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Dr Rangan ChatterjeeDr Rangan Chatterjee

The Real Reason Pain, Fatigue & Anxiety Won't Go Away | Howard Schubiner

The Thrive Tour: Transform Your Health and Happiness, a live show: Book Your Tickets https://drchatterjee.com/live This episode is brought to you by: AG1: Get FREE AG1 Flavour Sampler, AGZ Sampler, Vitamin D3+K2 and Welcome Kit with your first AG1 subscription (worth $87, US only) https://bit.ly/43FwxQl Imagine being told for 25 years that your pain is incurable – then making a full recovery within six weeks. That’s exactly what happened to one of the case studies in this episode and his story is far from exceptional. Could it be that much of the chronic pain we accept in life isn’t evidence our body is broken, but a sign our brain is trying to protect us? My guest this week is Dr Howard Schubiner, one of the world’s leading experts in chronic pain and the mind-body interaction. He’s spent more than 20 years working wonders with people who’d been told their pain was untreatable. He’s published over 100 scientific papers, runs one of the most respected programmes of its kind in the US, and his new book, Unlearn Your Pain, is set to transform how we think about suffering. To kick off this game-changing conversation, Howard debunks some common beliefs around pain, including the assumption that an MRI scan will accurately diagnose back issues. We talk about why bulging discs, degeneration and other scary-sounding findings show up just as often in people who aren’t in pain. And why the language used in scan reports can sometimes do real harm. To explain this, Howard talks us through the difference between structural and neuroplastic pain. The key learning here? All pain is created by the brain, through something called predictive processing. In structural pain, there’s clear tissue damage so your brain creates pain to help you protect the area and seek help. In neuroplastic pain, there’s some sort of perceived danger but no real injury. Here’s what’s important: both types are real. You are feeling pain. The difference is in the treatment. For that, Howard shares his five-part framework for reversing neuroplastic pain – and it has nothing to do with painkillers. He also reveals how the same principles can be applied to tinnitus, dizziness, brain fog, long covid, IBS, anxiety, depression, fatigue and more. We talk childhood, the personality traits that subtly make us more vulnerable to neuroplastic symptoms, and why women are so often the ones carrying the weight. Whether you're living with a long-term condition yourself, supporting someone who is, or you’re simply curious about the communication pathways between our bodies and our brains, this is an episode you won’t want to miss. #feelbetterlivemore Find out more about Dr Schubiner: Website https://unlearnyourpain.com/ Twitter https://twitter.com/hschubiner Dr Schubiner’s book: UNLEARN YOUR PAIN The Science of Recovering from Chronic Pain, Fatigue, Anxiety, and Depression US https://amzn.to/3RySyzy UK https://amzn.to/4u5Qv3s #feelbetterlivemore #feelbetterlivemorepodcast ------- Order MAKE CHANGE THAT LASTS. US & Canada version https://amzn.to/3RyO3SL, UK version https://amzn.to/3Kt5rUK ----- Follow Dr Chatterjee at: Website: https://drchatterjee.com/ Facebook: https://www.facebook.com/drchatterjee Twitter: https://twitter.com/drchatterjeeuk Instagram: https://www.instagram.com/drchatterjee/ Newsletter: https://drchatterjee.com/subscription DISCLAIMER: The content in the podcast and on this webpage is not intended to constitute or be a substitute for professional medical advice, diagnosis, or treatment. Never disregard professional medical advice or delay in seeking it because of something you have heard on the podcast or on my website.

Dr. Rangan ChatterjeehostDr Howard Schubinerguest
Jun 3, 20261h 27mWatch on YouTube ↗

EVERY SPOKEN WORD

  1. 0:00 – 2:04

    Why pain isn’t a direct measure of damage: the brain’s role

    1. RC

      What do you think are some of the most common myths that exist out there when it comes to the topic of pain?

    2. HS

      What I always tell people is you can't understand pain unless you understand the brain. And this is like, "What? Wait a minute." [laughs] 'Cause everyone understands pain. Everyone knows that your body's damaged when you have pain. So the first myth is that pain always is caused by some structural damage or injury-

    3. RC

      Mm

    4. HS

      ... to the body. And we know through the simple fact that you can have an injury and have no pain. Have you ever experienced that, where you had an injury and it didn't actually hurt? And this has been documented thousands of times, so we know that occurs. But if you can have an injury and have no pain... I mean, I-- A friend of mine shot a nail in his hand and had no pain. I mean, come on. [laughs] So the point is, the brain determines whether there's pain or not. That is revolutionary and remarkable, just that. And so-- And you can have pain in the absence of injury. So when you put those two facts together, they're facts. You can have an injury and have no pain. You can have pain without an injury. Now, you have to ask yourself the question, when you have pain, what is it? What's going on? And that opens the door to a whole new understanding of what pain is.

    5. RC

      Yeah. One of the key messages I get from your work and from your latest book, Unlearn Your Pain, is that pain is really a signal.

    6. HS

      Exactly.

    7. RC

      Okay? It's a signal that we need to understand. And instead of just looking at the pain as, "Oh, I have pain. How do I treat it?" It's also important to understand-

    8. HS

      Yeah

    9. RC

      ... why am I currently in pain? As you say-

    10. HS

      Yeah

    11. RC

      ... a friend of yours shot a nail into their hand. I think if you ask a hundred people on the street-

    12. HS

      Yeah

    13. RC

      ... "Will that cause you pain?"

    14. HS

      Yeah.

  2. 2:04 – 3:16

    Context, threat, and survival: why the same injury can hurt—or not

    1. RC

      They'll say, "Yeah, of course it will." With your friend, for example, why would you say it did not cause pain?

    2. HS

      It's a question of what's most important. If you're running across the field and you break an ankle, you want pain. You need pain. Your brain is turning on pain. It's getting signals from your ankle. It's turning on pain to tell you, "Stop. Don't, don't run. Don't walk on a broken ankle. Get help. Get healed." But if you're running and someone's chasing you, [laughs] maybe you wouldn't get pain because the fear, the danger of being, being chased is greater than the, than the danger of the injury. And my friend who shot it, he was alone at a construction site, so he wasn't gonna get help if he just stands there i, in, in complete pain. So his brain kind of, it sounds weird, I know, made a decision, "Go to the hospital."

    3. RC

      Yeah. This is such a key point, Howard, because what you're proposing is fundamentally at odds with how most of the public and most of the medical profession look at pain.

    4. HS

      Yeah.

  3. 3:16 – 6:49

    Chronic pain myths: ‘incurable’ and the problem with a structural-only model

    1. RC

      And why so many conventional treatments don't work. And in your book, you say another myth is that people think that chronic pain is irreversible and incurable.

    2. HS

      Yes.

    3. RC

      Why is that a myth?

    4. HS

      Why that idea exists is because once pain becomes chronic, it's defined as three months, and certainly six months, a year, five years, you're getting assessments to determine the cause of the pain. And if you have a kidney stone, that's gonna be found easily. If you have appendicitis, it's gonna be found easily. You know, if you have a ear infection. So the, the, the medical treatments and certainly, you know, disease, medical tissue damage, pathology can cause pain. We all know that. But once you've passed three months, six months, a year, now you haven't been able to be diagnosed with something that's easily reparable. So now it's chronic. And the treatments that we've had in medicine for chronic pain like this are managing it, coping with it, rather than reversing it. Because they're viewed as the first myth [laughs] that it's, that it's structural, so we'll treat the structural damage, but you can't because you either can't find it or the treatments aren't effective.

    5. RC

      Yeah. Myth number three, physical findings are always indicative of tissue injury.

    6. HS

      Yeah.

    7. RC

      What does that mean?

    8. HS

      Well, if you've seen people with fibromyalgia, and all pain is real, okay? We're not saying that the pain is in people's heads, that it's fake, that it's their fault. No one with pain or the other conditions I talk about in the book should be shamed or blamed. No one. And the point of the book is to have compassion for people who are suffering. Once we understand that, that we need to have compassion and caring for people, then we need to look at them in their whole person, look at their whole life. So we'll talk more about that in a minute. But fibromyalgia is a disorder of sev- often severe pain, pain all over the body, horrible sometimes. Often, you know, thought to be incurable by traditional medical reasoning and... But these folks with fibromyalgia often have tender spots, so they're very tender in the body, all over, these different tender spots, and you push on them, it's tender. So there must be something wrong there because it's tender. But it turns out the brain can cause tenderness. And, uh, you're familiar with Lorimer Moseley, one of the-Australian, a great pain scientist, and he did a study with people with chronic back pain, and he inserted tiny needles in the muscles to, um, see where there was muscle tension and where there was not muscle tension. So what he found is that there was places where there was pain and muscle tension. So he goes, "Oh, the, the brain can cause muscle tension and can cause pain." But there were places where there was no muscle tension and pain, so the brain can cause pain in the absence of muscle tension, and then there were places where there was muscle tension but no pain. So the muscle tension isn't necessarily indicative of pain. Pain is generated by a, a decision, [laughs] that's so weird, a decision made in the brain.

    9. RC

      A subconscious decision.

    10. HS

      Yes, 100%.

  4. 6:49 – 8:04

    When tests are ‘normal’: validating suffering and restoring hope

    1. RC

      Why we're perhaps emphasizing this is because for many years patients have often felt that I've got really bad pain, whether that's in my neck or my back or my head or my foot, whatever it might be-

    2. HS

      Yeah

    3. RC

      ... and they go and see the doctor, and the tests they do, let's assume they come back as normal.

    4. HS

      Right.

    5. RC

      Right? So if they can't find a structural problem, sometimes patients are left feeling, "I think the doctor thinks it's in my head."

    6. HS

      Yeah, yeah.

    7. RC

      Right? They feel they're not listened to. They feel disregarded. This is very, very common, as you well know, Howard.

    8. HS

      100%.

    9. RC

      So that, so that understanding that, "No, wait a minute, there are many factors that can lead to the brain wanting to create pain."

    10. HS

      Absolutely. It's asking the question. It's just being open enough to ask the question. And people need to be seen, and people need to be heard, and people need to be validated as suffering. Their suffering is real. And, but they also need to have this question asked and answered because maybe we're cutting off hope. Because so many people I've seen, for 23 years now doing this work, with pain and other conditions, have been told, "You're incurable. You're

  5. 8:04 – 11:46

    A breakthrough case: Gary’s 25 years of pain and a rapid recovery

    1. HS

      gonna suffer the rest of your life in pain." And so one of the stories in the book is a guy named Gary. 25 years of severe pain. 25 years going to the top medical centers in the US, getting X-rays and MRIs showing, seemingly showing damage. We'll talk about that in a minute.

    2. RC

      [laughs]

    3. HS

      Not all, uh, MRIs and X-rays show the cause of pain. But anyway, he was told he was incurable. He had injections, medication. Nothing worked. Had to quit his job, reduced to, to being in a recliner, depressed and suicidal. 25 years. And he sees a physio who says, "You know, you're not as damaged as you think you are. The brain can cause pain." And he's like, you know, "Come on, give me a break. What do you mean? 25 years, my brain is causing this severe pain? Pain is horrible." He says, "Well, that can happen." So he's like, that idea, he gets the question asked. And then one day he's walking into a pharmacy to get a refill of medication, and his pain is a five, and he walks into the pharmacy and he sees a long line. Well, he knows when he stands for a long time, his pain is bad, but his pain jumps from a five to a nine just seeing the line. And he's like, "What just happened? What just happened? That was my brain." And that was the moment where the question got answered for him, and he started-- He couldn't walk, he couldn't stand, but he started walking because his physio said, "You're not damaging yourself. You're not injuring yourself. The diagnosis is this is neuroplastic pain, not structural pain." And he started walking. He started giving himself messages of safety. And in six weeks he's better. Six weeks after 25 years.

    4. RC

      Completely better.

    5. HS

      Completely. And he's- goes on vacation to Europe, and he's walking 20,000 steps. I mean, unbelievable.

    6. RC

      Yeah. It's incredible. I mean, your book is full of incredible case studies.

    7. HS

      Mm.

    8. RC

      And at the same time, you do acknowledge that and say, "Listen, not everyone's recovery is as rapid or as complete as this," right?

    9. HS

      Absolutely. Absolutely.

    10. RC

      But, but many of the times it is.

    11. HS

      Yeah.

    12. RC

      And even if it takes longer, there is still hope there.

    13. HS

      Yeah.

    14. RC

      You know, when you were relaying that story, and I do remember reading that story-

    15. HS

      [laughs]

    16. RC

      ... in the book, there was two key things in what you said for me. One is that the physio beautifully reassured him-

    17. HS

      Mm

    18. RC

      ... and said, "Hey, honestly, I've, I've looked at everything. There, there's nothing wrong with your back. Okay, there's nothing structurally wrong with your back. And did you know that the, the brain can actually create pain?" Which of course sounds like it's the first time Gary had heard that in 25 years.

    19. HS

      Of course.

    20. RC

      So that's of course really important. But the second thing you said which really stood out to me, Howard, is the patient, so Gary in this instance, realized something that I think is the most important thing that any patient can ever realize when they're trying to make change, whether it's to do with chronic pain or anything else-

    21. HS

      Mm

    22. RC

      ... is to start to really cultivate that self-awareness of how what they do, what they think, how their stress levels are, how that then impacts their symptoms.

    23. HS

      Yeah.

    24. RC

      That awareness is golden because then you've opened the door for that individual to go, "Oh, where else in my life might my thoughts and perceptions and stress levels impact my symptoms?"

  6. 11:46 – 13:37

    Predictive processing and conditioning: the neuroscience behind learned pain

    1. HS

      And this is real because neuroscience of predictive processing is now fact. Predictive processing mean that our- means that our brains generate our experience, which sounds like a woo-woo concept.But in actuality, our brains do generate what we see. You can see in your sleep when you're dreaming, so you don't need your eyes to see. Most of the fibers that go to the visual cortex come from within the brain.

    2. RC

      Mm.

    3. HS

      So all that, all that messaging, all that understanding of how the brain works is that our brain has to create what we experience. So when you touch a hot stove, it's not your finger causing pain. So understanding that, and then understanding the other neuroscience fact is that stress and emotions activate the same parts of the brain as does a physical injury. This is revolutionary.

    4. RC

      Wow.

    5. HS

      And so we really can understand why this is happening. It's not like, oh, it's just stress. It's actually neural circuits, and the conditioned responses of how the brain works. Neurons that fire together, wire together. Everyone knows that. And so when, when Gary would stand up, it wasn't that his body was damaged, it was the standing was causing his brain to turn on pain because of a learned response, and that's the whole point of this work. If pain, and we'll talk about anxiety, depression, fatigue, if those sensations can be learned, they can be unlearned. And, and that, that hope and that agency that you talk about where people feel like they can do something, uh, makes all the difference in the world.

  7. 13:37 – 19:00

    MRI findings, fear, and ‘dangerous’ interpretations

    1. RC

      Yeah. Another myth that you talk about in the book is this idea that an MRI scan will accurately diagnose the cause of chronic back pain-

    2. HS

      Mm-hmm

    3. RC

      ... for most people.

    4. HS

      Yes.

    5. RC

      Why is that a myth?

    6. HS

      [laughs] It is so big. It is so widespread to know that MRIs can show the inside of the body. Which is true, they can. It's revolutionary. Amazing technology. I was a doctor before there were MRIs, and we're like, "Oh my God, you can do the scan, you can see tumors, cysts, bleeds, everything," and you could see degenerative discs. But it turns out that discs degenerate over time, just as hair gets gray over time, and graying of hair does not actually cause pain. So we know that normal, healthy people, starting in their twenties and thirties, start to have disc degeneration as seen on an MRI. Th- But people without pain have very high levels of disc degeneration. So if you're, if you're in your fifties, you have a 60% chance of having disc degeneration. If you're in sixties, you have an 80% chance of having disc degeneration with no pain. So if you-- And the same, uh, is true for bulging discs, spinal stenosis, spondylolisthesis, facet arthropathy or arthritis of the spine. All those increase with age in normal people. So if you have no pain and you get an MRI, you see those findings. If you have pain and you get an MRI, you see the same findings. Why would you assume that that's the cause of the pain? That's making an assumption. And we've seen, obviously, in this kind of work, seen people recover with those findings. When I was in my thirties and forties, I had neck pain all the time. Uh, why? Well, Howard, here's your MRI. You have bulging discs. You have three large bulging discs. You've got facet arthropathy. You're getting old. But then the pain would come and go. If it's structural, why would it come and go? Why would it turn on and off? It turned out, in retrospect, that it was stress building up in my life of the pressure to be the best doctor and teacher and researcher and husband and father.

    7. RC

      Yeah.

    8. HS

      All those pressures were, were just built up and-- but I didn't realize at the time. Now I have no neck pain, but my MRI is still abnormal. So this is so important for people to understand. In the, in the book, there's a chart which shows exactly what percentage of people who have no pain at all have these common MRI findings. So that is the-- one of the biggest myths out there.

    9. RC

      If you have pain and you go and see a doctor, usually the doctor wants to see if there's a structural element to it.

    10. HS

      Which they should.

    11. RC

      Which they should, right? And so they'll, you know, le- let's say send you for a scan. Even if they don't, you as a patient may want your doctor to send you for something.

    12. HS

      Sure.

    13. RC

      The problem is when the MRI scan comes back, if it is anything but normal, then one of the most dangerous things, I think, happens. I, I, I don't use the word dangerous to exaggerate.

    14. HS

      Mm.

    15. RC

      I think it really is dangerous because you get told, oh, that you've got degenerative discs. And we said this on the first podcast when you came on. That word degeneration-

    16. HS

      Mm

    17. RC

      ... is not something anybody wants to hear about their body. That in itself is fear-inducing for many people.

    18. HS

      Yeah.

    19. RC

      And then the assumption is made that, oh, of course, [chuckles] now I know why I have the pain. The patient takes on the belief when they're in pain that, "Oh my God, at least I know what it is. I have a degenerative spine."

    20. HS

      Right.

    21. RC

      So if we understand that the brain creates pain and that fear and danger are massive signals to the brain in order to create the pain, you know, sometimes getting an MRI i- is not like a neutral thing. It's positively problematic or, or the reporting of that MRI could potentially be problematic.

    22. HS

      There's two studies on this done in the UK, both on these exact things, which are in the bookOne of the studies showed that when you give people the normal reading, "Oh, the reading is, yes, you've had degenerative, you've got bulging discs, you've got spinal stenosis. Just read that," over six weeks people got worse. Just knowing that MRI, they got worse. They were more likely to have injections. They had more pain, more likely to have, um, more procedures. So, but if you just said, "Oh, here's your findings, but these findings are also seen in normal people of your age," people didn't get worse. So the interpretation of the MRI made a huge difference. The other study that showed was that the unfettered use of MRIs, more and more MRIs were causing more and more danger in terms of more procedures, more surgeries, and more pain. So people are getting worse. That's one of the factors that causes chronification of pain, is people do less and less, and they're more and more fearful. And the more and more fear leads to actually more and more pain.

  8. 19:00 – 24:31

    Structural pain vs. neuroplastic pain: defining the difference (and why both are real)

    1. RC

      So you've mentioned a couple of terms, right? You, you've said structural pain a few times.

    2. HS

      Mm.

    3. RC

      You've also said neuroplastic pain. Okay? I just wanna make sure everyone listening has got this absolutely clear before we go any further. Can you just briefly explain what is the difference between the two?

    4. HS

      Yeah, yeah. It's so important. I'm glad you, [laughs] I'm glad you're bringing this up. So structural means there's tissue damage causing the pain. In a gallbladder d- you know, cholecystitis, gallbladder infection, you have s- you have pain in your right upper quadrant. You can see the infection. You have a fractured arm. You can see the fracture. You know, structural tissue damage, injury, pathology. All doctors are good at diagnosing that.

    5. RC

      Would spraining an ankle, having it swollen, would that fit here, or that's-

    6. HS

      Yeah

    7. RC

      ... that's more acute pain, I guess.

    8. HS

      Yeah, well-

    9. RC

      But it's still structural

    10. HS

      ... structural, structural. Yeah, structural. Uh, acute pain can also be neuroplastic. You know, on the way here, I was in the Uber getting here, and all of a sudden I noticed my head was hurting. What was going on? [laughs] I don't get headaches typically, but I'm gonna see Rangan. I think I made a mistake of looking up how many followers you had. [laughs] That scared me, you know? And all of a sudden, I had this headache, and it was acute, but nothing had happened. You know, I hadn't injured my head. I was sitting in the car.

    11. RC

      Yeah.

    12. HS

      But that was acute pain. That was neuroplastic. Neuroplastic pain means that the brain is turning on pain because of a danger signal. In this case, it was an emotional danger for me coming on this podcast, and, uh, this is extremely common. Everyone has had this happen-

    13. RC

      Yeah

    14. HS

      ... in their lives. And s- and neuroplastic pain is just as real as structural pain.

    15. RC

      When, when you mentioned, um, that all pain is created in the brain, are you saying that is the same for structural problems s- as well? So let's say I sprain my ankle badly, and it's hot, and it's swollen. People will say, or they would think that, yeah, because it's swollen and there's pressure on the joints-

    16. HS

      Sure

    17. RC

      ... it's those inflammatory mediators that are causing the pain. But you're still saying it's the brain that ultimately is creating the pain, right?

    18. HS

      Yeah. Those signals are going through the nerves to the spinal cord to the brain, but those aren't pain signals. They're danger signals. The brain has to interpret those. 99-plus percent of the time when you have an injury, yes, the brain will turn on pain because pain is a protector. We need pain. We need pain when we're injured. To, it's a message.

    19. RC

      Mm.

    20. HS

      Um, but it is still the brain, and that's the revolution in understanding pain.

    21. RC

      Yeah.

    22. HS

      Uh, and the pain that occurs in the absence of injury, like the headache I was having this morning or the neck pain that I had in my 30s, uh, was caused by the brain in the absence of injury.

    23. RC

      What's really interesting, Howard, is that you now through your work, which has been decades in this field, treating people, studying it, researching it, publishing, I think you've published over 100 papers-

    24. HS

      Mm-hmm

    25. RC

      ... so, you know, there is proper, rigorous scientific research behind the things that you're talking about here today. And in your five-part model to treat pain, which we're gonna get to shortly, number four is emotional processing therapies-

    26. HS

      Mm-hmm

    27. RC

      ... right?

    28. HS

      Yeah.

    29. RC

      To me, it seems that you probably have something that many people don't have enough of these days, which is that self-awareness-

    30. HS

      Mm

  9. 24:31 – 29:49

    Skeptic’s bridge: everyday examples of mind-body symptoms and social safety

    1. RC

      Yeah. If there's a skeptic listening who is saying, "Come on, Howard. What, so you're in the car, and what, your thoughts about a podcast suddenly are giving you a headache?"

    2. HS

      Mm-hmm.

    3. RC

      What would you say to that skeptic?

    4. HS

      That these, this is part of being human. It turns out we're-- human beings need to be connected to each other and need to feel safe, and the brain has this danger signal, and everyone has experienced these kinds of neuroplastic, or sometimes we call it mind-body type symptoms. And if you look at people's lives and you look at your own life, most people will see times when they had that. And the neuroscience is showing this is real. This is exactly what's going on. We have fMRI studies of the brain showing that emotions and stress and emotions are intimately related to pain. When I was, um, three, I was almost three, I had a s- um, sister come home from, baby sister come home from the hospital, and, um, I started to stutter. I mean, what was going on? All of a sudden, you know, I just developed some stuttering problem? Well, I didn't, I didn't want a baby sister. [laughs] I was the king. I was the firstborn. I was the king of the household. And, uh, my, my mother is so smart. She recognized that when I sang, I didn't stutter. And so instead of taking me to speech therapy and medicalizing this problem and making me more aware and more focused on the stutter and making me fearful of it and, and feeling embarrassed about it, we just sang, and it went away. And so, you know, children, everybody has these reactions. You know, when a child is having a tummy ache before going to school, uh, you know, it's not-- there's nothing-- chances are there's nothing wrong with them.

    5. RC

      Yeah.

    6. HS

      Chances are there's something in their life that they just feel unsafe about, and that's this understanding and compassion that we can have for people, uh, in these situations.

    7. RC

      Yeah, I would say the medical profession has a really good awareness in children that stress can cause pain.

    8. HS

      Yeah.

    9. RC

      Because, you know, you know, even when I was at medical school, I think when you learn about chronic abdominal pain in children-

    10. HS

      Yeah

    11. RC

      ... stress and emotions are a huge part of that.

    12. HS

      Right.

    13. RC

      Of course, it doesn't mean you don't look for a physical cause or what you might call a structural cause, right?

    14. HS

      Yeah.

    15. RC

      But a lot of the time, it is emotional.

    16. HS

      Yeah.

    17. RC

      Right? Not wanting to go to school, stress about something.

    18. HS

      Yeah.

    19. RC

      You know, a repressed emotion.

    20. HS

      Parents arguing or feeling un- you know, uns- not feeling smart enough or being bullied or whatever.

    21. RC

      Yeah. So, so that awareness is there within the profession already.

    22. HS

      Yeah.

    23. RC

      Another way we can look at this, if we don't believe that our thoughts can start affecting our physiology is, you know, many people know the feeling of feeling nervous or before an exam, they might feel the need to urinate-

    24. HS

      Yes

    25. RC

      ... or use the bathroom, right?

    26. HS

      Yep, yep.

    27. RC

      Well, that-- it's a similar thing, right?

    28. HS

      Same thing.

    29. RC

      It's stress in the mind. "Oh my God, I'm not prepared enough. What might happen?" Or, "I've got to give a public presentation, you know. Will I do it?"

    30. HS

      Right.

  10. 29:49 – 31:33

    Neuroplastic symptoms beyond pain: a wide spectrum of modern complaints

    1. RC

      It's just so powerful when you think about it. And, and, and in many ways it's quite obvious when you think about it, right? But the prevailing norm is so far away from that. It's almost, you know, the book title is Unlearn Your Pain.

    2. HS

      [laughs]

    3. RC

      I, I would go further than that. It's unlearn-Many myths-

    4. HS

      [laughs]

    5. RC

      ... about your body.

    6. HS

      Yeah.

    7. RC

      Because you don't just stick to pain, actually. If we have time later, we'll come to this-

    8. HS

      Yeah

    9. RC

      ... but you, you sort of expand this out to anxiety, depression, osteoarthritis-

    10. HS

      Mm-hmm

    11. RC

      ... symptoms like tinnitus.

    12. HS

      Mm-hmm.

    13. RC

      Right? Many, many other symptoms. There's a, there's a whole page of, uh ... There's, I think, three pages-

    14. HS

      Three pages [laughs]

    15. RC

      ... where you list symptoms that could be neuroplastic or have a neuroplastic component.

    16. HS

      Yes.

    17. RC

      And I was thinking as I was reading that, these are literally the bulk of the conditions that cause the bulk of the problems in modern medicine, particularly general practice.

    18. HS

      Mm-hmm.

    19. RC

      And the conditions that we don't generally have really good treatments for. They're the patients who would come in and you didn't quite know what was going on, so you'd end up giving a prescription-

    20. HS

      Mm-hmm

    21. RC

      ... and say, "If it's not better in four weeks, come back." And I'm-

    22. HS

      Yeah.

    23. RC

      Again, I'm not criticizing anyone doing that. It's, it's an attempt to try and help, but it's very clear that there just isn't a clear understanding of neuroplastic conditions.

    24. HS

      Yeah, exactly, and it's not common sense. It's obvi- Once you s- once you see this-

    25. RC

      You can't unsee it

    26. HS

      ... you can't.

    27. RC

      Yeah.

    28. HS

      And most of the people who do this work have had their own life experiences, so they could see it in themselves or their family members.

  11. 31:33 – 38:47

    The five-part recovery model begins: assessment and FIT criteria

    1. RC

      Yeah. I want to go into this treatment paradigm that you lay out, this five-part model to treat neuroplastic pain, and you're saying-

    2. HS

      Mm

    3. RC

      ... the bulk of pain that people struggle with-

    4. HS

      Yes, yes

    5. RC

      ... is neuroplastic.

    6. HS

      Yeah.

    7. RC

      You know, maybe even 90%, maybe more [laughs] , maybe a bit less.

    8. HS

      It's in that category.

    9. RC

      But a lot, right? And there's five components to this: assessment, education, reappraising symptoms, emotional processing therapies, and finally, number five, making changes in one's life. I wonder if we could just go through them all sequentially because I think a lot of things will come out as we go through that model.

    10. HS

      Yes. Yes.

    11. RC

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    12. HS

      I mean, the first step is, as you said, it's what doctors need to do: rule out a structural problem, look for some disease. You know, the last thing any doctor wants to do, last thing I ever want to do is miss a structural condition, miss somebody who has a cancer, who has an infection, who has a, a fracture, who has an autoimmune disease, et cetera. So that's step one.

    13. RC

      But is it also worth looking at it the other way, which is if we're trying to rule out something serious, that mentality often will lead to a scan.

    14. HS

      Yes. Of course. Many scans. Many tests.

    15. RC

      Many scans, right?

    16. HS

      Yeah.

    17. RC

      But we're also saying that scans in and of themselves can be problematic in many cases.

    18. HS

      Right.

    19. RC

      So if you're not getting any of those red flag symptoms, do you think it's reasonable for a doctor to not go down the route of scanning? At least say, "Look, there's nothing in your history that indicates that. Why don't we try some other things first?"

    20. HS

      It is not only trying other things first, but it's a second level of assessment.

    21. RC

      Okay.

    22. HS

      So the second level of assessment is, first level is ruling out a structural problem. Second level is ruling in a neuroplastic condition.

    23. RC

      Okay.

    24. HS

      So how do we do that? Well, that's what I was saying a bit earlier about how if the pain is in the right side, right shoulder, and then it's in the left, why is that? If it goes away when you're on vacation, then comes back when you come back to work. If it rises up when you go to visit your relatives who you have trouble with. If it goes away when you're on a boat. There's all these ... And/or it's triggered by the wind or the weather or heat or cold or stress. So all these clues, like with Gary walking into the pharmacy, that was his click moment, but we have all these things. And doctors, it's very easy to actually do this kind of assessment to rule in a neuroplastic. And then once you see it, then you say, "Well, gee, we probably don't need the scan in that case, in this case."

    25. RC

      One of the examples you gave there, uh, I think it was either back pain or neck pain, "Oh, it's not there when I'm on vacation, but it is there when I'm at work."

    26. HS

      Yeah.

    27. RC

      Of course, some people would say that could be to do with-Sitting posture, right?

    28. HS

      Right.

    29. RC

      They might, they might think, "Oh, on holiday, you know, I'm, I'm out walking every day. I'm not sat in front of a laptop. I'm in the pool."

    30. HS

      Yes.

  12. 38:47 – 1:01:06

    Steps 2–3: education and symptom reappraisal (pain reprocessing)

    1. RC

      Okay. So, so step one is assessment.

    2. HS

      Right.

    3. RC

      Step two is education.

    4. HS

      Yes.

    5. RC

      What's education all about?

    6. HS

      It's explaining how the brain works. It's explaining predictive processing, that our brain literally creates what we see, what we hear, and what we feel. So it's, it's validating people to understand, again, that their pain or other symptoms are real. They're not imaginary. They're not fake. They shouldn't be shamed or blamed at all. And because the brain can produce this level, even very severe symptoms that last a long time, it, it can be because the brain gets stuck in a loop, a conditioned loop, a, a horrible habit of continuing to turn on pain, you know, every, every morning, every evening, you know, all the time. And so it's really understanding that neuroplasticity means the brain can organize itself and change. So it gives, it gives validation. It gives compassion because we're, we're linking the stressful situations in their life to the onset of these conditions. So we're understanding them as a whole person. We're seeing them as a whole person, not just seeing their disease, not just validating their disease, but validating them as a whole person and then offering hope because of, because neuroplastic implies neuroplasticity, which implies change, reversal.

    7. RC

      You know, Howard, for many years I've been coming to the conclusion that the most important thing in our bodies when it comes to health and wellbeing is the state of our nervous systems.

    8. HS

      Mm-hmm.

    9. RC

      We literally see the world through the state of our nervous system, you know. The nervous system that's wound up and tight, you're gonna see threat and stress everywhere. A nicely relaxed, uncoiled nervous system, you're more compassionate, joyful. You will see the other side of the argument when someone says something and not react, right? And as I was reading Unlearn Your Pain over the last few days, it really reinforced that belief for me that the state of your nervous system is everything. When your nervous system feels as though it's under threat in any way, even mild threats, there are all kinds of symptoms that you will experience that could well be related to that.

    10. HS

      Hmm.

    11. RC

      And too often in medicine we look at the symptom and try and treat the symptom. Uh, uh, the question for me over the last few days was if someone had a truly calm, relaxed nervous system, which of course is very rare now in the modern world-

    12. HS

      Mm-hmm

    13. RC

      ... because of the way in which we live, I imagine many, many seemingly unrelated symptoms would just go.

    14. HS

      Yeah. Yeah.

    15. RC

      'Cause they're there for a reason.

    16. HS

      Yes. Because we're really understanding the whole person and understanding the causes of these things, you know, in, in, in reality. Seeing, seeing the truth of what's going on. And so it's on one hand, the symptoms themselves create more and more fear. The symptoms themselves create more and more-

    17. RC

      Yeah

    18. HS

      ... more and more upsetness and dis-, you know, dis-ease, so to speak, which makes things worse in and of themselves. But at the same time, when we look at people's lives-To really understand the connection between their lives, between what's going on in their relationships, what's going on in their work, what happened in their childhood in terms of, uh, traumatizing types of experiences that, that have sensitized the brain to be more sensitive, sensitized this subconscious danger signal to be more likely to react later in life.

    19. RC

      Mm.

    20. HS

      And we know, you know, we know for certain that traumatic experiences in childhood, and they don't always have to be the biggest ones.

    21. RC

      Mm.

    22. HS

      But the hurts of not feeling seen or not feeling heard or being criticized, et cetera, um, have impact or can have impact later in life when other stresses occur.

    23. RC

      Yeah. I always remember my very first conversation with Gabor Maté, I think back in 2018.

    24. HS

      Mm.

    25. RC

      And Gabor said something to me about childhood trauma. He said, "It's not only when bad things happen to you, it's also when not enough good things happen."

    26. HS

      Yes. And what he's really great about is saying, it's not only that the bad thing has happened, but then you weren't attended to.

    27. RC

      Yeah.

    28. HS

      You weren't cared for. And so, you know, many of the stories in my book have to do with that, where people, and especially women who have, who have higher levels of emotional abuse, higher levels of sexual abuse, higher levels of online bullying, higher levels of, uh, interpersonal, interpersonal violence, uh, harassment in the workplace.

    29. RC

      And h- and higher rates of neuroplastic conditions.

    30. HS

      Exactly.

  13. 1:01:06 – 1:19:33

    Steps 4–5: emotional processing and life changes that remove ongoing threat

    1. RC

      ... but they're all there in the book. Step four, emotional processing therapies. I loved this section. This is so interesting to me how our emotions can affect our health, how anger, guilt, shame can potentially cause pain, right?

    2. HS

      Yeah.

    3. RC

      It's incredible. So, you know, let's go through it. What, what's the deal with, uh, stage four, emotional processing therapies?

    4. HS

      Yeah. Like you said, Rangan, it's recognizing that emotions are important. They're real. They have major effect on us, and if you're living with guilt, you're living with shame, you're, you're, you're living with this toxicity of beating yourself up. Most of people with living with shame and guilt is undeserved. They haven't really done anything wrong, and it's very clear, and fMRI studies show that emotions are related to pain signals or depression signals or fatigue signals, et cetera. Uh, if you're living with anger, upset, carrying the grudges that, that we do, how's that, how's that helping us, you know? It's creating this toxicity in our lives, and it's creating the neural circuits that can fuel these sensations and s- neuroplastic symptoms. So, uh, and as I said, uh, traumatic experiences early in life and later in life activate the danger signal and make the danger signal more sensitized as people go through life. So one of the, um, first people I saw was a woman who had headaches for 17 years, and that's a long time. She'd been to three top headache referral centers, injections, medication. Everything they tried, nothing worked. And when she asked, "What's the cause of my headache?" They would go, "I don't know." You know, "We don't know." But what could I do? Well, I can listen to her, and I can talk to her.

    5. RC

      Mm.

    6. HS

      And her life was pretty straightforward. She didn't have horrible, traumatizing experiences in childhood except that her father was unpredictable. He came home some days from work, he was fine, happy and good. Other days, he was mean and ugly and angry and upset, and he would grab her and yell at her and scream at her.

    7. RC

      Oh.

    8. HS

      So fearful. But she was fine. She would describe her childhood as being fine. And so when she got the headaches when she was in her 30s, uh, I asked, "What was going on in your life then?" "Well, let's see. I had a new boss." "Well, what was he like?" "Unpredictable." He was unpredictable, just like her father. He would be fine and happy and good, and then sometimes he would go into-

    9. RC

      Mm

    10. HS

      ... rages and yell at people, demean them, debase them. It was scary. And her brain, like we were saying earlier, her brain was like, "Well, wait a minute. This is not good."

    11. RC

      Mm.

    12. HS

      And the headaches started. And now she understood them in a completely different light, and she could change her appraisal of them, as we just spoke about, but she could also change her emotions about them, and she could allow herself to f- to f- e- feel the emotions of the fear, of the anger that she had toward her father, toward her bo- boss. And the, the method we've used, called emotional awareness and expression therapy, is to help people express their feelings in safe and healthy ways so that they can resolve them, and then they're not hanging on to underlying grudges and anger. They're not hanging on to underlying shame and guilt. And it turns out you can, you can purposely change your emotions, change how safe you feel in your life in relation not only to current events that are scary or feeling trapped or hurt or betrayed, but also past events, so it's actually a treatment for trauma.

    13. RC

      I'm just wondering how would, how people actually do this. So there may be people listening who have realized throughout this last section that, yeah, you know, I'm carrying a bit of resentment or anger or shame or whatever it might be. Howard's saying I need to feel it. But, you know, what, what are people meant to do with that? I mean, are they meant to shout, cry, hit the wall, journal? You know? Or, or can all of these things work potentially depending on the individual?

    14. HS

      Yeah. Yeah, there's a lot of ways to do emotional processing. There's a lot of different therapies involved or that people have developed over the years. Journaling is certainly one of them, and a lot of people have found that to be very useful. Um, I, uh, I lost my job, uh, four years ago. I was a senior doctor at my hospital for 20 years. But the hospital had budget crises, and they let me go. What doctor loses their job? [laughs] I mean, it seems, like, inconceivable. It's the last thing I ever thought would have happened to me, and my back started to hurt. And I've-- I told people, "The hospital let me go." That's kind of funny, right? And everyone said, "Oh, I lose jobs. Everyone loses jobs. It's no big deal." So my back is hurting, and it's-- I'm kind of hobbling around, and I do pain reappraisal. I do a assessment. I'm not damaged. I-- nothing happened to me. I had no injury. I do pain reappraisal. I'm telling myself, "I'm safe. I'm okay. Keep moving. Everything's fine." Didn't workI'm in my car three weeks later, and I realize it's not funny. I have feelings about this that I haven't expressed, that I haven't even recognized these feelings because I was just holding them down. And the first feeling was anger. So if you have anger, you can keep it in, which is toxic to yourself. You can let it out in the real world, which is damaging. Violence is not a helpful solution. Yelling at people in real life-

    15. RC

      Mm

    16. HS

      ... yelling at the people you care about is not gonna be, um, beneficial to anybody.

    17. RC

      Mm.

    18. HS

      So but I could let the anger out in a safe and healthy way. I just started screaming. I just started screaming and yelling. I was swearing-

    19. RC

      In, in your house?

    20. HS

      In my car. I was in my car. [laughs]

    21. RC

      Okay.

    22. HS

      Yeah. I was alone. No one could hear me. And I just started screaming and yelling all this stuff and swearing and cursing. And then I imagined, [laughs] this is so silly and so crazy and funny, but I imagined blowing up the hospital with TNT, like in a cartoon.

    23. RC

      Mm-hmm.

    24. HS

      [sighs] And then I could relax. And then I could-- I just let that anger all out, and I could just release it and not hold on to it. And it was safe and healthy, and it only takes a relatively short time. Then I went to the other main feeling, which was hurt and sadness. They kicked me aside. They let me go. My God. And all the hurts and sadnesses from my life started coming up. And what do you do when you're hurt or, or you're sad for somebody? You care about them. You hug them.

    25. RC

      Mm.

    26. HS

      You give them compassion. So I started turning that hurt into compassion for myself. A friend of mine called me, who was compassionate toward me right at that time. And so I could alleviate some of the hurt. And then I realized, you know what? The hospital, they put up with me for twenty years. I never made any money for them. I wasn't a high producer. I wasn't making-- doing injections or anything. And I forgave them, and I thanked them, and I had gratitude for the twenty years I was there. And as I forgave them, as I processed the anger and the hurt and the forgiveness, and the pain just disappeared on the spot. It's amazing how powerful that can be.

    27. RC

      Thank you for sharing that story, Howard. Um, it's-- it is incredible to hear that... There were so many things that happened there, but your ability or willingness to not pretend that you weren't feeling anger and hurt, right? Because that's what we do, don't we? We're very good at kidding ourselves.

    28. HS

      Yeah.

    29. RC

      All of us, myself included. You know, uh, you, you-- we can pretend things of, "Oh, yeah, that didn't bother me. You know, everything's fine." Y- y- you know what I mean? It's, and it's-

    30. HS

      It's, it's uncomfortable. It's uncomfortable to feel our feelings. We want to kind of push them down or push them away.

  14. 1:19:33 – 1:27:05

    Who needs which steps, and the core message: hope, agency, and better-than-before outcomes

    1. RC

      Do people need to address all five parts of this model in order to get better?

    2. HS

      [laughs] Great question. Uh, sometimes just the first two steps are enough.

    3. RC

      A proper assessment and education, that it's the brain-

    4. HS

      Yes, yes

    5. RC

      ... that's creating pain.

    6. HS

      Yes. Sometimes that is enough because people may not have se- severely traumatic things in their life-

    7. RC

      Yeah

    8. HS

      ... or difficult situations, and they have the freedom. If you, if you get a, a test result saying, "Oh, we just did your biopsy and it's cancer. I'm so sorry." And then the next day they say, "Oh, sorry, wrong slide. We mixed the slides up. You're fine. You're fine," there's a liberation there. It's like, "Oh my God, I was so worried, but now I'm fine." That liberation can change the neural circuits in their brain by understanding, having the felt sense of I'm actually okay. So that can be enough for some people, and some people need more of the therapy, more of the emotional work, et cetera.

    9. RC

      Yeah. It's a very complete model. I can see how not everyone needs all five stages, but some people are gonna need to go all the way-

    10. HS

      Yeah

    11. RC

      ... from one all the way through to five. Irrespective of that though, the message I get from that model, and frankly all of your work and your book, is one of hope.

    12. HS

      Mm.

    13. RC

      It's that even if you've struggled for years with chronic pain, in whatever form that shows up for you, even if you've been to multiple doctors and taken multiple painkillers and you have not got better yet, you're basically saying that there is hope. There may be things that you've not tried yet. You may have a belief that only a problem with structure can cause pain.

    14. HS

      Mm.

    15. RC

      And what happens if you live your life with a different belief? That actually, wait a minute, my body's not broken.

    16. HS

      Mm.

    17. RC

      It's my brain that is choosing to create pain. Why is my brain choosing to create pain? It's very empowering, and I, and I basically love the idea that you can apply this thinking model beyond pain.

    18. HS

      Mm-hmm.

    19. RC

      You can apply it to depression-

    20. HS

      Yeah

    21. RC

      ... and anxiety and fatigue, right?

    22. HS

      And I write about these in-

    23. RC

      You do, in detail

    24. HS

      ... detail. In detail. Looking at the science behind it, looking at some of the myths that are there, that are out there.

    25. RC

      I then think the section-

    26. HS

      You know

    27. RC

      ... on long covid is gonna be very insightful for people who are struggling, because that is something that a lot of people struggle with.

    28. HS

      Yeah.

    29. RC

      But there are common principles, right?

    30. HS

      Yeah.

Episode duration: 1:27:05

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