# How to Combat Pain  ## Episode metadata - Episode title: How to Combat Pain - Show: Hidden Brain - Owner / Host: Hidden Brain, Shankar Vedantam - Guests: [Rachel Zoffness](https://share.snipd.com/person/2f6422e9-ff46-4278-a50a-864f6f3b1f43) - Episode publish date: 2026-07-20 - Episode AI description: Rachel Zoffness, a pain psychologist and author, explains how pain is crafted by the brain and shaped by context. She shares striking stories about threat and safety, contrasts acute and chronic pain, and explores emotions, social connection, lifestyle habits, and expectation effects that alter pain experience. - Duration: 50:24 - Episode URL: [Open in Snipd](https://share.snipd.com/episode/5cc995fd-ffe9-4b10-ae99-730349215e34) - Show URL: [Open in Snipd](https://share.snipd.com/show/c94a26f6-1a03-4020-a574-bec10c59f432) - Export date: 2026-07-22T00:33:09 ## Snips ### [Pain Is A Constructed Danger Alarm](https://share.snipd.com/snip/375ae637-b170-4516-8ea8-7963892410d5) 🎧 03:46 - 08:02 (04:16) <iframe src="https://share.snipd.com/embed/obsidian-player/snip/f7aab416-2e8d-4407-bce3-15c1dd957681" width="100%" height="100" style="border: none; border-radius: 12px;" sandbox="allow-scripts allow-same-origin allow-forms allow-popups allow-clipboard-write" ></iframe> - Pain is a brain-made danger alarm rather than a direct readout of tissue damage. - Rachel Zoffness explains the brain uses sensory data, memories, emotions, and social cues to decide whether to generate pain and how much. #### 💬 Quote > Our brain is our body's danger detector. That's our brain's job, is to save our lives. And pain is our body's warning system. > — Rachel Zoffness Rachel Zoffness on how the brain constructs pain #### 📚 Transcript **Shankar Vedantam:** But is that really all there is to it? At the University of California, San Francisco, psychologist Rachel Zofnitz studies the nature of pain. She has found that our minds play a much larger role in our experience of pain than many of us realize. And they also play a much larger role in how we need to deal with pain. Rachel Zofnitz, welcome to Hidden Brain. One **Rachel Zoffness:** of my favorite ever podcasts. I'm so honored to be here. **Shankar Vedantam:** Rachel, as you began your own research training, you were taught a one-dimensional biomedical **Rachel Zoffness:** model of pain. Can you describe that model for me? Absolutely. antiquated way of looking at disease and pain that focuses primarily, if not exclusively, on anatomy and physiology and bones and body parts. And what that means in the biomedical frame of things is that when we talk about treating pain, we also talk primarily, if not exclusively, about biomedical solutions. And that takes the form of pills and procedures. So here's what I observe as a clinician and pain researcher. What I observe is that if you have chronic knee pain, you will be sent to 762 knee specialists, but we never talk about your brain at **Shankar Vedantam:** all. So early on in your own training, Rachel, you encountered a pair of clinical cases documented in the medical literature, which got you thinking about pain in a different way. One was about a 29-year construction worker who got injured. Can you set up the scene for me and describe what happened to this worker? **Rachel Zoffness:** I love these two stories, and I call them a tale of two nails, because who doesn't like rhymes? So yes, the first story, the first tale of nails, is a construction worker who was working on a job site when he jumped off a plank straight onto a seven-inch nail. And that nail drove through his boot clear through to the other side. Oh my God. Yes. **Shankar Vedantam:** So the pain must have just been excruciating. **Rachel Zoffness:** It was excruciating. And his colleagues rushed him off to the emergency department. And he was sedated with a lot of good drugs, like, you know, fentanyl and other opioids. And when the good doctors removed his boot, they discovered that a miracle had occurred. The nail had passed between the space between his toes. There was no puncture wound. There was no blood. And there was no tissue damage. **Shankar Vedantam:** Well, but why was he in such excruciating pain? It makes no sense, right? **Rachel Zoffness:** So here's what pain science tells us, which is so important and fascinating about the science of pain. Our brain is our body's danger detector. That's our brain's job, is to save our lives. And pain is our body's warning system. It's our danger detection system. So brain, including this construction worker's brain, used all available information to decide whether or not to make pain and how much. knowledge of his dangerous work environment. It included memories of past pain experiences, which, by the way, are stored in our hippocampus. It used data from his five senses, including this visual of this giant nail sticking out of his boot. It incorporated emotions like panic. And because his brain perceived potential threat of danger, it made pain to protect him. And I'm using those words on purpose. His brain perceived potential danger. And so it made pain to protect him. --- ### [Miracle Nail In Boot Caused Severe Pain](https://share.snipd.com/snip/534046d7-6d30-4511-bd4d-494c01fd4543) 🎧 05:39 - 06:36 (00:57) <iframe src="https://share.snipd.com/embed/obsidian-player/snip/f5ce3113-a88b-4954-9843-c5da1cc0c68c" width="100%" height="100" style="border: none; border-radius: 12px;" sandbox="allow-scripts allow-same-origin allow-forms allow-popups allow-clipboard-write" ></iframe> - A construction worker jumped on a seven-inch nail and reported excruciating pain despite no tissue damage. - The brain amplified pain because visual threat, panic, and social alarm signaled danger at the scene. #### 💬 Quote > When the good doctors removed his boot, they discovered that a miracle had occurred. The nail had passed between the space between his toes. There was no puncture wound. There was no blood. And there was no tissue damage. > — Rachel Zoffness Rachel Zoffness recounting the construction worker anecdote #### 📚 Transcript **Rachel Zoffness:** I love these two stories, and I call them a tale of two nails, because who doesn't like rhymes? So yes, the first story, the first tale of nails, is a construction worker who was working on a job site when he jumped off a plank straight onto a seven-inch nail. And that nail drove through his boot clear through to the other side. Oh my God. Yes. **Shankar Vedantam:** So the pain must have just been excruciating. **Rachel Zoffness:** It was excruciating. And his colleagues rushed him off to the emergency department. And he was sedated with a lot of good drugs, like, you know, fentanyl and other opioids. And when the good doctors removed his boot, they discovered that a miracle had occurred. The nail had passed between the space between his toes. There was no puncture wound. There was no blood. --- ### [Hidden Nail In Face With Little Pain](https://share.snipd.com/snip/6ac24bf9-2872-4c9e-9e9c-4b4966d07cf3) 🎧 08:57 - 10:45 (01:47) <iframe src="https://share.snipd.com/embed/obsidian-player/snip/1071f3a9-18fe-40ff-8294-a9355ca36752" width="100%" height="100" style="border: none; border-radius: 12px;" sandbox="allow-scripts allow-same-origin allow-forms allow-popups allow-clipboard-write" ></iframe> - Another construction worker was struck by a nail gun but felt little pain and kept working; scans later found a four-inch nail in his face. - His brain perceived safety (saw a nail bury in the wall) so the pain alarm stayed low. #### 💬 Quote > Because he saw that nail shoot across the room and bury in the wall across from him, his brain was under the mistaken impression that the construction worker's body was safe. > — Rachel Zoffness Rachel Zoffness explaining why significant damage produced little pain #### 📚 Transcript **Rachel Zoffness:** That's right. So this construction worker was on a job site in Colorado, and he was using a nail gun. And the nail gun accidentally misfired, and it ricocheted backwards, and it clocked him in the jaw. But he saw a nail go shooting across the room and bury in the wall across from him. So he had like a mild toothache and a mild headache, but he continued on with work and life for six days. So **Shankar Vedantam:** in this case, the nail gun goes off, but he sees the nail embed itself in the wall far away from him. And even though he has a little bit of the recoil that hits his face, he thinks he's basically okay. That's **Rachel Zoffness:** exactly right. And at the end of six days, six days of eating and sleeping and continuing on with life, he turns to his wife and says, you know, I think I'm going to get this toothache checked out. So he goes to a dentist, and the dentist does a scan of his patient's jaw. And much to both men's surprise, they discover a four-inch nail embedded in his face. Wait, **Shankar Vedantam:** I thought you said the nail was basically flying across the room and embedding itself in the wall. **Rachel Zoffness:** That's right. So nail guns, I don't use many nail guns, but nail guns can actually release more than one nail at a time. They have like a rapid release. So he saw a nail shoot across the room and somehow, not sure the physics of this, but somehow a second nail came out of the nail gun and it went up through the bottom of his jaw and into his face. I actually spoke with the surgeon that conducted the surgery, and he said, he's the luckiest guy ever. That nail was protruding into his prefrontal cortex. --- ### [Phantom Pain Shows Pain Lives In The Brain](https://share.snipd.com/snip/94f65e0c-d9c5-43d8-aca9-23f2561252cb) 🎧 15:50 - 17:52 (02:02) <iframe src="https://share.snipd.com/embed/obsidian-player/snip/2d6a2389-ecdd-4471-8480-97eaf13f0ccb" width="100%" height="100" style="border: none; border-radius: 12px;" sandbox="allow-scripts allow-same-origin allow-forms allow-popups allow-clipboard-write" ></iframe> - Pain is constructed by the brain, evident from phantom limb pain where missing limbs still hurt. - Rachel Zoffness notes acute and chronic pain are designed and treated differently, with chronic pain widespread globally. #### 💬 Quote > If you can have terrible leg pain in a leg that is no longer attached to your body, that tells us pretty definitively that pain must be constructed somewhere else. > — Rachel Zoffness Rachel Zoffness on phantom limb pain #### 📚 Transcript **Rachel Zoffness:** You got it. So it's very easy to believe that pain lives exclusively in the body part that hurts, right? So if you have a bad back or you have an aching knee, it's easy to believe that that pain is being constructed exclusively by your back or your knee. But neuroscience tells us that is not true. Pain is ultimately constructed by the brain. And one of the reasons we know this is because of a condition called phantom limb pain. And phantom limb pain occurs when someone loses a limb, an or a leg, and they continue to have terrible pain in the missing body part. Now, if you can have terrible leg pain in a leg that is no longer attached to your body, that tells us pretty definitively that pain must be constructed somewhere else. And we now know that somewhere else **Shankar Vedantam:** is the brain. So one of the animating ideas here, Rachel, is something that we have discussed previously on Hidden Brain. The brain was designed by evolution to help us survive. And survival involves understanding what happened to us in the past. But even more, survival is really about deciding what to do next. And you're arguing that pain, like many other signals that the brain gives us, really about future action rather than merely an accounting of past events. **Rachel Zoffness:** That's right. So pain's job is to protect us. There are people who do not feel very much pain, and they don't live very long. The problem is there's a very big difference between acute pain, which is three months or fewer, and chronic pain, which is three months or longer. They are designed differently, they work differently in the brain and nervous system, and they are treated differently. And the problem is that we have a chronic pain epidemic. --- ### [Pain Requires A Biopsychosocial View](https://share.snipd.com/snip/b12aa201-e010-4195-af8e-8def0295b00d) 🎧 30:35 - 32:59 (02:24) <iframe src="https://share.snipd.com/embed/obsidian-player/snip/4788102b-c043-48d6-9b0a-608c5365bfcb" width="100%" height="100" style="border: none; border-radius: 12px;" sandbox="allow-scripts allow-same-origin allow-forms allow-popups allow-clipboard-write" ></iframe> - Pain is biopsychosocial: biological, psychological, and social factors all overlap to create pain. - Rachel Zoffness emphasizes neglecting psychological and sociological domains misses two thirds of the pain problem. #### 💬 Quote > Pain is more complex and beautiful and nuanced than that. So if you imagine a Venn diagram with three overlapping circles, we have bio on the top, psychological factors and sociological factors and pain lives in the messy middle. > — Rachel Zoffness Rachel Zoffness describing the biopsychosocial model #### 📚 Transcript **Rachel Zoffness:** Right. So if listeners remember nothing else from today's podcast, I hope they remember this word, biopsychosocial. And I want to say clearly, this is not my pet invention. I did not come up with this. Neuroscience has known for 65 years that pain is never a purely biomedical phenomenon, something to do just with bones and body parts. Pain is more complex and beautiful and nuanced than that. So if you imagine a Venn diagram with three overlapping circles, we have bio on the top, biological factors that contribute to pain. We've got psychological factors and we've got sociological factors and pain lives in the messy middle of all the things that make you, you. **Shankar Vedantam:** I'm wondering if you could spend a minute talking about what's in each of those circles, Rachel. **Rachel Zoffness:** Yes. So the bio domain of pain is the one we've all heard the most about. It's genetics and tissue damage, system dysfunction. It's also diet, exercise and sleep. And those are all critically important when it comes to the experience of pain. But what I want us to notice is that if we're only focusing on the bio domain of pain, which is what we do in Western medicine, we are literally missing two thirds of the pain problem. So in the psych domain of pain, we now know negative emotions like stress, anxiety, and depressed mood will amplify the pain alarm, while positive emotions like joy and happiness and relaxation and gratitude will lower the brain's pain alarm. And in the sociological domain of pain, we have social and environmental factors, and that includes socioeconomic status, access to care, race and ethnicity, social support or lack thereof, and our environment, which includes history of abuse and trauma. --- ### [Social Connection Acts As Natural Pain Modulator](https://share.snipd.com/snip/18804f2d-2210-4cdb-a709-43af9aa8d90a) 🎧 34:44 - 36:50 (02:06) <iframe src="https://share.snipd.com/embed/obsidian-player/snip/d66addee-f788-4eee-9728-c846d285267c" width="100%" height="100" style="border: none; border-radius: 12px;" sandbox="allow-scripts allow-same-origin allow-forms allow-popups allow-clipboard-write" ></iframe> - Social connection physiologically reduces pain by releasing dopamine, serotonin, and endogenous opioids, while isolation raises cortisol and worsens pain. - Rachel Zoffness cites research on loneliness raising morbidity and mortality and linking trauma with chronic pain. #### 💬 Quote > When we are with other people, we feel better both emotionally and physically. And when we are isolated, we feel worse physically and emotionally. > — Rachel Zoffness Rachel Zoffness on social factors affecting pain #### 📚 Transcript **Rachel Zoffness:** One of the worst punishments you can give a human being is solitary confinement. What does it say about human beings that one of the worst things you can do to us is isolate us from others? Humans evolved to be social. In fact, social behavior is so critical for our survival that our brains evolved a mechanism to reward us for engaging in it. In the presence of other people, our brains produce feel-good brain like dopamine, which of course is motivation and reward, serotonin, which boosts our mood, and endogenous opioids. When we are with other people, we feel better both emotionally and physically. And when we are isolated, we feel worse physically and emotionally. And there's one more data point I want to share with you. There's been a lot of research conducted on the elderly. And among those who are lonely and isolated and alone, rates of morbidity and mortality are higher rates of disease and death. And so what that means is if you are healthy and you're lonely and isolated and alone, you are more likely to get sick. If you are already sick, you are more likely to get sicker and you are also more likely to die. And there's a number of reasons for this. one of the reasons that I find so compelling is that when we are chronically lonely and isolated, our bodies produce high levels of cortisol, which is a stress hormone that over time suppresses our immune system, which of course affects morbidity and mortality and also pain. Social behavior absolutely and profoundly changes our human body and it has a huge impact on the pain we feel. --- ### [Create A Low Pain Recipe By Changing Habits](https://share.snipd.com/snip/2ffb0dda-997d-4ca6-a4c7-12309783b071) 🎧 37:00 - 39:05 (02:05) <iframe src="https://share.snipd.com/embed/obsidian-player/snip/ba2d5797-5df5-42b8-a359-8ecea007c112" width="100%" height="100" style="border: none; border-radius: 12px;" sandbox="allow-scripts allow-same-origin allow-forms allow-popups allow-clipboard-write" ></iframe> - Map your personal high pain recipe and deliberately build a matching low pain recipe by changing sleep, diet, movement, and social factors. - Rachel Zoffness gives sleep hygiene examples and replacing 'high pain' ingredients with healthier routines. #### 💬 Quote > For every ingredient in the high pain recipe, there is a matching corresponding ingredient that we have the power and agency to change to create what I call a low pain recipe. > — Rachel Zoffness Rachel Zoffness advising how to modify pain 'recipes' #### 📚 Transcript **Shankar Vedantam:** in working with patients who are dealing with pain, you help them improve their sleep and diet and daily rhythms. Talk a little bit about the value of doing this, Rachel. **Rachel Zoffness:** That's right. So just as there's a recipe for brownies, there is always a recipe for pain. And we talked about how pain is biopsychosocial. in this recipe for a high pain day, there are a number of biological, psychological, and sociological ingredients that are going into pain amplification. So I'm going to give you my high pain recipe. and I've had a poor night's sleep and I'm eating a crap diet and I'm not protecting time to move my body and exercise and I'm socially isolated, I know that combined with some other ingredients, that is going to construct what I like to call a high pain recipe. Now, the really cool thing about constructing pain recipes with my patients is that as soon as I'm able to help them map out a high pain recipe, we are then able to construct a low pain recipe. And a low pain recipe is often just the opposite. So I mentioned poor sleep. Poor sleep for me is a predictor of high pain. So I know that if I want to change my pain recipe, I need to start implementing a sleep protocol. For example, for myself, I know that I need to set a sleep time and a wake time. I know that I need to stop doom scrolling before bed and put my phone away a couple of hours before getting into bed. I know that if I can't sleep and I'm getting anxious and restless, I need to get out of bed and go somewhere else and not lay in bed feeling restless and anxious. So for every ingredient in the high pain recipe, there is a matching corresponding ingredient that we have the power and agency to change to create what I call a low pain recipe. --- ### [Challenge Pain Voice With Detective Questions](https://share.snipd.com/snip/0aee3710-5a3d-475d-b245-8a39afbb34bb) 🎧 41:30 - 42:47 (01:17) <iframe src="https://share.snipd.com/embed/obsidian-player/snip/a0589ff9-da04-4f3b-8ed0-3658850d3bc7" width="100%" height="100" style="border: none; border-radius: 12px;" sandbox="allow-scripts allow-same-origin allow-forms allow-popups allow-clipboard-write" ></iframe> - Use detective questions to challenge 'pain voice' negative predictions and test whether thoughts are factual. - Ask 'Is this thought a fact?' to separate protective pain voice from reality and reduce fear-driven immobilization. #### 💬 Quote > One detective question that I like to recommend is, is this thought a fact? And by fact, I mean unquestionably, undeniably, absolutely true. > — Rachel Zoffness Rachel Zoffness on reframing negative pain-related thoughts #### 📚 Transcript **Rachel Zoffness:** of my favorite strategies for dealing with pain voice is this strategy called using detective questions. And by that I mean pain voice likes to speak in hyperbole and negative predictions that actually aren't rooted in reality. the only way sometimes for us to see for sure that the thought is just a thought and not a fact is to test its veracity. And by testing its veracity, I mean, I'm going to sit down and ask those thoughts some questions. And I call these detective questions because I want to investigate whether thought is true or whether it's a trap. Because chances are high if it's pain voice, it's trapping me into being scared and immobilized in order to protect me. Again, pain voice isn't mean. It's just trying to protect you and keep you immobilized until you get the help you need. So one detective question that I like to recommend is, is this thought a fact? And by fact, I mean unquestionably, undeniably, absolutely true. So the thought you offered, I'm broken, I'll never get better. Is that a fact? --- ### [Sister's Gummy Swap Triggered Placebo Relief](https://share.snipd.com/snip/6b1b1154-9dfb-430e-be80-c035c4386a9f) 🎧 44:05 - 46:50 (02:45) <iframe src="https://share.snipd.com/embed/obsidian-player/snip/6c2bad1d-2f3e-45b2-ae6f-d0ff051a0c0a" width="100%" height="100" style="border: none; border-radius: 12px;" sandbox="allow-scripts allow-same-origin allow-forms allow-popups allow-clipboard-write" ></iframe> - Kai's sister swapped CBD gummies for regular cherry gummies and his pain vanished after sleep, demonstrating a powerful placebo effect. - The experiment revealed expectation and routine (sleep) lowered Kai's brain pain alarm repeatedly over a week. #### 💬 Quote > She handed him a regular cherry gummy bear. He got sleepy and tired. He wheeled himself into the living room. He lay down on the couch. He fell asleep. And when he woke up, his pain was gone. > — Rachel Zoffness Rachel Zoffness recounting Kai's placebo story #### 📚 Transcript **Rachel Zoffness:** Kai was a patient I had, I believe he was in his 40s, and he was wheeled into my office by his sister, Iko. He had a condition called Fabry disease, and he wasn't able to go to work, and his pain was so terrible that he couldn't wear shoes or even cut his toenails. So he had these extremely long toenails that looked like talons, and it really just stood out to me because he wasn't even able to touch his own feet. As I got to know Iko and Kai, we talked about the science of pain. We talked about the role of the brain. We started putting together his pain recipe. And as we were on this journey together, Kai was prescribed by a trusted provider, CBD gummies. And so Kai went home and his sister gave him one of these CBD gummies. And if I remember correctly, it cherry flavored and bear shaped. And he took the CBD gummy and it made him very sleepy. And he wheeled himself into the living room and he laid down on the couch and he fell asleep. And when he woke up, his pain was gone and he couldn't believe it. And he stood up and he even touched his feet and he put on his shoes and he called his sister into the room. They were both astonished. And when he woke up the next morning, the pain had returned. So the next day they went through the same routine. She gave him a CBD gummy. He wheeled himself into the living room, lay down on the couch, fell asleep. When he woke up, the pain was gone. Now, his sister wondered if maybe there was more to it than just that. She wondered if his predictions and his expectations also had something to do with it. So she conducted an experiment. Without my knowledge, I did not know she was doing this, but she went to the store. She bought regular cherry gummy bears, and she swapped out his CBD gummies for these regular cherry gummies. And the next day, Kai came in to get his medication. She handed him a regular cherry gummy bear. And here's what happened. He got sleepy and tired. He wheeled himself into the living room. He lay down on the couch. He fell asleep. And when he woke up, his pain was gone. And Iko was astonished. And of course, Kai didn't even know that his gummies had been swapped out. And Iko did this every day for a week. She gave him a placebo gummy. Kai's pain disappeared. And the next day when the placebo effect wore off, she would give him a new regular cherry gummy bear. And after a week, she told me she felt so guilty that she told Kai what she had done and expected him to be enraged. --- ### [Pacing Protocol Helped Bedbound Teen Recover](https://share.snipd.com/snip/4eb73b8e-e18e-48dc-850e-ca2e8f45202b) 🎧 48:14 - 51:28 (03:14) <iframe src="https://share.snipd.com/embed/obsidian-player/snip/c17ee0af-f4a6-4462-b562-1c00ee3271d6" width="100%" height="100" style="border: none; border-radius: 12px;" sandbox="allow-scripts allow-same-origin allow-forms allow-popups allow-clipboard-write" ></iframe> - Sam, a 17-year-old bedbound for four years, improved by stepwise 'pacing' and targeting sleep, diet, movement, and social reengagement. - Rachel Zoffness describes concrete pacing steps from standing outside to walking around the block and reconnecting with friends. #### 💬 Quote > Week one, he got out of bed and he stood outside on the porch in the sun. Week two, he walked to the corner mailbox and he texted just one friend. Week three, he walked around the block and he invited a friend over. > — Rachel Zoffness Rachel Zoffness on Sam's recovery using pacing and lifestyle changes #### 📚 Transcript **Rachel Zoffness:** I first met Sam, he was 17 years old. He had been in bed for four years. He had long unwashed hair. was pasty and pale, and he was rocking himself back and forth on my couch with the pain. So he had been diagnosed with chronic migraine and diffuse amplified body pain of unknown etiology, meaning he had seen a bazillion doctors, something like 14 of them, and he had been on 40 medications, but nothing had helped, and no one really understood why Sam was in so much pain. So by training, I've been studying pain neuroscience, pain biology, and pain psychology for 35 years, but I think of myself really as a pain detective because it's my job to look at all of the biopsychosocial factors that are going into creating and amplifying the pain to see what I can do to help turn pain volume down. So as I conducted an assessment of Sam, I quickly learned that Sam had been living with crippling social anxiety and suicidality for many years without relief or adequate He was also sleeping poorly. He was up playing video games until four in the morning. He was on what I like to call a white food diet, which is not uncommon in America, where he was eating pizza, pasta, chips, and cereal, but he just didn't like fruits and vegetables, and so he wasn't eating them. And what became clear to me was that if I wanted to help Sam, I needed to help him target all of the ingredients in his recipe. Medications alone just weren't going to cut it, and of course they hadn't. So I met with Sam and his parents and we introduced him to fruits and vegetables, one per meal. We put Sam on a sleep hygiene protocol to help him improve his sleep. And I put him also on a pacing protocol. And we said before that pacing for pain is much like pacing for a marathon. what that meant for Sam, who had been bedbound for four years and had been completely socially isolated and depressed and alone, was that week one, he got out of bed and he stood outside on the porch in the sun. That was step one of his pacing protocol. Week two, he walked to the corner mailbox and he texted just one friend. Week three, he walked around the block and he invited a friend over to watch a movie. And you'll notice, you know, we're targeting sleep, we're targeting social behavior, we're targeting movement, we're targeting nutrition, we're targeting his mood and his physical health. All of the things we're targeting. And Sam also got a tutor and he started catching up in school. And here's what happened. As Sam's social and emotional and physical health started to improve, pain volume started to go down. --- Created with [Snipd](https://www.snipd.com) | Highlight & Take Notes from Podcasts # Snips updated after 2026-07-21T23:35:10 ### [Pain Is A Constructed Danger Alarm](https://share.snipd.com/snip/375ae637-b170-4516-8ea8-7963892410d5) 🎧 03:46 - 08:02 (04:16) <iframe src="https://share.snipd.com/embed/obsidian-player/snip/f7aab416-2e8d-4407-bce3-15c1dd957681" width="100%" height="100" style="border: none; border-radius: 12px;" sandbox="allow-scripts allow-same-origin allow-forms allow-popups allow-clipboard-write" ></iframe> - Pain is a brain-made danger alarm rather than a direct readout of tissue damage. - Rachel Zoffness explains the brain uses sensory data, memories, emotions, and social cues to decide whether to generate pain and how much. #### 💬 Quote > Our brain is our body's danger detector. That's our brain's job, is to save our lives. And pain is our body's warning system. > — Rachel Zoffness Rachel Zoffness on how the brain constructs pain #### 📚 Transcript **Shankar Vedantam:** But is that really all there is to it? At the University of California, San Francisco, psychologist Rachel Zofnitz studies the nature of pain. She has found that our minds play a much larger role in our experience of pain than many of us realize. And they also play a much larger role in how we need to deal with pain. Rachel Zofnitz, welcome to Hidden Brain. One **Rachel Zoffness:** of my favorite ever podcasts. I'm so honored to be here. **Shankar Vedantam:** Rachel, as you began your own research training, you were taught a one-dimensional biomedical **Rachel Zoffness:** model of pain. Can you describe that model for me? Absolutely. antiquated way of looking at disease and pain that focuses primarily, if not exclusively, on anatomy and physiology and bones and body parts. And what that means in the biomedical frame of things is that when we talk about treating pain, we also talk primarily, if not exclusively, about biomedical solutions. And that takes the form of pills and procedures. So here's what I observe as a clinician and pain researcher. What I observe is that if you have chronic knee pain, you will be sent to 762 knee specialists, but we never talk about your brain at **Shankar Vedantam:** all. So early on in your own training, Rachel, you encountered a pair of clinical cases documented in the medical literature, which got you thinking about pain in a different way. One was about a 29-year construction worker who got injured. Can you set up the scene for me and describe what happened to this worker? **Rachel Zoffness:** I love these two stories, and I call them a tale of two nails, because who doesn't like rhymes? So yes, the first story, the first tale of nails, is a construction worker who was working on a job site when he jumped off a plank straight onto a seven-inch nail. And that nail drove through his boot clear through to the other side. Oh my God. Yes. **Shankar Vedantam:** So the pain must have just been excruciating. **Rachel Zoffness:** It was excruciating. And his colleagues rushed him off to the emergency department. And he was sedated with a lot of good drugs, like, you know, fentanyl and other opioids. And when the good doctors removed his boot, they discovered that a miracle had occurred. The nail had passed between the space between his toes. There was no puncture wound. There was no blood. And there was no tissue damage. **Shankar Vedantam:** Well, but why was he in such excruciating pain? It makes no sense, right? **Rachel Zoffness:** So here's what pain science tells us, which is so important and fascinating about the science of pain. Our brain is our body's danger detector. That's our brain's job, is to save our lives. And pain is our body's warning system. It's our danger detection system. So brain, including this construction worker's brain, used all available information to decide whether or not to make pain and how much. knowledge of his dangerous work environment. It included memories of past pain experiences, which, by the way, are stored in our hippocampus. It used data from his five senses, including this visual of this giant nail sticking out of his boot. It incorporated emotions like panic. And because his brain perceived potential threat of danger, it made pain to protect him. And I'm using those words on purpose. His brain perceived potential danger. And so it made pain to protect him. --- ### [Miracle Nail In Boot Caused Severe Pain](https://share.snipd.com/snip/534046d7-6d30-4511-bd4d-494c01fd4543) 🎧 05:39 - 06:36 (00:57) <iframe src="https://share.snipd.com/embed/obsidian-player/snip/f5ce3113-a88b-4954-9843-c5da1cc0c68c" width="100%" height="100" style="border: none; border-radius: 12px;" sandbox="allow-scripts allow-same-origin allow-forms allow-popups allow-clipboard-write" ></iframe> - A construction worker jumped on a seven-inch nail and reported excruciating pain despite no tissue damage. - The brain amplified pain because visual threat, panic, and social alarm signaled danger at the scene. #### 💬 Quote > When the good doctors removed his boot, they discovered that a miracle had occurred. The nail had passed between the space between his toes. There was no puncture wound. There was no blood. And there was no tissue damage. > — Rachel Zoffness Rachel Zoffness recounting the construction worker anecdote #### 📚 Transcript **Rachel Zoffness:** I love these two stories, and I call them a tale of two nails, because who doesn't like rhymes? So yes, the first story, the first tale of nails, is a construction worker who was working on a job site when he jumped off a plank straight onto a seven-inch nail. And that nail drove through his boot clear through to the other side. Oh my God. Yes. **Shankar Vedantam:** So the pain must have just been excruciating. **Rachel Zoffness:** It was excruciating. And his colleagues rushed him off to the emergency department. And he was sedated with a lot of good drugs, like, you know, fentanyl and other opioids. And when the good doctors removed his boot, they discovered that a miracle had occurred. The nail had passed between the space between his toes. There was no puncture wound. There was no blood. --- ### [Hidden Nail In Face With Little Pain](https://share.snipd.com/snip/6ac24bf9-2872-4c9e-9e9c-4b4966d07cf3) 🎧 08:57 - 10:45 (01:47) <iframe src="https://share.snipd.com/embed/obsidian-player/snip/1071f3a9-18fe-40ff-8294-a9355ca36752" width="100%" height="100" style="border: none; border-radius: 12px;" sandbox="allow-scripts allow-same-origin allow-forms allow-popups allow-clipboard-write" ></iframe> - Another construction worker was struck by a nail gun but felt little pain and kept working; scans later found a four-inch nail in his face. - His brain perceived safety (saw a nail bury in the wall) so the pain alarm stayed low. #### 💬 Quote > Because he saw that nail shoot across the room and bury in the wall across from him, his brain was under the mistaken impression that the construction worker's body was safe. > — Rachel Zoffness Rachel Zoffness explaining why significant damage produced little pain #### 📚 Transcript **Rachel Zoffness:** That's right. So this construction worker was on a job site in Colorado, and he was using a nail gun. And the nail gun accidentally misfired, and it ricocheted backwards, and it clocked him in the jaw. But he saw a nail go shooting across the room and bury in the wall across from him. So he had like a mild toothache and a mild headache, but he continued on with work and life for six days. So **Shankar Vedantam:** in this case, the nail gun goes off, but he sees the nail embed itself in the wall far away from him. And even though he has a little bit of the recoil that hits his face, he thinks he's basically okay. That's **Rachel Zoffness:** exactly right. And at the end of six days, six days of eating and sleeping and continuing on with life, he turns to his wife and says, you know, I think I'm going to get this toothache checked out. So he goes to a dentist, and the dentist does a scan of his patient's jaw. And much to both men's surprise, they discover a four-inch nail embedded in his face. Wait, **Shankar Vedantam:** I thought you said the nail was basically flying across the room and embedding itself in the wall. **Rachel Zoffness:** That's right. So nail guns, I don't use many nail guns, but nail guns can actually release more than one nail at a time. They have like a rapid release. So he saw a nail shoot across the room and somehow, not sure the physics of this, but somehow a second nail came out of the nail gun and it went up through the bottom of his jaw and into his face. I actually spoke with the surgeon that conducted the surgery, and he said, he's the luckiest guy ever. That nail was protruding into his prefrontal cortex. --- ### [Phantom Pain Shows Pain Lives In The Brain](https://share.snipd.com/snip/94f65e0c-d9c5-43d8-aca9-23f2561252cb) 🎧 15:50 - 17:52 (02:02) <iframe src="https://share.snipd.com/embed/obsidian-player/snip/2d6a2389-ecdd-4471-8480-97eaf13f0ccb" width="100%" height="100" style="border: none; border-radius: 12px;" sandbox="allow-scripts allow-same-origin allow-forms allow-popups allow-clipboard-write" ></iframe> - Pain is constructed by the brain, evident from phantom limb pain where missing limbs still hurt. - Rachel Zoffness notes acute and chronic pain are designed and treated differently, with chronic pain widespread globally. #### 💬 Quote > If you can have terrible leg pain in a leg that is no longer attached to your body, that tells us pretty definitively that pain must be constructed somewhere else. > — Rachel Zoffness Rachel Zoffness on phantom limb pain #### 📚 Transcript **Rachel Zoffness:** You got it. So it's very easy to believe that pain lives exclusively in the body part that hurts, right? So if you have a bad back or you have an aching knee, it's easy to believe that that pain is being constructed exclusively by your back or your knee. But neuroscience tells us that is not true. Pain is ultimately constructed by the brain. And one of the reasons we know this is because of a condition called phantom limb pain. And phantom limb pain occurs when someone loses a limb, an or a leg, and they continue to have terrible pain in the missing body part. Now, if you can have terrible leg pain in a leg that is no longer attached to your body, that tells us pretty definitively that pain must be constructed somewhere else. And we now know that somewhere else **Shankar Vedantam:** is the brain. So one of the animating ideas here, Rachel, is something that we have discussed previously on Hidden Brain. The brain was designed by evolution to help us survive. And survival involves understanding what happened to us in the past. But even more, survival is really about deciding what to do next. And you're arguing that pain, like many other signals that the brain gives us, really about future action rather than merely an accounting of past events. **Rachel Zoffness:** That's right. So pain's job is to protect us. There are people who do not feel very much pain, and they don't live very long. The problem is there's a very big difference between acute pain, which is three months or fewer, and chronic pain, which is three months or longer. They are designed differently, they work differently in the brain and nervous system, and they are treated differently. And the problem is that we have a chronic pain epidemic. --- ### [Pain Requires A Biopsychosocial View](https://share.snipd.com/snip/b12aa201-e010-4195-af8e-8def0295b00d) 🎧 30:35 - 32:59 (02:24) <iframe src="https://share.snipd.com/embed/obsidian-player/snip/4788102b-c043-48d6-9b0a-608c5365bfcb" width="100%" height="100" style="border: none; border-radius: 12px;" sandbox="allow-scripts allow-same-origin allow-forms allow-popups allow-clipboard-write" ></iframe> - Pain is biopsychosocial: biological, psychological, and social factors all overlap to create pain. - Rachel Zoffness emphasizes neglecting psychological and sociological domains misses two thirds of the pain problem. #### 💬 Quote > Pain is more complex and beautiful and nuanced than that. So if you imagine a Venn diagram with three overlapping circles, we have bio on the top, psychological factors and sociological factors and pain lives in the messy middle. > — Rachel Zoffness Rachel Zoffness describing the biopsychosocial model #### 📚 Transcript **Rachel Zoffness:** Right. So if listeners remember nothing else from today's podcast, I hope they remember this word, biopsychosocial. And I want to say clearly, this is not my pet invention. I did not come up with this. Neuroscience has known for 65 years that pain is never a purely biomedical phenomenon, something to do just with bones and body parts. Pain is more complex and beautiful and nuanced than that. So if you imagine a Venn diagram with three overlapping circles, we have bio on the top, biological factors that contribute to pain. We've got psychological factors and we've got sociological factors and pain lives in the messy middle of all the things that make you, you. **Shankar Vedantam:** I'm wondering if you could spend a minute talking about what's in each of those circles, Rachel. **Rachel Zoffness:** Yes. So the bio domain of pain is the one we've all heard the most about. It's genetics and tissue damage, system dysfunction. It's also diet, exercise and sleep. And those are all critically important when it comes to the experience of pain. But what I want us to notice is that if we're only focusing on the bio domain of pain, which is what we do in Western medicine, we are literally missing two thirds of the pain problem. So in the psych domain of pain, we now know negative emotions like stress, anxiety, and depressed mood will amplify the pain alarm, while positive emotions like joy and happiness and relaxation and gratitude will lower the brain's pain alarm. And in the sociological domain of pain, we have social and environmental factors, and that includes socioeconomic status, access to care, race and ethnicity, social support or lack thereof, and our environment, which includes history of abuse and trauma. --- ### [Social Connection Acts As Natural Pain Modulator](https://share.snipd.com/snip/18804f2d-2210-4cdb-a709-43af9aa8d90a) 🎧 34:44 - 36:50 (02:06) <iframe src="https://share.snipd.com/embed/obsidian-player/snip/d66addee-f788-4eee-9728-c846d285267c" width="100%" height="100" style="border: none; border-radius: 12px;" sandbox="allow-scripts allow-same-origin allow-forms allow-popups allow-clipboard-write" ></iframe> - Social connection physiologically reduces pain by releasing dopamine, serotonin, and endogenous opioids, while isolation raises cortisol and worsens pain. - Rachel Zoffness cites research on loneliness raising morbidity and mortality and linking trauma with chronic pain. #### 💬 Quote > When we are with other people, we feel better both emotionally and physically. And when we are isolated, we feel worse physically and emotionally. > — Rachel Zoffness Rachel Zoffness on social factors affecting pain #### 📚 Transcript **Rachel Zoffness:** One of the worst punishments you can give a human being is solitary confinement. What does it say about human beings that one of the worst things you can do to us is isolate us from others? Humans evolved to be social. In fact, social behavior is so critical for our survival that our brains evolved a mechanism to reward us for engaging in it. In the presence of other people, our brains produce feel-good brain like dopamine, which of course is motivation and reward, serotonin, which boosts our mood, and endogenous opioids. When we are with other people, we feel better both emotionally and physically. And when we are isolated, we feel worse physically and emotionally. And there's one more data point I want to share with you. There's been a lot of research conducted on the elderly. And among those who are lonely and isolated and alone, rates of morbidity and mortality are higher rates of disease and death. And so what that means is if you are healthy and you're lonely and isolated and alone, you are more likely to get sick. If you are already sick, you are more likely to get sicker and you are also more likely to die. And there's a number of reasons for this. one of the reasons that I find so compelling is that when we are chronically lonely and isolated, our bodies produce high levels of cortisol, which is a stress hormone that over time suppresses our immune system, which of course affects morbidity and mortality and also pain. Social behavior absolutely and profoundly changes our human body and it has a huge impact on the pain we feel. --- ### [Create A Low Pain Recipe By Changing Habits](https://share.snipd.com/snip/2ffb0dda-997d-4ca6-a4c7-12309783b071) 🎧 37:00 - 39:05 (02:05) <iframe src="https://share.snipd.com/embed/obsidian-player/snip/ba2d5797-5df5-42b8-a359-8ecea007c112" width="100%" height="100" style="border: none; border-radius: 12px;" sandbox="allow-scripts allow-same-origin allow-forms allow-popups allow-clipboard-write" ></iframe> - Map your personal high pain recipe and deliberately build a matching low pain recipe by changing sleep, diet, movement, and social factors. - Rachel Zoffness gives sleep hygiene examples and replacing 'high pain' ingredients with healthier routines. #### 💬 Quote > For every ingredient in the high pain recipe, there is a matching corresponding ingredient that we have the power and agency to change to create what I call a low pain recipe. > — Rachel Zoffness Rachel Zoffness advising how to modify pain 'recipes' #### 📚 Transcript **Shankar Vedantam:** in working with patients who are dealing with pain, you help them improve their sleep and diet and daily rhythms. Talk a little bit about the value of doing this, Rachel. **Rachel Zoffness:** That's right. So just as there's a recipe for brownies, there is always a recipe for pain. And we talked about how pain is biopsychosocial. in this recipe for a high pain day, there are a number of biological, psychological, and sociological ingredients that are going into pain amplification. So I'm going to give you my high pain recipe. and I've had a poor night's sleep and I'm eating a crap diet and I'm not protecting time to move my body and exercise and I'm socially isolated, I know that combined with some other ingredients, that is going to construct what I like to call a high pain recipe. Now, the really cool thing about constructing pain recipes with my patients is that as soon as I'm able to help them map out a high pain recipe, we are then able to construct a low pain recipe. And a low pain recipe is often just the opposite. So I mentioned poor sleep. Poor sleep for me is a predictor of high pain. So I know that if I want to change my pain recipe, I need to start implementing a sleep protocol. For example, for myself, I know that I need to set a sleep time and a wake time. I know that I need to stop doom scrolling before bed and put my phone away a couple of hours before getting into bed. I know that if I can't sleep and I'm getting anxious and restless, I need to get out of bed and go somewhere else and not lay in bed feeling restless and anxious. So for every ingredient in the high pain recipe, there is a matching corresponding ingredient that we have the power and agency to change to create what I call a low pain recipe. --- ### [Challenge Pain Voice With Detective Questions](https://share.snipd.com/snip/0aee3710-5a3d-475d-b245-8a39afbb34bb) 🎧 41:30 - 42:47 (01:17) <iframe src="https://share.snipd.com/embed/obsidian-player/snip/a0589ff9-da04-4f3b-8ed0-3658850d3bc7" width="100%" height="100" style="border: none; border-radius: 12px;" sandbox="allow-scripts allow-same-origin allow-forms allow-popups allow-clipboard-write" ></iframe> - Use detective questions to challenge 'pain voice' negative predictions and test whether thoughts are factual. - Ask 'Is this thought a fact?' to separate protective pain voice from reality and reduce fear-driven immobilization. #### 💬 Quote > One detective question that I like to recommend is, is this thought a fact? And by fact, I mean unquestionably, undeniably, absolutely true. > — Rachel Zoffness Rachel Zoffness on reframing negative pain-related thoughts #### 📚 Transcript **Rachel Zoffness:** of my favorite strategies for dealing with pain voice is this strategy called using detective questions. And by that I mean pain voice likes to speak in hyperbole and negative predictions that actually aren't rooted in reality. the only way sometimes for us to see for sure that the thought is just a thought and not a fact is to test its veracity. And by testing its veracity, I mean, I'm going to sit down and ask those thoughts some questions. And I call these detective questions because I want to investigate whether thought is true or whether it's a trap. Because chances are high if it's pain voice, it's trapping me into being scared and immobilized in order to protect me. Again, pain voice isn't mean. It's just trying to protect you and keep you immobilized until you get the help you need. So one detective question that I like to recommend is, is this thought a fact? And by fact, I mean unquestionably, undeniably, absolutely true. So the thought you offered, I'm broken, I'll never get better. Is that a fact? --- ### [Sister's Gummy Swap Triggered Placebo Relief](https://share.snipd.com/snip/6b1b1154-9dfb-430e-be80-c035c4386a9f) 🎧 44:05 - 46:50 (02:45) <iframe src="https://share.snipd.com/embed/obsidian-player/snip/6c2bad1d-2f3e-45b2-ae6f-d0ff051a0c0a" width="100%" height="100" style="border: none; border-radius: 12px;" sandbox="allow-scripts allow-same-origin allow-forms allow-popups allow-clipboard-write" ></iframe> - Kai's sister swapped CBD gummies for regular cherry gummies and his pain vanished after sleep, demonstrating a powerful placebo effect. - The experiment revealed expectation and routine (sleep) lowered Kai's brain pain alarm repeatedly over a week. #### 💬 Quote > She handed him a regular cherry gummy bear. He got sleepy and tired. He wheeled himself into the living room. He lay down on the couch. He fell asleep. And when he woke up, his pain was gone. > — Rachel Zoffness Rachel Zoffness recounting Kai's placebo story #### 📚 Transcript **Rachel Zoffness:** Kai was a patient I had, I believe he was in his 40s, and he was wheeled into my office by his sister, Iko. He had a condition called Fabry disease, and he wasn't able to go to work, and his pain was so terrible that he couldn't wear shoes or even cut his toenails. So he had these extremely long toenails that looked like talons, and it really just stood out to me because he wasn't even able to touch his own feet. As I got to know Iko and Kai, we talked about the science of pain. We talked about the role of the brain. We started putting together his pain recipe. And as we were on this journey together, Kai was prescribed by a trusted provider, CBD gummies. And so Kai went home and his sister gave him one of these CBD gummies. And if I remember correctly, it cherry flavored and bear shaped. And he took the CBD gummy and it made him very sleepy. And he wheeled himself into the living room and he laid down on the couch and he fell asleep. And when he woke up, his pain was gone and he couldn't believe it. And he stood up and he even touched his feet and he put on his shoes and he called his sister into the room. They were both astonished. And when he woke up the next morning, the pain had returned. So the next day they went through the same routine. She gave him a CBD gummy. He wheeled himself into the living room, lay down on the couch, fell asleep. When he woke up, the pain was gone. Now, his sister wondered if maybe there was more to it than just that. She wondered if his predictions and his expectations also had something to do with it. So she conducted an experiment. Without my knowledge, I did not know she was doing this, but she went to the store. She bought regular cherry gummy bears, and she swapped out his CBD gummies for these regular cherry gummies. And the next day, Kai came in to get his medication. She handed him a regular cherry gummy bear. And here's what happened. He got sleepy and tired. He wheeled himself into the living room. He lay down on the couch. He fell asleep. And when he woke up, his pain was gone. And Iko was astonished. And of course, Kai didn't even know that his gummies had been swapped out. And Iko did this every day for a week. She gave him a placebo gummy. Kai's pain disappeared. And the next day when the placebo effect wore off, she would give him a new regular cherry gummy bear. And after a week, she told me she felt so guilty that she told Kai what she had done and expected him to be enraged. --- ### [Pacing Protocol Helped Bedbound Teen Recover](https://share.snipd.com/snip/4eb73b8e-e18e-48dc-850e-ca2e8f45202b) 🎧 48:14 - 51:28 (03:14) <iframe src="https://share.snipd.com/embed/obsidian-player/snip/c17ee0af-f4a6-4462-b562-1c00ee3271d6" width="100%" height="100" style="border: none; border-radius: 12px;" sandbox="allow-scripts allow-same-origin allow-forms allow-popups allow-clipboard-write" ></iframe> - Sam, a 17-year-old bedbound for four years, improved by stepwise 'pacing' and targeting sleep, diet, movement, and social reengagement. - Rachel Zoffness describes concrete pacing steps from standing outside to walking around the block and reconnecting with friends. #### 💬 Quote > Week one, he got out of bed and he stood outside on the porch in the sun. Week two, he walked to the corner mailbox and he texted just one friend. Week three, he walked around the block and he invited a friend over. > — Rachel Zoffness Rachel Zoffness on Sam's recovery using pacing and lifestyle changes #### 📚 Transcript **Rachel Zoffness:** I first met Sam, he was 17 years old. He had been in bed for four years. He had long unwashed hair. was pasty and pale, and he was rocking himself back and forth on my couch with the pain. So he had been diagnosed with chronic migraine and diffuse amplified body pain of unknown etiology, meaning he had seen a bazillion doctors, something like 14 of them, and he had been on 40 medications, but nothing had helped, and no one really understood why Sam was in so much pain. So by training, I've been studying pain neuroscience, pain biology, and pain psychology for 35 years, but I think of myself really as a pain detective because it's my job to look at all of the biopsychosocial factors that are going into creating and amplifying the pain to see what I can do to help turn pain volume down. So as I conducted an assessment of Sam, I quickly learned that Sam had been living with crippling social anxiety and suicidality for many years without relief or adequate He was also sleeping poorly. He was up playing video games until four in the morning. He was on what I like to call a white food diet, which is not uncommon in America, where he was eating pizza, pasta, chips, and cereal, but he just didn't like fruits and vegetables, and so he wasn't eating them. And what became clear to me was that if I wanted to help Sam, I needed to help him target all of the ingredients in his recipe. Medications alone just weren't going to cut it, and of course they hadn't. So I met with Sam and his parents and we introduced him to fruits and vegetables, one per meal. We put Sam on a sleep hygiene protocol to help him improve his sleep. And I put him also on a pacing protocol. And we said before that pacing for pain is much like pacing for a marathon. what that meant for Sam, who had been bedbound for four years and had been completely socially isolated and depressed and alone, was that week one, he got out of bed and he stood outside on the porch in the sun. That was step one of his pacing protocol. Week two, he walked to the corner mailbox and he texted just one friend. Week three, he walked around the block and he invited a friend over to watch a movie. And you'll notice, you know, we're targeting sleep, we're targeting social behavior, we're targeting movement, we're targeting nutrition, we're targeting his mood and his physical health. All of the things we're targeting. And Sam also got a tutor and he started catching up in school. And here's what happened. As Sam's social and emotional and physical health started to improve, pain volume started to go down. --- # Snips updated after 2026-07-21T23:50:49 ### [Pain Is A Constructed Danger Alarm](https://share.snipd.com/snip/375ae637-b170-4516-8ea8-7963892410d5) 🎧 03:46 - 08:02 (04:16) <iframe src="https://share.snipd.com/embed/obsidian-player/snip/f7aab416-2e8d-4407-bce3-15c1dd957681" width="100%" height="100" style="border: none; border-radius: 12px;" sandbox="allow-scripts allow-same-origin allow-forms allow-popups allow-clipboard-write" ></iframe> - Pain is a brain-made danger alarm rather than a direct readout of tissue damage. - Rachel Zoffness explains the brain uses sensory data, memories, emotions, and social cues to decide whether to generate pain and how much. #### 💬 Quote > Our brain is our body's danger detector. That's our brain's job, is to save our lives. And pain is our body's warning system. > — Rachel Zoffness Rachel Zoffness on how the brain constructs pain #### 📚 Transcript **Shankar Vedantam:** But is that really all there is to it? At the University of California, San Francisco, psychologist Rachel Zofnitz studies the nature of pain. She has found that our minds play a much larger role in our experience of pain than many of us realize. And they also play a much larger role in how we need to deal with pain. Rachel Zofnitz, welcome to Hidden Brain. One **Rachel Zoffness:** of my favorite ever podcasts. I'm so honored to be here. **Shankar Vedantam:** Rachel, as you began your own research training, you were taught a one-dimensional biomedical **Rachel Zoffness:** model of pain. Can you describe that model for me? Absolutely. antiquated way of looking at disease and pain that focuses primarily, if not exclusively, on anatomy and physiology and bones and body parts. And what that means in the biomedical frame of things is that when we talk about treating pain, we also talk primarily, if not exclusively, about biomedical solutions. And that takes the form of pills and procedures. So here's what I observe as a clinician and pain researcher. What I observe is that if you have chronic knee pain, you will be sent to 762 knee specialists, but we never talk about your brain at **Shankar Vedantam:** all. So early on in your own training, Rachel, you encountered a pair of clinical cases documented in the medical literature, which got you thinking about pain in a different way. One was about a 29-year construction worker who got injured. Can you set up the scene for me and describe what happened to this worker? **Rachel Zoffness:** I love these two stories, and I call them a tale of two nails, because who doesn't like rhymes? So yes, the first story, the first tale of nails, is a construction worker who was working on a job site when he jumped off a plank straight onto a seven-inch nail. And that nail drove through his boot clear through to the other side. Oh my God. Yes. **Shankar Vedantam:** So the pain must have just been excruciating. **Rachel Zoffness:** It was excruciating. And his colleagues rushed him off to the emergency department. And he was sedated with a lot of good drugs, like, you know, fentanyl and other opioids. And when the good doctors removed his boot, they discovered that a miracle had occurred. The nail had passed between the space between his toes. There was no puncture wound. There was no blood. And there was no tissue damage. **Shankar Vedantam:** Well, but why was he in such excruciating pain? It makes no sense, right? **Rachel Zoffness:** So here's what pain science tells us, which is so important and fascinating about the science of pain. Our brain is our body's danger detector. That's our brain's job, is to save our lives. And pain is our body's warning system. It's our danger detection system. So brain, including this construction worker's brain, used all available information to decide whether or not to make pain and how much. knowledge of his dangerous work environment. It included memories of past pain experiences, which, by the way, are stored in our hippocampus. It used data from his five senses, including this visual of this giant nail sticking out of his boot. It incorporated emotions like panic. And because his brain perceived potential threat of danger, it made pain to protect him. And I'm using those words on purpose. His brain perceived potential danger. And so it made pain to protect him. --- ### [Miracle Nail In Boot Caused Severe Pain](https://share.snipd.com/snip/534046d7-6d30-4511-bd4d-494c01fd4543) 🎧 05:39 - 06:36 (00:57) <iframe src="https://share.snipd.com/embed/obsidian-player/snip/f5ce3113-a88b-4954-9843-c5da1cc0c68c" width="100%" height="100" style="border: none; border-radius: 12px;" sandbox="allow-scripts allow-same-origin allow-forms allow-popups allow-clipboard-write" ></iframe> - A construction worker jumped on a seven-inch nail and reported excruciating pain despite no tissue damage. - The brain amplified pain because visual threat, panic, and social alarm signaled danger at the scene. #### 💬 Quote > When the good doctors removed his boot, they discovered that a miracle had occurred. The nail had passed between the space between his toes. There was no puncture wound. There was no blood. And there was no tissue damage. > — Rachel Zoffness Rachel Zoffness recounting the construction worker anecdote #### 📚 Transcript **Rachel Zoffness:** I love these two stories, and I call them a tale of two nails, because who doesn't like rhymes? So yes, the first story, the first tale of nails, is a construction worker who was working on a job site when he jumped off a plank straight onto a seven-inch nail. And that nail drove through his boot clear through to the other side. Oh my God. Yes. **Shankar Vedantam:** So the pain must have just been excruciating. **Rachel Zoffness:** It was excruciating. And his colleagues rushed him off to the emergency department. And he was sedated with a lot of good drugs, like, you know, fentanyl and other opioids. And when the good doctors removed his boot, they discovered that a miracle had occurred. The nail had passed between the space between his toes. There was no puncture wound. There was no blood. --- ### [Hidden Nail In Face With Little Pain](https://share.snipd.com/snip/6ac24bf9-2872-4c9e-9e9c-4b4966d07cf3) 🎧 08:57 - 10:45 (01:47) <iframe src="https://share.snipd.com/embed/obsidian-player/snip/1071f3a9-18fe-40ff-8294-a9355ca36752" width="100%" height="100" style="border: none; border-radius: 12px;" sandbox="allow-scripts allow-same-origin allow-forms allow-popups allow-clipboard-write" ></iframe> - Another construction worker was struck by a nail gun but felt little pain and kept working; scans later found a four-inch nail in his face. - His brain perceived safety (saw a nail bury in the wall) so the pain alarm stayed low. #### 💬 Quote > Because he saw that nail shoot across the room and bury in the wall across from him, his brain was under the mistaken impression that the construction worker's body was safe. > — Rachel Zoffness Rachel Zoffness explaining why significant damage produced little pain #### 📚 Transcript **Rachel Zoffness:** That's right. So this construction worker was on a job site in Colorado, and he was using a nail gun. And the nail gun accidentally misfired, and it ricocheted backwards, and it clocked him in the jaw. But he saw a nail go shooting across the room and bury in the wall across from him. So he had like a mild toothache and a mild headache, but he continued on with work and life for six days. So **Shankar Vedantam:** in this case, the nail gun goes off, but he sees the nail embed itself in the wall far away from him. And even though he has a little bit of the recoil that hits his face, he thinks he's basically okay. That's **Rachel Zoffness:** exactly right. And at the end of six days, six days of eating and sleeping and continuing on with life, he turns to his wife and says, you know, I think I'm going to get this toothache checked out. So he goes to a dentist, and the dentist does a scan of his patient's jaw. And much to both men's surprise, they discover a four-inch nail embedded in his face. Wait, **Shankar Vedantam:** I thought you said the nail was basically flying across the room and embedding itself in the wall. **Rachel Zoffness:** That's right. So nail guns, I don't use many nail guns, but nail guns can actually release more than one nail at a time. They have like a rapid release. So he saw a nail shoot across the room and somehow, not sure the physics of this, but somehow a second nail came out of the nail gun and it went up through the bottom of his jaw and into his face. I actually spoke with the surgeon that conducted the surgery, and he said, he's the luckiest guy ever. That nail was protruding into his prefrontal cortex. --- ### [Phantom Pain Shows Pain Lives In The Brain](https://share.snipd.com/snip/94f65e0c-d9c5-43d8-aca9-23f2561252cb) 🎧 15:50 - 17:52 (02:02) <iframe src="https://share.snipd.com/embed/obsidian-player/snip/2d6a2389-ecdd-4471-8480-97eaf13f0ccb" width="100%" height="100" style="border: none; border-radius: 12px;" sandbox="allow-scripts allow-same-origin allow-forms allow-popups allow-clipboard-write" ></iframe> - Pain is constructed by the brain, evident from phantom limb pain where missing limbs still hurt. - Rachel Zoffness notes acute and chronic pain are designed and treated differently, with chronic pain widespread globally. #### 💬 Quote > If you can have terrible leg pain in a leg that is no longer attached to your body, that tells us pretty definitively that pain must be constructed somewhere else. > — Rachel Zoffness Rachel Zoffness on phantom limb pain #### 📚 Transcript **Rachel Zoffness:** You got it. So it's very easy to believe that pain lives exclusively in the body part that hurts, right? So if you have a bad back or you have an aching knee, it's easy to believe that that pain is being constructed exclusively by your back or your knee. But neuroscience tells us that is not true. Pain is ultimately constructed by the brain. And one of the reasons we know this is because of a condition called phantom limb pain. And phantom limb pain occurs when someone loses a limb, arm, or a leg, and they continue to have terrible pain in the missing body part. Now, if you can have terrible leg pain in a leg that is no longer attached to your body, that tells us pretty definitively that pain must be constructed somewhere else. And we now know that somewhere else **Shankar Vedantam:** is the brain. So one of the animating ideas here, Rachel, is something that we have discussed previously on Hidden Brain. The brain was designed by evolution to help us survive. And survival involves understanding what happened to us in the past. But even more, survival is really about deciding what to do next. And you're arguing that pain, like many other signals that the brain gives us, is about future action rather than merely an accounting of past events. **Rachel Zoffness:** That's right. So pain's job is to protect us. There are people who do not feel very much pain, and they don't live very long. The problem is there's a very big difference between acute pain, which is three months or fewer, and chronic pain, which is three months or longer. They are designed differently, they work differently in the brain and nervous system, and they are treated differently. And the problem is that we have a chronic pain epidemic. --- ### [Pain Requires A Biopsychosocial View](https://share.snipd.com/snip/b12aa201-e010-4195-af8e-8def0295b00d) 🎧 30:35 - 32:59 (02:24) <iframe src="https://share.snipd.com/embed/obsidian-player/snip/4788102b-c043-48d6-9b0a-608c5365bfcb" width="100%" height="100" style="border: none; border-radius: 12px;" sandbox="allow-scripts allow-same-origin allow-forms allow-popups allow-clipboard-write" ></iframe> - Pain is biopsychosocial: biological, psychological, and social factors all overlap to create pain. - Rachel Zoffness emphasizes neglecting psychological and sociological domains misses two thirds of the pain problem. #### 💬 Quote > Pain is more complex and beautiful and nuanced than that. So if you imagine a Venn diagram with three overlapping circles, we have bio on the top, psychological factors and sociological factors and pain lives in the messy middle. > — Rachel Zoffness Rachel Zoffness describing the biopsychosocial model #### 📚 Transcript **Rachel Zoffness:** Right. So if listeners remember nothing else from today's podcast, I hope they remember this word, biopsychosocial. And I want to say clearly, this is not my pet invention. I did not come up with this. Neuroscience has known for 65 years that pain is never a purely biomedical phenomenon, something to do just with bones and body parts. Pain is more complex and beautiful and nuanced than that. So if you imagine a Venn diagram with three overlapping circles, we have bio on the top, biological factors that contribute to pain. We've got psychological factors and we've got sociological factors and pain lives in the messy middle of all the things that make you, you. **Shankar Vedantam:** I'm wondering if you could spend a minute talking about what's in each of those circles, Rachel. **Rachel Zoffness:** Yes. So the bio domain of pain is the one we've all heard the most about. It's genetics and tissue damage, system dysfunction. It's also diet, exercise and sleep. And those are all critically important when it comes to the experience of pain. But what I want us to notice is that if we're only focusing on the bio domain of pain, which is what we do in Western medicine, we are literally missing two thirds of the pain problem. So in the psych domain of pain, we now know negative emotions like stress, anxiety, and depressed mood will amplify the pain alarm, while positive emotions like joy and happiness and relaxation and gratitude will lower the brain's pain alarm. And in the sociological domain of pain, we have social and environmental factors, and that includes socioeconomic status, access to care, race and ethnicity, social support or lack thereof, and our environment, which includes history of abuse and trauma. --- ### [Social Connection Acts As Natural Pain Modulator](https://share.snipd.com/snip/18804f2d-2210-4cdb-a709-43af9aa8d90a) 🎧 34:44 - 36:50 (02:06) <iframe src="https://share.snipd.com/embed/obsidian-player/snip/d66addee-f788-4eee-9728-c846d285267c" width="100%" height="100" style="border: none; border-radius: 12px;" sandbox="allow-scripts allow-same-origin allow-forms allow-popups allow-clipboard-write" ></iframe> - Social connection physiologically reduces pain by releasing dopamine, serotonin, and endogenous opioids, while isolation raises cortisol and worsens pain. - Rachel Zoffness cites research on loneliness raising morbidity and mortality and linking trauma with chronic pain. #### 💬 Quote > When we are with other people, we feel better both emotionally and physically. And when we are isolated, we feel worse physically and emotionally. > — Rachel Zoffness Rachel Zoffness on social factors affecting pain #### 📚 Transcript **Rachel Zoffness:** One of the worst punishments you can give a human being is solitary confinement. What does it say about human beings that one of the worst things you can do to us is isolate us from others? Humans evolved to be social. In fact, social behavior is so critical for our survival that our brains evolved a mechanism to reward us for engaging in it. In the presence of other people, our brains produce feel-good brain like dopamine, which of course is motivation and reward, serotonin, which boosts our mood, and endogenous opioids. When we are with other people, we feel better both emotionally and physically. And when we are isolated, we feel worse physically and emotionally. And there's one more data point I want to share with you. There's been a lot of research conducted on the elderly. And among those who are lonely and isolated and alone, rates of morbidity and mortality are higher rates of disease and death. And so what that means is if you are healthy and you're lonely and isolated and alone, you are more likely to get sick. If you are already sick, you are more likely to get sicker and you are also more likely to die. And there's a number of reasons for this. one of the reasons that I find so compelling is that when we are chronically lonely and isolated, our bodies produce high levels of cortisol, which is a stress hormone that over time suppresses our immune system, which of course affects morbidity and mortality and also pain. Social behavior absolutely and profoundly changes our human body and it has a huge impact on the pain we feel. --- ### [Create A Low Pain Recipe By Changing Habits](https://share.snipd.com/snip/2ffb0dda-997d-4ca6-a4c7-12309783b071) 🎧 37:00 - 39:05 (02:05) <iframe src="https://share.snipd.com/embed/obsidian-player/snip/ba2d5797-5df5-42b8-a359-8ecea007c112" width="100%" height="100" style="border: none; border-radius: 12px;" sandbox="allow-scripts allow-same-origin allow-forms allow-popups allow-clipboard-write" ></iframe> - Map your personal high pain recipe and deliberately build a matching low pain recipe by changing sleep, diet, movement, and social factors. - Rachel Zoffness gives sleep hygiene examples and replacing 'high pain' ingredients with healthier routines. #### 💬 Quote > For every ingredient in the high pain recipe, there is a matching corresponding ingredient that we have the power and agency to change to create what I call a low pain recipe. > — Rachel Zoffness Rachel Zoffness advising how to modify pain 'recipes' #### 📚 Transcript **Shankar Vedantam:** in working with patients who are dealing with pain, you help them improve their sleep and diet and daily rhythms. Talk a little bit about the value of doing this, Rachel. **Rachel Zoffness:** That's right. So just as there's a recipe for brownies, there is always a recipe for pain. And we talked about how pain is biopsychosocial. in this recipe for a high pain day, there are a number of biological, psychological, and sociological ingredients that are going into pain amplification. So I'm going to give you my high pain recipe. and I've had a poor night's sleep and I'm eating a crap diet and I'm not protecting time to move my body and exercise and I'm socially isolated, I know that combined with some other ingredients, that is going to construct what I like to call a high pain recipe. Now, the really cool thing about constructing pain recipes with my patients is that as soon as I'm able to help them map out a high pain recipe, we are then able to construct a low pain recipe. And a low pain recipe is often just the opposite. So I mentioned poor sleep. Poor sleep for me is a predictor of high pain. So I know that if I want to change my pain recipe, I need to start implementing a sleep protocol. For example, for myself, I know that I need to set a sleep time and a wake time. I know that I need to stop doom scrolling before bed and put my phone away a couple of hours before getting into bed. I know that if I can't sleep and I'm getting anxious and restless, I need to get out of bed and go somewhere else and not lay in bed feeling restless and anxious. So for every ingredient in the high pain recipe, there is a matching corresponding ingredient that we have the power and agency to change to create what I call a low pain recipe. --- ### [Challenge Pain Voice With Detective Questions](https://share.snipd.com/snip/0aee3710-5a3d-475d-b245-8a39afbb34bb) 🎧 41:30 - 42:47 (01:17) <iframe src="https://share.snipd.com/embed/obsidian-player/snip/a0589ff9-da04-4f3b-8ed0-3658850d3bc7" width="100%" height="100" style="border: none; border-radius: 12px;" sandbox="allow-scripts allow-same-origin allow-forms allow-popups allow-clipboard-write" ></iframe> - Use detective questions to challenge 'pain voice' negative predictions and test whether thoughts are factual. - Ask 'Is this thought a fact?' to separate protective pain voice from reality and reduce fear-driven immobilization. #### 💬 Quote > One detective question that I like to recommend is, is this thought a fact? And by fact, I mean unquestionably, undeniably, absolutely true. > — Rachel Zoffness Rachel Zoffness on reframing negative pain-related thoughts #### 📚 Transcript **Rachel Zoffness:** of my favorite strategies for dealing with pain voice is this strategy called using detective questions. And by that I mean pain voice likes to speak in hyperbole and negative predictions that actually aren't rooted in reality. the only way sometimes for us to see for sure that the thought is just a thought and not a fact is to test its veracity. And by testing its veracity, I mean, I'm going to sit down and ask those thoughts some questions. And I call these detective questions because I want to investigate whether thought is true or whether it's a trap. Because chances are high if it's pain voice, it's trapping me into being scared and immobilized in order to protect me. Again, pain voice isn't mean. It's just trying to protect you and keep you immobilized until you get the help you need. So one detective question that I like to recommend is, is this thought a fact? And by fact, I mean unquestionably, undeniably, absolutely true. So the thought you offered, I'm broken, I'll never get better. Is that a fact? --- ### [Sister's Gummy Swap Triggered Placebo Relief](https://share.snipd.com/snip/6b1b1154-9dfb-430e-be80-c035c4386a9f) 🎧 44:05 - 46:50 (02:45) <iframe src="https://share.snipd.com/embed/obsidian-player/snip/6c2bad1d-2f3e-45b2-ae6f-d0ff051a0c0a" width="100%" height="100" style="border: none; border-radius: 12px;" sandbox="allow-scripts allow-same-origin allow-forms allow-popups allow-clipboard-write" ></iframe> - Kai's sister swapped CBD gummies for regular cherry gummies and his pain vanished after sleep, demonstrating a powerful placebo effect. - The experiment revealed expectation and routine (sleep) lowered Kai's brain pain alarm repeatedly over a week. #### 💬 Quote > She handed him a regular cherry gummy bear. He got sleepy and tired. He wheeled himself into the living room. He lay down on the couch. He fell asleep. And when he woke up, his pain was gone. > — Rachel Zoffness Rachel Zoffness recounting Kai's placebo story #### 📚 Transcript **Rachel Zoffness:** Kai was a patient I had, I believe he was in his 40s, and he was wheeled into my office by his sister, Iko. He had a condition called Fabry disease, and he wasn't able to go to work, and his pain was so terrible that he couldn't wear shoes or even cut his toenails. So he had these extremely long toenails that looked like talons, and it really just stood out to me because he wasn't even able to touch his own feet. As I got to know Iko and Kai, we talked about the science of pain. We talked about the role of the brain. We started putting together his pain recipe. And as we were on this journey together, Kai was prescribed by a trusted provider, CBD gummies. And so Kai went home and his sister gave him one of these CBD gummies. And if I remember correctly, it cherry flavored and bear shaped. And he took the CBD gummy and it made him very sleepy. And he wheeled himself into the living room and he laid down on the couch and he fell asleep. And when he woke up, his pain was gone and he couldn't believe it. And he stood up and he even touched his feet and he put on his shoes and he called his sister into the room. They were both astonished. And when he woke up the next morning, the pain had returned. So the next day they went through the same routine. She gave him a CBD gummy. He wheeled himself into the living room, lay down on the couch, fell asleep. When he woke up, the pain was gone. Now, his sister wondered if maybe there was more to it than just that. She wondered if his predictions and his expectations also had something to do with it. So she conducted an experiment. Without my knowledge, I did not know she was doing this, but she went to the store. She bought regular cherry gummy bears, and she swapped out his CBD gummies for these regular cherry gummies. And the next day, Kai came in to get his medication. She handed him a regular cherry gummy bear. And here's what happened. He got sleepy and tired. He wheeled himself into the living room. He lay down on the couch. He fell asleep. And when he woke up, his pain was gone. And Iko was astonished. And of course, Kai didn't even know that his gummies had been swapped out. And Iko did this every day for a week. She gave him a placebo gummy. Kai's pain disappeared. And the next day when the placebo effect wore off, she would give him a new regular cherry gummy bear. And after a week, she told me she felt so guilty that she told Kai what she had done and expected him to be enraged. --- ### [Pacing Protocol Helped Bedbound Teen Recover](https://share.snipd.com/snip/4eb73b8e-e18e-48dc-850e-ca2e8f45202b) 🎧 48:14 - 51:28 (03:14) <iframe src="https://share.snipd.com/embed/obsidian-player/snip/c17ee0af-f4a6-4462-b562-1c00ee3271d6" width="100%" height="100" style="border: none; border-radius: 12px;" sandbox="allow-scripts allow-same-origin allow-forms allow-popups allow-clipboard-write" ></iframe> - Sam, a 17-year-old bedbound for four years, improved by stepwise 'pacing' and targeting sleep, diet, movement, and social reengagement. - Rachel Zoffness describes concrete pacing steps from standing outside to walking around the block and reconnecting with friends. #### 💬 Quote > Week one, he got out of bed and he stood outside on the porch in the sun. Week two, he walked to the corner mailbox and he texted just one friend. Week three, he walked around the block and he invited a friend over. > — Rachel Zoffness Rachel Zoffness on Sam's recovery using pacing and lifestyle changes #### 📚 Transcript **Rachel Zoffness:** I first met Sam, he was 17 years old. He had been in bed for four years. He had long unwashed hair. was pasty and pale, and he was rocking himself back and forth on my couch with the pain. So he had been diagnosed with chronic migraine and diffuse amplified body pain of unknown etiology, meaning he had seen a bazillion doctors, something like 14 of them, and he had been on 40 medications, but nothing had helped, and no one really understood why Sam was in so much pain. So by training, I've been studying pain neuroscience, pain biology, and pain psychology for 35 years, but I think of myself really as a pain detective because it's my job to look at all of the biopsychosocial factors that are going into creating and amplifying the pain to see what I can do to help turn pain volume down. So as I conducted an assessment of Sam, I quickly learned that Sam had been living with crippling social anxiety and suicidality for many years without relief or adequate He was also sleeping poorly. He was up playing video games until four in the morning. He was on what I like to call a white food diet, which is not uncommon in America, where he was eating pizza, pasta, chips, and cereal, but he just didn't like fruits and vegetables, and so he wasn't eating them. And what became clear to me was that if I wanted to help Sam, I needed to help him target all of the ingredients in his recipe. Medications alone just weren't going to cut it, and of course they hadn't. So I met with Sam and his parents and we introduced him to fruits and vegetables, one per meal. We put Sam on a sleep hygiene protocol to help him improve his sleep. And I put him also on a pacing protocol. And we said before that pacing for pain is much like pacing for a marathon. what that meant for Sam, who had been bedbound for four years and had been completely socially isolated and depressed and alone, was that week one, he got out of bed and he stood outside on the porch in the sun. That was step one of his pacing protocol. Week two, he walked to the corner mailbox and he texted just one friend. Week three, he walked around the block and he invited a friend over to watch a movie. And you'll notice, you know, we're targeting sleep, we're targeting social behavior, we're targeting movement, we're targeting nutrition, we're targeting his mood and his physical health. All of the things we're targeting. And Sam also got a tutor and he started catching up in school. And here's what happened. As Sam's social and emotional and physical health started to improve, pain volume started to go down. ---