: 00:16:18

You know it so well. I mean, it's. It's like for anyone who's. Who's listening, you. You may see yourself in this.

When I say, it's almost like you have another person in your. It's like a twin, a shadow self. That's an interesting. Yeah. In fact, I. You guys. My husband even said.

We were in couples therapy a couple of years ago talking about this, and he said, you know, there's a third person and I were on our relationship, and I was like, excuse me, like, I was not prepared for this in therapy. And what he was talking about was actually my. My pain body or sort of my pain self. And he wasn't saying it in a way that was hurtful by any stretch.

He was talking about the need to care for that whole aspect of me.

And I, you know, I really think that's true, that we almost develop a relationship with our pain because it becomes an inner voice that you cannot ignore.

And it's involuntarily letting you know when you see something slippery, when you get invited to a party and you're thinking, I can't stay up dancing until 1 o' clock in the morning like everybody else. It, it's showing up all the time.

You can walk into a bank and sit down in a chair and realize this chair is bad for me and I'm going to be stuck here waiting for a banker for 20 minutes and I can't be in this chair. So the fact that it's always going, going, going, it's like you can't get away from it.

Are we almost feeding our own pain or are we setting ourselves up in a way to kind of be in pain? Because we're always anticipating it sometimes and.

Megan: 00:17:59

Most often you're not aware of it.

Yeah, that's part of my practice and what has informed my research, which is bringing some of that subconscious protection up to your conscious awareness. Because when you're not aware of it. Shout out to Carl Jung for this one. Yeah, when you're not aware of it, you can't work on it, right?

Holly: 00:18:23

Yes, yes.

Megan: 00:18:24

Till I bring my subconscious to my conscious, I'll just call it fate or I'll call it life. I'll call it oops. You know, my, my waves of pain that I have no way of predicting or, yeah, controlling.

And that's one of my favorite aspects of my practice is helping people to understand, number one, you're not crazy. Yeah, things really are happening and they really are changing the way that you are interpreting and sensing what's going on in your body.

And number two, this is a solvable problem.

Holly: 00:19:01

So there's, it's interesting to hear that we might actually be able to turn a subconscious process into something we're conscious of. And I wonder if for some people that feels at first counterintuitive.

Like, no, I want to think about my pain less, I want to give my pain less attention. But in reality it's almost like I'm trying to think of, you know, a child that isn't going to be ignored. Right.

You, you can turn your back on that screaming two year old that is like unlikely to change the fact that they're upset and dysregulated.

And so in a way, while we're trying to shove our pain down and sort of, you know, tough it out and push through in a way, we're almost separating ourselves from what could be a really healthy recognition process where we, we go ahead and bring it to the forefront and we say, hello, warning signal. Like, I hear you, thank you. Let's be in conversation about this. Like, do you, do you see that that can actually help.

Then how does it help us manage our chronic pain?

Megan: 00:20:08

Absolutely. Yeah. And it's one of those. It is a very counterintuitive thing to think about.

As, you know, people in chronic pain will tell you I'm never not aware of it, that I do do things to distract myself. And one of the keys to me, when people tell me about their symptom pattern is when people say, oh, it's always worse at night.

Holly: 00:20:31

Oh, is there less going on?

Megan: 00:20:33

Yes. When I'm trying to go to sleep, when I'm. When I'm shutting down, when I'm trying to. And then it starts to sound warning, warning, warning.

And in part because I think that when I'm, you know, working during the day or I'm taking care of my kids or I'm lifing. Yeah. It's almost like I've taken that smoke alarm off of the wall and I've put it under six blankets. It's still going off and it's still.

Holly: 00:20:58

A little bit in the ground.

Megan: 00:21:00

But I can go on with my life because I have to. Right. A lot of us don't have the option to say, I'm going to stay in bed today. Right, right.

And so then you go into bed and you've put that fire alarm back on or smoke alarm back on the wall, and now it's really starting to talk to you. And so the counterintuitive thing is. Yes, to not go away from the pain, but actually go towards it and reinterpret the signals. So sometimes people.

This can be very scary for people to say, wait a minute, you want me to tune into my pain? You want me to tune into my symptoms. That terrifying. And I understand that. And it can be.

And so a lot of times we'll take a very graded exposure approach.

So we'll find out where is the place that you feel the best, that you feel the safest, that you feel warm and cozy and happy and loved and all of those things.

And we'll have that in our back pocket and we'll say, okay, we're going to dip a toe into observing and following the sensations that are going on in your body. And then when it gets to be too much, we go back to Hawaii, we go to Wisconsin in the mountains, we go to wherever it is that you feel great.

We go to your bed, we go to your bathtub.

Holly: 00:22:18

Right.

Megan: 00:22:19

The great news is you don't actually have to go there. You can visualize it. Yeah. But when I first ask people to observe and follow and go towards their pain. It can be a very scary thing.

And it's that counterintuitive thing of like, wait, you want me to go towards something that feels terrible that I'm constantly aware of? Right.

That is how you start to bring it to the conscious awareness and recognize what are maybe some of those non biological triggers that you're brain has associatively learned or connected with that threat detection. So really? Oh, go ahead.

Holly: 00:23:00

Oh, no, no, please. I've got 800 questions. So like, yeah, you keep going.

Megan: 00:23:06

There's really interesting research on people with chronic pain who are artists and Frida Kahlo is a great example of this. Yes. Ask people to draw themselves as a self portrait. Yeah. They will omit the part where they have chronic pain.

Holly: 00:23:25

Whoa.

Megan: 00:23:26

And so Frida Kahlo is someone that had a lot of spine and leg pain and her legs are almost always covered or changed in some way. They're either like behind something or I have a patient who is an artist who's drawn herself without her arm. She draws it like it's behind her.

Holly: 00:23:46

Oh, wow.

Megan: 00:23:47

She'll paint it that way. Yeah. So that is so fascinating. So like you say, we do kind of. There is a bit of a protection mechanism where I've kind of disconnected myself.

And you'll also hear it in the language that people use. They'll say, oh, that back.

Holly: 00:24:05

Yes. Or the knee that don't necking up again. Yes.

Megan: 00:24:10

As opposed to my back or my knee. I've. I've separated myself from it.

Holly: 00:24:16

You know, it's. I'm so glad you brought up Frida and art also.

Not only do I love her so much and find her inspiring, but her illustrations, her painting and drawing around her body and her brokenness is fascinating because you're right that she, you know, maybe she shied away from it at first, so she was kind of covering up certain parts of her body. And then she did what maybe you're encouraging now, which is to start owning that quote, unquote brokenness.

Like, I'm thinking of these images that she created around her. What was that that she wore?

Now, I know this isn't an art history podcast, but she, she wore a supportive corset, not for aesthetic purposes, but to sort of hold herself together. Yeah.

And I just, I'm heartbroken by and inspired and love the art where you see, you know, it's like a pierced heart through that armor and just that vulnerability.

And it's almost like it took her getting to the point where she could really just paint her heart out around that pain and that brokenness that kind of spurred her life forward and kept her going. And so we can. It's almost like the Tale of Two Cities or the tape. Right.

Like, we can, you know, metaphorically cover that part of ourselves and try to distance from it and hear its echoes knocking anyway and be bandied about by it on the good days and bad days. And why, you know, why is that knee going again? Or it's something that we can lean into a little bit more.

Megan: 00:25:56

What.

Holly: 00:25:57

What kind of conversations? Like, are you encouraging us from a practical matter to even maybe talk to our pain?

Like, I mean, I was taught to do that with my anxiety and fear at times where it was like, you know, you want to say hello, fear? Thank you for being here today. You know, I'm not mad at you for being here. You have a role to play, and you're here to protect me and thank you.

So without going into my whole psychobabble, you know, details like, what would that look like for someone or sound like for someone to kind of meet their pain and welcome that subconscious.

Megan: 00:26:35

Yeah. So I would encourage people less to talk to their pain, at least in the beginning.

But something that's known to you, that works for you, by all means, give it a shot. I'd say the side effect profile. Profile is pretty low. Yeah. But what I would encourage would be a version of somatic tracking and so trucking. Yes.

You would either lie down or sit down and observe and follow the sensations that are happening in your body at any given moment. It's hard. I will say this. It's very difficult when you're in a flare and when things are intense.

So it's a great thing to practice in the short term when things are feeling good.

Holly: 00:27:21

Okay.

Megan: 00:27:22

As you either sit down or lie down and you just sort of do a body scan. And you can do this with a guided meditation. There are so many.

I just, you know, usually recommend YouTube to people because it's free and easy and a way to kind of systematically go through your body and observe. Yeah. Then you sort of observe neutral sensations. So do I feel my bottom on the chair? Do I feel my back against the bed?

Do I feel a grumble in my tummy? Those types of sensations.

And then you could go to pleasant sensations like, oh, I feel the air coming in and out of my body with ease, or I feel the coolness of the air coming in through my nose or mouth. Those types of things. And then as that gets better, then you start to notice some of the less pleasant Sensations.

And again, you're just going to go into those sensations and then come back out in the short term as you're starting to say, okay, this is interesting. I like to say you said tale of two cities, maybe I would say tale of two bodies. Right. I like to say you're kind of bringing it back into the fold.

You're saying this is my knee.

And then like you mentioned, kind of reinterpreting those signals rather than saying, oh my gosh, this is that again, it's going to be all encompassing. I'm not going to be able to do xyz. It's for weeks. This is the. Another flare.

I can start to challenge some of those assumptions and I can start to challenge some of the meaning that I've made around that. So I could say, oh, this is my body sending the warning signals. Again, this is my body protecting me. Thank you so much, I appreciate that.

Just kind of like what you were saying with your emotional states recognizing that its purpose is not to signal damage, but to let you know, hey, something's different over here. Something is asking for your attention. And sometimes just the act of giving it attention can cause it to shift and change.

Holly: 00:29:39

And sometimes we can't do that for ourselves.

It's like we need someone else either to, you know, through hands on or like I've noticed even over the course of body work, in one session of body work that the pain moved, right. We started in one place thinking, you know, we were here and then we ended up, you know, in the lower back just in the course of that.

So that, you know, that's, that's really interesting how it just sort of makes space for it to actually start, you know, kind of flushing or, you know, to, to be recognized, I guess rather than ignored. When I ignore my pain, it is like that two year old in a tantrum. It gets louder, it gets redder, you know, just.

I see it as like the red screaming face. But I, I want to go back also to a word that you mentioned that I think is really fascinating around all of this, which is fearful.

And because that, you know, what we're talking about is that that fear of going into a scenario that we're not going to be able to fulfill, going, you know, into life, you know, like travel's coming up. How am I going to get through the airport? I'm not in a position to ask for a wheelchair, but man, is it going to be challenging to get from A to B.

Are we more fearful once we've been living with chronic pain like does or is it that we just are more practical because we know what hurts and we know our limits.

Megan: 00:31:16

There's a spectrum, right?

And so there are people that are going to plan their vacation to a T, because I need the lay flat seat and I need to make sure the elevator is working in the hotel and I need to make sure the terminal is not too far away and all of these things. Right? And then there are people that say, okay, yeah, it's probably going to be annoying, but I'll manage it. Or, you know, and.

And by and large, fear is the most frequently studied component of chronic pain. When we think about the biopsychosocial model and what emotions are most often studied, at least I'd say the last probably 15 years. 10, 15 years.

And that's in part because we recognize that the amygdala and the threat detection center through fmris are areas that light up consistently in people with chronic pain. And so then it was thought to be, oh, is this just a fear response?

Which is really, again, just kind of a distilling and oversimplification of what's truly going on. But there are people that will have a lot of fear that will contribute to increased pain perception.

And again, it's putting your nervous system on alert, right? You're saying to your nervous system, okay, what's going on here? We're constantly scanning, we're constantly ready.

Anything that looks like it could be a threat, I'm going to sound that alarm saying that to an already sensitized nervous system. So those are. That is a feedback loop that can be very challenging to overcome, but again, not impossible.

And so part of the reframing is, okay, I'm recognizing I'm having a lot of fear about this. I'm thinking about all the possible scenarios. Could I think about this going well? Okay. And that's.

Once I've established a relationship with someone and I've been working with them for a few visits, I like to start to shift our thinking and our talking about less about what's going on now and more about where we're going and what we're going towards. Because I'm not. I don't ask about pain.

This is a funny kind of another paradoxical thing that a pain science researcher and physical therapist would not ask someone, what's your pain number? Every eight and Right. Because I don't want to redirect you to your pain every single day and every single session. Oh, I ask, what's new?

Holly: 00:34:00

What's different?

Megan: 00:34:00

What's the same?

Holly: 00:34:02

Oh, that's interesting.

Megan: 00:34:04

Or I ask about your crazy neighbor. How are they doing still? Yeah, interesting. Let's talk about it. Let's get on the table and let's get to work. Right.

I'm not constantly redirecting you to your pain. I want you to be thinking about those other synapses about. So you are going to go on that vacation. That's going to be awesome.

Tell me about what you have planned. And you're going to go to your son's tennis match. That's really exciting.

Have you ever thought about getting back on the court and hitting balls together? That's a good goal. Let's think about working towards that, those types of things, so that we're really focusing on the other aspects of life.

Not to ignore what we're doing here, but to recognize that there are other possibilities.

Holly: 00:34:49

So this is going to sound. Well, you. You tell me how it sounds, or others can comment and let us know how this sounds.

Might sound a little bit wackadoodle, but I'm wondering if that fear component that you're describing, in a way, has made me and maybe some others out there, if you recognize yourself in this, almost hold on to the pain a little bit more. It's like a security blanket.

Because for a moment there, Dr. Megan, when you said, I want to get you thinking about what's coming about, you know, maybe. Maybe you will get back on the pickleball court. Maybe you will, you know, be able to make it all the way through to an evening of dancing.

There's part of me that wants to say, whether it's you're saying that or my husband's saying that, or the, you know, cruise director of the vacation saying that I want say, well, but hold on. I know. I don't know if I can hold, but you're taking. You're almost taking my safety away. I'm not there yet. I. I'm not in a safe place.

My brain is pulling me back. And in a way, I'm wondering if that becomes like a safety blanket that stops serving me.

It's like I'm holding on to it because I think it's going to keep me protected. And I'm worried. Well, you know, if I go off to this, you know, this. This event, no one there is going to be protecting me.

I have to be thinking about whether I'm gonna get knocked around or, you know, be up too late or whatever it is.

And I wonder sometimes, Dr. Megan, if, like, I'm actually gripping on to it almost like a narrative, like you know, I am broken, I am in pain, I have a bad.

Megan: 00:36:42

This.

Holly: 00:36:42

I have a. And you hear it all the time where it's like, oh, hey, are you going to go ax throwing with the team?

Or you know, hey, did you stick around for that last drink last night? And you'll hear people say like, oh, not with my knee, or not with the migraines I've been having.

And you wonder if they even gave themselves a chance to do it. A lot of times I don't. So does sometimes our fear narrative actually keep us stuck in a pain place?

Megan: 00:37:11

It can, absolutely.

And I think that's a hard thing to navigate with people because if I say that the way that you just said it and you did it very eloquently, but it can sound like this is your fault. Right. And then I'm putting the onus back on you to say, well, if you would just stop with that narrative. Right, right.

But again, you probably didn't realize, and most people probably don't realize that they are in that pain narrative. And so again, bringing that up to conscious awareness of what are the fears around this? What are the beliefs around this?

And can we start to challenge those? You know, I hear all the time, oh, well, we have bad backs in our family, or yeah, you have arthritis or those types of things.

And yes, but are there, are there family members for which that is not true. And oftentimes there are. Right. And so it's not a hard and fast. We know that genetics play a role, but it's not the whole picture.

So bringing some of that up to conscious awareness so that we can work on it is a really big part of it. I didn't realize I was holding on to so much fear. I didn't realize I was over protecting myself in a way. And again, think about the purpose of pain.

The purpose of pain is to protect us. It's to keep us safe. And if we think about the purpose of emotions, we can think about them very similarly. Fear keeps me safe. Disgust keeps me safe.

If I eat something button, I have a disgust response and then I don't experience that again. Right, right. Joy brings me more towards the things that I want to go towards. And so there are some people. I know this is also very controversial.

So I don't want to go too deep into that, but let's.

Holly: 00:39:17

Let's get controversial.

Megan: 00:39:18

Yeah, that. That really talk about emotions as part of our protective mechanisms is, is also.

Holly: 00:39:29

I know this could even be a whole nother episode. But what about anxiety? Sort of the Cousin of fear, maybe as anxiety, and even then its second cousin, depression. Is it true? I mean, I've.

I've read or I've heard, but who knows, you know, based on sources these days, there's, like, a study for everything. There's a study that can, you know, prove or disprove anything.

Megan: 00:39:53

Sure.

Holly: 00:39:54

What about the sort of onset of depression? Is that one of the elements that comes in?

Like, can our brain chemistry actually change to the point where maybe mood is dysregulated, where it's not just fear?

Megan: 00:40:11

Yes. Yeah. And depression is more common in chronic pain, and chronic pain is more common in people who are depressed.

Holly: 00:40:19

Yes. Okay.

Megan: 00:40:21

So we don't know whether one begets the other or the other. We know that there's a correlation, but we don't know the causation in terms of depression. But in terms of anxiety, the fear component is part of it.

Let's just speak to the anxiety.

There are multiple different types of anxiety, but one type of anxiety is anxiety that comes from the body, from signals from our body that are either misinterpreted or not fully understood, and that can contribute to an anxiety piece. And that's really what I work on in my practice with people, is, okay, you're having a sensation from your body.

Let's observe it and follow it and see how you're interpreting that.

Because, again, bringing that to conscious awareness and challenging some of those beliefs can be really powerful ways of shifting that, and not just shifting that in the moment for us, but shifting it with practice over the long term.

Holly: 00:41:26

I wonder if sometimes people are not ready to give up their pain because there is a. An unresolved element to the pain, such as maybe a trauma or a trauma echo.

Like, the pain reminds them of a trauma they experienced maybe as a child or what have you. And so that requires deeper digging that maybe they're not ready to do.

Megan: 00:41:55

So.

Holly: 00:41:56

There could be that, you know, piece of it. And then I think there's also an element. I'll.

I'll be really, really honest, Dr. Megan, that there have been times where I felt like I'm not ready to be asked to be a full participant in life yet just because I want to be. I'm not there yet. Like, I've been protecting myself for 26 years now.

And if you just suddenly came along and waved a magic wand and took all my pain away, yes, I'd feel incredible. But I might not even recognize myself.

I might say I'm not even ready to be that person yet, because that person is going to get back in the pool and start doing laps again. She's going to play tennis again. She's going to.

And I've actually, you know, like, a lot of people in pain have carved out a different kind of life for myself.

Rather than, you know, running half marathons or playing hours and hours of tennis on a Sunday, you know, maybe I'm learning to brew my own beer, or I'm. Right, I'm. I'm in a poetry class or I'm. What have you. So we learn to kind of tap into other areas of our lives.

It's, like, scary to all of a sudden think of, like, oh, my gosh, this thing that I've been thinking about in, you know, protecting myself around, and it's been my narrative for all these years. Like, now it's just. Just gone. And who am I? So do you see, you know, either. Either parts of that sort of where people kind of hold on a little bit?

Megan: 00:43:21

Absolutely. We see that on the way in and on the way out.

Because the thing about chronic pain, if I'm someone that was very active, very athletic, very involved in some physical pursuit or like, just, you know, I worked 14 hours a day or whatever it was.

Holly: 00:43:40

Right.

Megan: 00:43:41

That's how I identified myself, and that's who I was. And then if I have chronic pain for a long time, this is who I am now. And if you're telling me things can be different, that can be very threatening.

Holly: 00:43:57

Yes.

Megan: 00:43:57

You're telling me, oh, I want you to get back to tennis, and I want you to get back to pickleball, and I want you to get back to hiking hours and hours. Yeah, I see that for you. And that's great.

You know, that can be really, you know, a thing that's hard as a clinician to not want to help that person get to where they want to be. But also we have to recognize those things don't come overnight, you know?

Yeah, it's going to go from where I am today, where I spend most of my time at home and safe, and I really control my surroundings to keep myself safe. And then you're telling me I'm going to go all the way over here. No dice.

Holly: 00:44:36

Yeah.

Megan: 00:44:37

Over six months, over 12 months, you can start to expand. And what I oftentimes hear people say when they're in chronic pain is that my life has gotten very small. It's control.

Holly: 00:44:48

Yes.

Megan: 00:44:49

Right. The number of things that I am willing to do or that I feel capable of doing is pretty minimal.

Holly: 00:44:57

Right.

Megan: 00:44:57

And then as I'm coming out of Pain. People often say my life is expanding, I'm meeting these new people, I'm doing these new things. All of a sudden I'm in a dance class.

I know how I would do.

And yeah, I think activating somebody's threat detection center, when you say, when you try to go from 0 to 60 is much more likely than if you were to say, what could you do today? What could you try? What do you think would feel safe?

And if it's something as quote, unquote minimal, which I don't love that word, but if it's something as small, maybe as visualizing myself, go on a walk, could I do that once a day for four minutes? Could I scan my body and see how it feels once a day for five minutes? Right. Those are the places where you start and then you build on that.

And people say, oh my gosh, I can't believe my life before and I can't believe where I am now.

Holly: 00:46:08

Like shrink and expand. And it takes courage really to move through both. I mean, it takes a lot of courage to recognize where you can't play anymore.

Even if, you know, might not be permanent.

But particularly for people like you said, Dr. Megan, if, you know, they're used to being an athlete or they're used to someone who they prided themselves on working 14 hours a day or hey, I used to get on an airplane, plane and hit, you know, three time zones in one week. And that identity, it's. It's scary to lose that.

But it's also ironically, very scary to start widening your aperture again and looking around and saying, maybe I could go to that dance class. Maybe I, you know, can take that business trip to three cities in one week.

And I love what you're saying about like kind of, but we don't have to go from zero to 60 like that. Sorry, you're going to say something too.

Megan: 00:47:08

Well, that's okay. Yeah. Our nervous systems are wired for sameness.

Holly: 00:47:13

Uhhuh. Is this why I eat? Well, I be, I don't anymore, but I would be happy to eat the same burrito with the same six ingredients like every day.

I mean, maybe just cuz I'm wacky, but like is, is that where that's coming from? Because not like stay in the minutes.

Megan: 00:47:29

Yeah. Some people feel safer if they eat the same thing every day.

And some people feel safer if they take the same route to work every day or if do the same, you know, brush hair, brush teeth, wash face, go to bed, you know, like that order. Yeah, exactly. Our nervous systems are Wired for sameness. And. And so when you see things that are not the same, good or bad. Yeah. We go away from them.

Holly: 00:47:58

Huh.

Megan: 00:47:59

Often we go towards sameness. And you see just people who choose, like, dysfunctional relationships. Right. And you think, like, why are they doing this over and over again?

Because that's known to me. I will choose known to me, good or bad, over unknown.

Holly: 00:48:15

Wow. Yeah, that's. My dad always said, the devil you know versus the devil you don't know. That's so interesting. Yeah, I. I found myself and.

And I've heard from friends who've said, you know, I turned down, let's say, a ski weekend. You know, I just. I couldn't imagine myself being able to get comfortable in that scenario.

I knew everyone was going to be bombing down the mountain, and I wasn't. And so, you know, I bailed out of it. And what's interesting is that there was no halfway. There was no.

It's like an immediate safety door kind of drops shut, and it's like, well, the trip to Aspen is off. Rather than considering these sort of shades of gray that get us closer. I'm gonna go on this trip, but I'm gonna.

I'm not gonna get on the mountain or, you know, imagining kind of what baby steps would be to get there. Right.

Megan: 00:49:11

And like you say, sometimes people need help with those baby steps because if I've been in this protect mode for so long, all I see are the black and the white. I'm not seeing it gray. And sometimes you need somebody to show you the gray and say, actually, there's all these possibilities in between.

And our safety, you know, garage door shut valve is all set to different intensities. So maybe your friend who turned down the ski vacation, her intensity was shut to immediate. No.

Yeah, because of past experiences, because of her current physical state, because of all the reasons. Whereas someone like yourself would say, oh, maybe I'm going to go do different things while I'm on this trip, or whatever. So. Yeah.

And that's really where I think we get into some of the psychological aspects of pain, which I think we're going to talk about in our next episode.

Holly: 00:50:10

Yes, we are. We have so much more coming. I.

You know, of course, I could keep this going for another hour easily, because everything that you're saying just makes me think of all these additional questions. And so I'm just. I'm jotting it down. Ready for our next chat? Yeah.

When we get back together, let's really unpack the psychology, you know, around all of that and sort of that, that element to it.

And I know we're also going to, we're going to dabble in areas like your social environment and how that affects your pain journey, the types of people that you're surrounded with, the kinds of conversations and sharing that happens. So lots more to come. You want to stick with us. And I think also we always want to sign off by reminding you. I, I don't want to steal it from you.

Dr. Megan, you were the one who said as long as you're breathing, your brain can change. Yeah, yeah. Your pain can change.

Like if, if it's been a five year journey or 25 year journey, all of this is plastic in the way that it can evolve and change.

I love Dr. Megan, what you took us through today and understanding that there is an inner process of sort of calling forth things and making it safe to think about things that maybe we bury.

Megan: 00:51:32

Thank you so much for this conversation.

Outro: 00:51:37

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