Hey guys! I recently had the opportunity to interview a neuroscientist named Tor Wager. He is the Director of the Cognitive and Affective Neuroscience Laboratory which is dedicated to research on the placebo affect, the way the brain processes pain, and how our beliefs impact our health. I enjoyed every second of this interview because I learned so much. I highly recommend reading this interview to gain a better understanding of how pain works and how chronic pain can be treated.

Takeaways:

• Placebos can have powerful effects on the body. They can cause a release of opioids within the brain.

• The Cureable app is an amazing resource for people with chronic pain. I really loved the interview and education parts of the app.

• Pain reprocessing therapy uses a lot of cognitive behavioral therapy, mindfulness, and exposure techniques. One of the main ideas behind pain reprocessing therapy is understanding the connection between fear and pain.

• Graded exposure therapy is effective in reducing pain because it can decrease the fear surrounding activities and pain.

• Pain catastrophizing and the fear of physical activity can increase pain. Addressing these two problems can significantly decrease pain.

• Subtracting activities that you bring you joy from your life (such as sports, arts, spending time with family and friends) can worsen your pain. You have to be willing to push the boundaries of what you think your body can handle.

Can you tell us how you became interested in the field of neuroscience and chronic pain?

For a lot of my life, I have been interested in how our thoughts and beliefs can affect our bodies and our health. That’s been an interest of mine since I was a kid. I didn’t really know how to study that or if it was even possible to study that. 

I have been very interested in self-regulation and the power of beliefs and their limits. I became interested in pain because it’s kind of mysterious in the way that it is objective in many ways. You can deliver painful stimuli experimentally. You can quantify the input and measure what happens on a psychophysical level. It’s entangled with our emotions and decisions. 

I started doing studies on the placebo effect. Pain is the best studied outcome with the placebo effect so it was a good place to start trying to understand the power of beliefs and suggestion.

I remember going to these classes in the 4th grade where they brought in a cat brain. They told us about this man who had a bombshell lodged in his head by his hypothalamus. When he turned his head left, he would laugh and when he turned it right, he would cry. I was always struck by that. Our personalities can be shaped by what is happening within our brains.

I discovered that you’re the director of the Cognitive and Affective Neuroscience Laboratory. Can you tell us about the research that is being done there?

Yeah so I am directing the brain imaging center here at Dartmouth and the Center for Cognitive Neuroscience. A lot of our research is not directly clinical. It’s pre-clinical and it’s about understanding brain mechanisms. We have done a lot of work on placebo affects and we are still doing this work. We just finished a study where we scanned 500 twins to determine how pain treatments impact the brain at a deep level.

Placebos can be powerful under certain circumstances because they can cause a release of opioids within the brain. They can dramatically affect people’s decisions, how people learn, and neuroplasticity within the brain. On the other hand, we have also learned about the limitations of the placebo effect.

We’re also studying brain stimulation and trying to determine if brain stimulation can modify pain. We’re studying mindfulness and meditative practices to see if these practices can change brain circuits in a meaningful way.

We did a study on pain reprocessing therapy with Alan Gordon and Howard Schubiner. My student, Yoni led that study. 

Do you find that there are people who are more receptive to placebos and those who do not respond as well?

That’s a great questions and it’s one that been really important since the beginning of medicine. The answer to this question is complex. There are people who, on average, are more susceptible. The problem is that it is not always consistent across the studies and there are many factors about the situation that matter. It’s really hard to predict in advance if someone will respond to a placebo or not. 

Here’s a story from one of the first people we tested in our lab. We had a placebo cream and told this guy that the cream will relieve pain and that it’s really powerful. He then states that he reacts badly to creams and he was really anxious about it. He might have genetics that make him more receptive to placebos, but he has this situational factor that plays a role. If I give him a pill, he might do great, but a cream probably won’t work for him. Different people respond differently to placebos in different contexts. Some people definitely respond to placebos more strongly than others, but it still depends on the magical combination of the right person in the right situation with the right cues. 

A lot of healing works in ways that we can’t capture systematically in studies because you can’t control when something is going to click in and resonate with a person and have a big impact.

Definitely. I think a lot of it also has to do with the relationship between a patient and their healthcare provider. You need to have a trusting relationship in order for this type of stuff to be effective.

When I was dealing with severe chronic pain, I had a doctor prescribe gabapentin for me. I was somewhat educated on placebos at this point and I remember that I kept telling myself, “This will be the one. This will be the medication that takes all of the pain away”. I was essentially trying to make a placebo happen. This did not work unfortunately. Maybe placebos don’t work if you try to force them too hard.

It’s really hard to talk ourselves into things too. There are a lot of unconscious forces within our brains that help make us believe one thing or another. You can’t always decide which things you will genuinely believe. What was the thing that was most helpful for you in getting better?

I can’t really give credit to one specific treatment that helped me get better because it was a combination of things. I think the first thing that really helped me was graded exposure therapy because my biggest trigger for pain was walking. I started doing graded exposure therapy every day and I slowly started to lose my fear of physical activity.

Another thing that really helped decrease my pain was treating my insomnia. I love sharing this with people because insomnia can be a really easy fix. I had really bad insomnia when I had chronic pain. I was not getting any sleep and I was in a constant state of exhaustion. Every day I would wake up in so much pain. Finally one of my doctors decided to prescribe me a medication called trazodone. The next day I woke up pain free for the first time in eight months. There are a lot of different ways to treat insomnia which could be medications, cognitive behavioral therapy, doing a sleep study, and several other options. 

The last thing on that really helped me was pain reprocessing therapy (PRT). PRT helped me reduce the fear that I had towards my pain. Somatic tracking and meditation has been incredibly helpful to me. I even worked with a virtual reality program and found that to be helpful as well. 

That makes a lot of sense. There is a strong connection between sleep and pain. Sleeplessness can really enhance pain.

It does, but fortunately, treating insomnia can be really straightforward and simple compared to treating chronic pain. I try to talk to people in medicine about this, but it’s not a common conversation providers are having with their chronic pain patients yet. I’m hoping this will change in the future.

That’s really interesting. I don’t know if pain education has changed over time, but a few years ago, there was almost no pain education in medicine. It was really just a few hours of pain education across four years of medical school. I think there is still this missing piece where physicians focus on pain in one part of the body as a purely nociceptive process and they don’t think about the rest of the person. Of course in the ER that is the normal approach. But if someone has chronic hip pain and nobody asks what other symptoms they are experiencing then that’s not really helpful. You can’t really tell if this is a localized or widespread problem. 

One of the things that we’re doing in my lab is working with the UK Biobank to look at relationships across different types of pain. The question is if you have one type of pain, migraines for example, do you also have other types of pain? And the answer is commonly yes. 

There are about 24 different types of pain conditions that are heritable and if you have one of these, you are more likely to have any number of the other ones as well. The genes that predispose people to have one type of chronic pain will predispose them to have other types of pain as well. What this is telling us is that once pain becomes chronic, it’s no longer just localized pathology. It’s now something that really relates to the brain. Once you put that information together with other stuff that we’re learning like sensitization of neural circuits and changes within the nervous system that promote chronic pain, a new picture of what chronic pain is emerges.

Absolutely. I completely agree with everything you’re saying. I think we’re at a changing point in medicine where more and more doctors are starting to gain a better understanding of chronic pain actually works. I think we’re struggling with trying to figure out how to communicate this information to people with chronic pain without making it sound like we think the pain is all in their head. A lot of patients come into a doctor’s office with the preconception that their pain is purely structural and that means we have to fix the structural problem. If you even say something in regards to their mental health or brain, the patient may assume that you’re accusing them of imagining their pain. Then it becomes more difficult for the provider to actually start implementing treatments that focus more on neurological processes. 

I was just talking about this the other day with a friend of mine who is an orthopedic surgeon about this exact problem. It’s really hard to have these conversations with patients. Do you have any ideas on how to have these conversations with patients?

Yeah, it’s really difficult. As someone who has been through this process, I definitely have some ideas. Everyone is different. Everyone is going to have their own beliefs and misconceptions regarding chronic pain. When I had chronic pain, I was very open-minded. I didn’t care if my pain was a physical or psychological problem. I just wanted to know how to make the pain go away. I think if my doctors had known this was my mentality regarding my pain, they would have had an easier time saying that we should try a more psychological based approach. 

As an ER nurse, I work with patients who have chronic pain almost every single day. These patients are not always in the ER because of their chronic pain, but a vast majority of these patients have chronic pain conditions like fibromyalgia, arthritis, migraines, and low back pain. The ER is an incredibly busy environment so I don’t always have the time to have long conversations with these patients about how to treat their pain. What I do instead is make them a list of resources with books, websites, and podcasts. This way patients can go home and do some research and gain a better understanding of how chronic pain can be treated. Even if this information doesn’t help them right away, in the future they may decide to use these resources when they realize that what they have been doing is not working. 

Sometimes I get to have longer conversations with patients about their mental health and better ways to treat their pain. Most of these reactions go really well. The other day I was talking to a patient with lower back pain and I was asking him about his anxiety and depression. At the end of the conversation, he told me that I was the first person to really talk with him about mental health and that I had made him feel seen. It was obvious that previous healthcare professionals had focused purely on his pain, but not on his mental health. That’s really unfortunate because mental health plays a really huge role in chronic pain. 

In the acute care setting, we don’t really have people who are trained in having these types of conversations with these patients. We have pain management doctors who have some education on this stuff, but they are more specialized in pain medications and procedures. I’m not against the use of pain medications in the treatment of chronic pain, I think they can be incredibly helpful at times. But if all we’re doing is prescribing medications, we are not treating the whole person. We’re treating a small piece of a much bigger picture. 

Yeah, then there is also a lot of economic and social factors forces that are working against the idea of providing holistic care. The way insurance works and the way hospitals and specialties are set up creates a lot of tension with providing care. Medicine started off more holistic. Hippocrates wrote, “I would rather know the person who has the disease than the disease the person has”.  I love that because it’s very holistic, but medicine has changed a lot, especially in the U.S. Specialists are trained to do one thing very well and that is often in the form of procedures. If you’re trained to do something really well, that’s what you’re going to use the most in treatments. It’s very hard to go outside of your expertise and do something different. 

What really pays the bills for hospitals is procedures and not conversations or advice. We’re spending less time talking to people and spending more time doing procedures.

It’s so true. One time I gave a presentation on providing patients with more education on chronic pain and resources that are available to them. The first thing someone said was, “That’s a great idea, but how can we monetize that?” And I’m sitting there realizing I hadn’t even considered that as a priority, but the reality is that money will always be a priority within healthcare. 

You are listed as one of the advisors for the Curable app. Can you tell us about the Curable app and the role that you played in its development?

Yes, but you won’t get much of an answer because I did not play a big role in its development. I knew the CEO, John Griffin and he wanted to build a scientific advisory board, but the app had already been developed at that point. I was available as someone who could understand the ideas and give advice if needed. It’s not my creation in anyway. I have heard stories that it has helped a lot of people. 

Have you interacted with the app at all? Have you been able to see how it works and try out the different exercises that they have for people?

Not that much to be honest. I can’t say too much about how the app works. I’m sure you know a lot more than I do.

Yeah, I played with it for a while. I think it’s an amazing app. I think it would be interesting to run a study on it in the future so we can have a better understanding of how people respond to it. And maybe get to the point where health insurance would pay for people to use this app. 

That’s interesting because I was talking back and forth with the CEO about whether we should run such a study a few years ago. They don’t really need to run a study because they can already develop it and market it to people. There might be other markets that they can’t access and randomized controlled trials might help with that. 

I’m actually in the process of co-authoring a paper on self-management therapies for chronic pain. What’s really interesting is that there are many apps that are being developed and other programs that focus more on mental health.

One of my colleagues who studies this stuff said that over a 10 year period over 2,000 different apps were developed for mental health. The problem we had in tackling this article is how do you study that because each one of these programs has it’s own flavor or version and they may change over time. 

It’s not like studying a drug where you can assume that you have the same thing manufactured the same way. I think we need a whole new paradigm for understanding these programs and how they work. 

What is it that you have found most useful with the Cureable app?

For me personally what really helped was listening to all the interviews that they have listed on the app. In these interviews people share their stories of how the Curable app and pain reprocessing therapy reduced their pain. This was good for me because I needed to be convinced that this app was worth my time and effort. I was so sick and tired of putting so much effort and time into things that were not working. I listened to every single interview and realized these people were not experiencing minor changes in their pain. It was making drastic changes in their pain, often times making the pain completely go away. Being able to hear these stories was incredibly helpful to me. 

I also really appreciated the education portion of the Curable app. The app gives these five minute dosages of chronic pain education and it explains the most effective ways to treat pain. I’m the type of person who truly has to understand how something works in order for me to believe that it will work. 

I once had a doctor prescribe me amitriptyline and all she said was that it would help calm my nervous system. That didn’t make any sense to me at the time. I didn’t believe calming my nervous system would relieve my pain because I had not been educated on the connection between pain and the nervous system. So the whole time I was taking amitriptyline, I didn’t believe it would work and I thought it was a waste of time. 

Once Curable taught me about pain reprocessing therapy, neurologic processes, and the relationship between fear and pain, then I was able to start implementing things like somatic tracking, journaling, and meditation because I believed that they could reduce my pain. 

Finding people who have overcome their chronic pain can be huge to people who are currently experiencing pain. When I was in constant pain, I was actively searching for people who had found ways to make their pain go away because I wanted to talk to them and find out how they did it. When you go on the internet looking for support groups, you don’t find people who have overcome their pain. Instead, you find people who have been in pain for 10 or 15 years and they tell everyone that treatments don’t work and that they’re going to be in constant pain for the rest of their lives. I became desperate to find someone who had managed to decrease their pain because I believe that I could do whatever that person did to make their pain go away and it would work on me. If they could do it, I could do it. 

That’s really interesting. I never thought about these support groups. I always thought having the support of people who are going through the same thing as you could be helpful. In the lab we have studied the power of connection and being with someone who truly understands you. That’s a really powerful force. But it sounds like you’re telling me that in these support groups there is also a negative side because they are telling you that you won’t get better. 

That was my experience. If you’re ever bored, go on Facebook and check out some of the chronic pain support groups on there. You will quickly discover that they are incredibly depressing and demoralizing. That’s why I tell people to stay off of Facebook when looking for support. I found that people on Instagram were more optimistic than people on Facebook. This may be because of generational differences. On Instagram, you have people in their teens and 20s who may have had better experiences with health care providers and therapists. This generation is more likely to reach out for help and talk about their mental health. My main advice to people on this topic is don’t go to support groups that make you feel sad and depressed after reading what they have to say.

We have talked a little about pain reprocessing therapy, but can we take some time to really explain what pain reprocessing therapy is and how it actually works?

It’s interesting because some people want to emphasize its uniqueness from other therapies and other people want to emphasize its commonalities with other psychological treatments. It’s a form of cognitive behavioral therapy (CBT) that uses a lot of CBT techniques and it also uses techniques that are related to acceptance and mindfulness. Exposure is another part of the process. 

It borrows from mindfulness as well. There are a lot of meditation strategies. There’s a lot of focus on the body and that’s an ingredient that is not a standard part of behavioral therapies. It’s helpful because one of the main contributing factors to pain is related to sensitization and changes in neural circuits. There’s a lot of fear and avoidance. People tend to want to push the pain away.

If you talk to Alan Gordon and Howard Schubiner, they were practicing this for years. It’s been practiced in other major medical centers as well. It’s not common among general practitioners and neurologists who are more trained on the physiology of pain. 

One of the principles underlying pain reprocessing therapy (PRT) is the idea that the connection between pain and fear needs to be acknowledged. There is a connection between stress and pain, emotional threats, and trauma. People with pain are often told that it’s structural and that they’re not going to get better. You have to change the narrative so that people know the brain matters, sensitization matters, and fear matters. I think that’s what differentiates CBT and PRT. Most practitioners will say that they can help you manage your pain, but not necessarily reduce it because they don’t know what’s causing the pain. This lacks a positive explanation and it doesn’t inspire hope that you can really get better. 

Tell me if anything I have said doesn’t resonate with you.

This all sounds very accurate. The avoidance behaviors are so common and it really reflects in the area of physical activity. People start to develop kinesiphobia (the fear of physical activity). We start to associate physical activity with pain. The brain starts to rewire itself to associate specific movements with pain so we stop doing those movements. 

The idea is to return your attention to the body. It puts you back in touch with your body. You can focus your attention on somatic experiences and that can help reverse avoidance activities. It helps your brain get a handle on the sensations you’re experiencing. Instead of just categorizing sensations as bad you can pay attention and ask questions like “what does this sensation feel like? Is it moving? Is it hot or cold?”. And then you start to understand your pain and categorize it as something that is neither good or bad.

A pain therapist that I worked with years ago at Columbia University would have patients imagine their pain. She would have them describe its color, shape, if it was hard or poky, and other characteristics. This was patients could work with their pain as an object. She would then guide them towards changing the object and to imagine that the edges are dulling and it’s becoming softer.

That’s actually an inspiration for one of the newest studies we’re doing in the lab. We’re using the same principle to see if we can reduce negative emotions and pain. It’s not clinical yet, but we’re giving people these strategies to see if the brain can decrease pain.

Then there is exposure and I think exposure is important because it reduces fear. Fear of pain sensations are a big park of pain sensitization within the nervous system.

It starts with a belief, which is why the narrative is so important. If you have a belief that your pain is something that’s medically unexplained but it’s definitely pathological, you will most likely believe that your pain is a sign of damage within the body. With that type of belief, pain is scary and you develop a lot of fear surrounding the pain. Fear amplifies potential threats so that you will want to avoid it.

If you look at basic sensory affects in vision neuroscience and auditory neuroscience, attending to a stimulus amplifies neural signals all the way back to the primary visual cortex. If you habitually attend to things over time, then that amplification gets built in. Our brains are plastic. They are always changing. Our auditory cortex is plastic. Our visual cortex is plastic. The brain is constantly learning and being updated. It’s learning to respond most strongly to the things that are most important in our environments. If that’s pain or other sensations within the body, then that’s what you’re training your brain to respond most strongly to. 

Exposure is attending to sensations in the body in a different way. When you do exposure to painful movements are situations, you’re telling yourself “I know this is safe. I don’t have to be afraid. I don’t have to avoid this. I don’t have to amplify it. This is part of my normal experience”. Doing this overtime in a safe context is the best way to eliminate any kind of fear, phobia, or hypersensitivity. 

It’s a way of inspiring people. Alan Gordon is inspiring because he was a pain sufferer with 18 different kinds of pain. He has credibility because he can say “I was there with you and now I am in no pain”. These types of testimonials show people that they can get better.

Yeah, it’s really amazing. I feel like you were touching on the topic of pain catastrophizing a little bit. The amount of attention that you give to your fear and pain can increase the pain and it starts influencing every decision that you make. 

Yeah, pain catastrophizing is a big thing that is linked to amplified pain and it’s a target for treatment. I want to go back to kinesiophobia which you mentioned earlier. There are strong correlations between pain catastrophizing and kinesiophobia. We did a study that showed when you decrease kinesiophobia, this is often followed by a decrease in pain. When you look at the kinesiophobia scale, you start to notice that kinesiophobia is really impacted by beliefs about pain and futuristic beliefs like thinking “My pain will only get worse over time. I’ll never get better”. As your imagining the future, you’re also creating the future. Overtime those are really damaging beliefs from a recovery stand point.

We published another paper following up on the PRT paper that is about pain beliefs and the causes of pain. That’s another difference between PRT and other cognitive behavioral therapies. It gives you a different idea about what is causing your pain. It’s not always something that is broken in your body, it’s more about your nervous system becoming sensitized to pain. And that’s something you can work with. It’s also important to recognize that it’s not your fault and it’s not made up. It is real pain. 

Yeah and once you take pain catastrophizing out of the picture and you learn to reframe your beliefs around pain, you realize it’s just a sensation that can be treated. Getting rid of pain catastrophizing can significantly reduce pain.

Working in the ER, I see all these pain conditions that are incredibly difficult to treat. These include trigeminal neuralgia, occipital neuralgia, cancer pain, endometriosis, and so many others. A lot of these things do have specific physical causes. Do you believe that approaches like pain reprocessing therapy and cognitive behavioral therapies can have an impact on these chronic pain conditions?

My answer in many cases is yes, but let me explain. This goes in kind of deep into the people’s ideas about what pain is and so forth. There are many conditions where there is something that is wrong with the body and the root origin of the pain signals come from that pathology whether it’s an infection, cancer, injury, or inflammation. This is the nociceptive component of pain which from a survival standpoint, you need this to exist. But you do want to be able to fix this problem. Then there is this overlay of nervous system sensitization which leads to avoidance and associative learning. Fear starts to develop. You may also have systemic inflammation or neuroinflammation. There are multiple things going into this chronic pain bucket. The part that’s really driving all of this is the brain and that is modifiable.

Stress and emotions can modify inflammation over time. The suffering that comes with chronic pain involves fear, anger, and other negative emotions. No matter what condition you have, there is a certain amount of this overlay that is treatable.

It’s kind of like the Bhuddist concept of the second arrow. The first arrow hits you and it causes pain. The second arrow that hits you is your reaction to the pain. The second arrow will hurt more.

This makes so much sense. I think about this stuff every day and I’m constantly theorizing what’s the best way to address pain in each individual person. Sometimes people do have pain because of structural damage and maybe that pain should only be a three out of ten. But then they start experiencing pain catastrophizing and now that pain is at a five. And then they start experiencing insomnia and now the pain is at a six. And then they develop kinesiophobia and that makes the pain even worse. Now the pain just keeps increasing because you have all of these layers on top of the structural pain

Yeah, that is exactly what I mean. You and I have talked to a number of people with different kinds of pains and problems and it’s heartbreaking. It’s humbling because the truth is that you do not know. There are many medical conditions that we just don’t understand and don’t know how to measure yet.

Pain means so many different things. Once an injury has healed and it’s become chronic pain, it’s safe pain. We have to discriminate. It’s not that all pain is safe. If I sprain my ankle while playing soccer, that is temporarily dangerous pain. Then I have to treat it and stay off of it. Chronic pain is often safe pain, even after an injury. I think it’s helpful that we talk about sensitization and avoidance. All of that stuff is natural because it’s part of the brain’s and body’s defense against bad things happening. 

When we have an acute injury, there’s inflammation, we stay off of it and we can withdraw a bit. Then there’s a resolution phase where we start re-engaging in activities and we start doing more even if it hurts. I started playing soccer again and it hurt a little, but I kept testing it and pushing that boundary back out. But if I had told myself “I don’t know if I can ever play soccer again and I don’t know if this pain is going to go away”, I never would have pushed that boundary and I might still be in pain.

And that’s where you see people being psychologically impacted by their pain. They start going into depression and feeling hopeless because they subtracted things from their life that had once brought them joy, whether it was playing a sport or going out with friends and family. They subtracted those things from their life because they thought it would make their pain better, but usually they still end up being in pain. Except now they are in depression and they have anxiety, and they may even be struggling with suicidal thoughts. All of that piles directly on top of the pain and adds more and more layers to their suffering. 

Yeah, absolutely. Eliminating activities, movements, and other sources of joy is a bad trap for pain. During that recovery phase, you want to push boundaries back out again. 

Yeah, this brings me back to my personal experience with pain and avoidance activities. When I was in college, I got into rock climbing. I thought it was so much fun. And then I developed chronic pain and I became convinced that I shouldn’t rock climb anymore. I told myself that rock climbing would cause more pain and that I should avoid any form of strenuous activities. Sometime after doing graded exposure with walking, I finally couldn’t wait any longer. This was also after I started taking medication for insomnia, but before I had discovered pain reprocessing therapy. It had been two years since I had been rock climbing  so I decided I would just try it for a few minutes. 

The moment I started climbing, the pain completely went away. I ended up staying for two hours instead of a few minutes and I was pain free the whole time. The pain came back after the rock climbing so I hadn’t found a cure, but I had discovered an escape for myself. 

Being able to bring rock climbing back into my life was incredible for both my physical and mental health. I was able to show myself that I am capable of doing hard things and not causing myself more pain in the process. 

That’s really neat and it improves your self efficacy. It promotes this antifragile belief.

Yeah because a lot of people with chronic pain start to develop this belief that their body is fragile. They become protective of their body and hypervigilent. It’s not healthy to think that way. It almost falls into the same category of victimization. You don’t necessarily see yourself as a victim, but you do see yourself as breakable. You become extra cautious and start believe that you’re not capable of doing things.