How To Heal Chronic Pain with Dr Howard Schubiner #310
Dr. Howard Schubiner, Director of the Mind Body Medicine Center, explains how chronic pain is often brain-generated, not structural. He discusses changing one's narrative on pain and using therapies like pain reprocessing to find healing.
Deep Dive Analysis
18 Topic Outline
Introduction to Chronic Pain and its Prevalence
Pain as a Brain-Generated Protector and Emotion
Acute vs. Chronic Pain and Common Conditions
Frustration in Healthcare for Chronic Pain
Brain's Role in Creating Pain: Predictive Processing
Misinterpretation of MRI Scans and Dangerous Diagnoses
Dr. Chatterjee's Personal Chronic Back Pain Journey
Emotional Weight and Pain Release
Pain as a Signal and Protector
Brain's Contextual Decision to Activate Pain
Chronic Pain, Stress, and Societal Trends
Posture, Repetitive Strain Injury, and Cultural Factors
Empathy and Listening in Chronic Pain Care
Illustrative Cases of Brain-Generated Pain
Pain Reprocessing Therapy Explained
Emotional Awareness and Personality Traits in Pain
Navigating Pain Medication and Personalized Treatment
A Message of Hope and Paradigm Shift
6 Key Concepts
Pain as a Protector
Pain is a discomforting experience and an emotion generated by the brain to alert us to a problem or danger, acting like a smoke alarm. It's a message from our brain telling us something needs attention or that we need to stop doing something.
Predictive Processing
This is the neuroscience of how the brain works, where it creates what we experience, including what we see, hear, and feel. The brain decides whether to actually turn on the experience of pain or not, based on impulses, expectations, and the overall context.
Neural Circuit-Based Pain
This refers to chronic pain that is generated by neural circuits in the brain, often activated by stress, emotions, and life situations. Even after any initial physical injury heals, these circuits can continue to be activated, creating a vicious cycle of pain, fear, and focus, making the pain persist.
Pain Reprocessing Therapy (PRT)
A therapeutic approach aimed at reversing neural circuit-based pain by changing the narrative around pain and retraining the brain. It involves understanding the pain is not due to structural damage, reducing fear, using positive self-talk, and engaging in graded exposure with messages of safety and calm to turn off the brain's danger alarm.
Emotional Awareness and Expression Therapy (EAET)
A therapy that addresses the emotional components contributing to chronic pain. It involves dealing with unexpressed or unprocessed emotions and life situations that can activate danger signals in the brain and perpetuate pain, drawing from intensive short-term dynamic psychotherapy and internal family systems work.
Nocebo Effect
This is the phenomenon where negative expectations or beliefs about a treatment or situation can lead to worse outcomes, such as increased pain. For example, people may experience more pain if they fear their pain medications are being forcibly taken away, as the brain enters a bigger state of fear.
11 Questions Answered
Chronic pain is any pain that has lasted for three to six months or longer. It is estimated to affect between a third to half of all UK adults, which is around 28 million people, and includes conditions like headaches, migraines, back pain, irritable bowel syndrome, and fibromyalgia.
No, chronic pain is very real and is created by the brain. It is not imaginary or made up, but rather originates from neural circuits in the brain, often activated by stress and emotions, not necessarily structural damage.
The brain creates what we experience, including pain, through a process called predictive processing. Sensory impulses go to the brain, but the brain decides whether to activate the experience of pain based on context, expectations, and its protective mechanisms, even in the absence of physical injury.
MRI scans often show 'abnormalities' like degenerative disc disease or bulging discs in people with no pain at all, as these are normal findings that occur with aging. Therefore, relying on these scans as the sole cause of pain can lead to erroneous diagnoses, fear, and potentially unnecessary or ineffective treatments.
Emotions and stress activate the exact same parts of the brain as a physical injury. Unprocessed emotions, difficult life situations, and chronic stress can activate danger signals in the brain, leading to the creation and perpetuation of real physical pain, even when there is no structural damage.
Yes, in many cases, chronic pain can be healed without using medication by helping patients understand the brain's role in creating pain, addressing underlying emotional causes, and changing their narrative and relationship to the pain.
Healthcare practitioners should listen to patients, show empathy, validate their pain as real, and carefully evaluate to rule out structural problems. They should also understand the neuroscience of brain-generated pain and guide patients towards therapies that address neural circuits and emotional factors.
Changing the narrative from believing one's body is broken to understanding that the brain is generating pain as a protective signal can interrupt the vicious cycle of fear, focus, and pain. Telling oneself 'I'm safe' and smiling can turn off the brain's danger alarm mechanism, which is the actual cause of the pain.
While poor posture can cause temporary soreness, it is not typically the cause of chronic pain unless combined with fear, worry, and stress. The brain's interpretation of posture, influenced by societal narratives and personal stress, plays a larger role in chronic pain development.
Early life trauma and adverse childhood events can sensitize the brain, making individuals more prone to developing chronic pain and other neural circuit-based problems later in life. Studies show a strong correlation between ACEs and the success rate of back surgery, with higher ACE scores leading to significantly lower success rates.
Painkillers can temporarily alleviate suffering, and some people may need them while engaging in therapies that address the root cause. However, they often act as a 'band-aid' and do not solve the underlying problem, and forced reductions can trigger the nocebo effect, making pain worse.
21 Actionable Insights
1. Reframe Pain as Protector
Understand that pain is not the problem itself, but a solution your brain creates to alert you to an underlying issue or perceived danger. View symptoms as a “blessing in disguise” pointing towards something that needs attention or care in your life.
2. Pain is Brain-Generated
Recognize that pain is primarily created by your brain, not necessarily by structural damage in the body part where it’s felt. Emotions and stress activate the same pain centers as physical injury, meaning emotional pain can manifest as real physical pain.
3. Change Pain Narrative
Actively change your internal narrative about pain, believing it’s a reversible neural circuit problem. When moving or encountering triggers, tell yourself you are “okay” and “safe,” and intentionally smile to turn off the brain’s danger alarm mechanism.
4. Cultivate Self-Compassion
Acknowledge and feel compassion for yourself regarding past or present life stressors and emotional injuries that may be contributing to your pain. Recognizing the link between stress and physical symptoms can be a powerful step towards healing.
5. Avoid Pain-Related Fear
Do not feed the vicious cycle of chronic pain by fearing it, focusing on it, worrying about it, or becoming frustrated by it. These responses signal danger to the brain, which can intensify and prolong the pain.
6. Recognize Neural Circuit Pain
Distinguish neural circuit-based pain from structural pain by its inconsistent nature—it turns on and off, shifts, moves, is triggered by innocuous things, or goes away on vacation and returns at work. This helps confirm the brain’s role.
7. Graded Exposure with Joy
Use graded exposure techniques by gradually moving or even imagining yourself moving with joy, calm, and messages of safety. This retrains your brain that these movements are not dangerous, breaking the fear-pain cycle.
8. Move with Calm & Joy
Pair calming practices like deep breathing and reassurance with physical movement, such as yoga. Moving gently with calm, joy, or peacefulness trains your brain that these movements are not dangerous, reinforcing new neural circuits.
9. Journal for Emotional Processing
Utilize journaling as a tool for emotional awareness and expression therapy. This practice helps process unexpressed or unprocessed emotions and life events that may be contributing to physical pain.
10. Mindful Pain Observation
After understanding that pain is a neural circuit problem, use mindfulness to observe sensations without fighting or frustration. Step back, watch the pain, and notice how it shifts, which can help your brain “drop” the sensation.
11. Set Boundaries, Say No
Recognize and address acquired personality traits, such as people-pleasing or perfectionism, that may stem from past experiences and contribute to chronic stress. Learn to stand up for yourself and say “no” to alleviate self-imposed pressure.
12. Knowledge Reduces Pain
Simply gaining knowledge and understanding that your pain is brain-generated and not due to structural damage can, for some, be enough to turn off the danger signal and reduce symptoms.
13. Temporary Pain Medication Use
If suffering severely, use pain medications temporarily to alleviate symptoms while actively engaging in pain reprocessing and emotional work. The goal is to reduce pain through these methods first, making medication tapering easier later.
14. ACEs Impact Chronic Pain
Understand that early life trauma and adverse childhood experiences (ACEs) can significantly sensitize the brain, increasing the likelihood and severity of chronic pain later in life, influencing treatment outcomes.
15. Posture Not Primary Cause
While posture can cause temporary soreness, it is unlikely to be the sole cause of chronic pain. Fear, worry, and stress about posture, combined with life stressors, are more significant contributors to persistent pain.
16. Listen with Empathy (HCPs)
As a healthcare professional, the most important therapy you can offer patients with chronic pain is to listen intently and show genuine empathy. This validates their experience and builds trust, which is crucial for healing.
17. Avoid Misattributing Scan Findings (HCPs)
Do not tell patients that common abnormalities found on MRI scans (e.g., bulging discs in asymptomatic individuals) are the cause of their pain. This creates an erroneous belief system that can worsen fear and hinder recovery.
18. Personalize Pain Management (HCPs)
Tailor your approach to pain management based on the patient’s individual history, beliefs, and current medication use. Meet patients where they are, offering new information and paths to healing without forcing a specific approach.
19. Clarify Medication Role (HCPs)
When prescribing pain medication, clearly communicate that it is for managing symptoms temporarily, not for curing the underlying problem. Offer to help patients investigate and address the root causes of their pain.
20. Focus on Creating Health (HCPs)
Instead of solely focusing on “what’s wrong” with a patient, shift the approach to “creating health” through holistic means like addressing emotional well-being, sleep, stress, and movement.
21. Therapists Treat Chronic Pain
Therapists (psychotherapists, psychologists, social workers) should recognize their crucial role in caring for chronic pain patients, especially since many seeking help for anxiety or depression also have co-occurring chronic pain conditions.
6 Key Quotes
The pain is not the problem, it's the solution. It's the solution that our brain has come up with to alert us to a problem.
Dr. Howard Schubiner
It's not all in your head. Your pain is very, very real. But the important message, the empowering message from my conversation with Howard, is that you can do something about it.
Dr. Rangan Chatterjee
The brain decides whether to actually turn on pain or not, whether to give you the experience of pain or not.
Dr. Howard Schubiner
The pain that occurs due to a fracture is exactly the same as the pain that occurs due to a stressful situation that occurs in our life. It's real pain and it can be severe pain.
Dr. Howard Schubiner
When you operate on pain, you get pain.
Dr. Howard Schubiner
How come nobody told me that there was a different path?
Dr. Howard Schubiner
1 Protocols
Pain Reprocessing Therapy (PRT)
Dr. Howard Schubiner- Change the narrative about pain, understanding it as a neural circuit problem rather than a structural issue.
- Think about yourself and the affected body part differently, fostering a belief in reversibility.
- As you go to lift, bend, or move, consciously tell yourself, 'I'm okay, I'm safe, I'm not in danger.'
- Smile while performing movements or even imagining them, as this helps turn off the brain's danger alarm mechanism.
- Use graded exposure techniques, starting with small movements or imagined movements, and reinforce messages of safety and calm.