heart attack feels like

thank you for coming. it's really apleasure to be here. and i hope everyone inthe back can hear me. i tend to speak very loudbut just raise your hand if you need me tospeak more loudly.

heart attack feels like, if you've heard any ofthe recent statistics, then you know that100 million americans live with ongoing pain,pain that's experienced on a fairly regular basis.

and so we're veryinterested in understanding how to better treat pain,how to better manage pain, and how to do it in a way thathelps people live the best quality of life possible. so as was mentioned,i'm a pain psychologist. i'm also a pain researcher. and i just want to takea moment to tell you a little bit about systemsneuroscience and pain lab at stanford.

we do a lot of differenttypes of studies. i'm going to be tellingyou about many of them over the courseof the next hour. but if you're interested inparticipating in pain research, this is our main website. the url is at the top. and you can learn aboutall of the cool stuff that we're doing. and you may be interested injoining one of the studies.

this is one specific study. this is actually a whole centeron the treatment for back pain. and this is funded by nih. and we're investigating howvarious treatments work. so cognitive behavioraltherapy, that's a psychological treatment,mindfulness-based, stress reduction,acupuncture, and real-time fmri for chronic pain,for chronic back pain. so when you join the study,you get free treatment.

we also pay you tobe in the study. and we're interestedin learning from you how these treatments work. we know that they'reeffective, but we're learning what are themechanisms behind how they work. as was mentioned,i am the co-chair of the task forceon pain psychology at the american academyof pain medicine. and this is just a reflectionof the growing interest

in psychology within thefield of pain medicine and the world thatpsychology plays. we're particularly interestedin broadening access to low cost, high qualitypain psychology care. other resources i wantto make you aware about. i write a column forpsychology today online. so if you're interestedin learning more about psychology andpain and the interface, you can go online andsee some of the postings

that i have there. and along those lines,in 2014 i wrote this book that i found myselfworking in clinic with people with chronic pain. and i found myself sayingthe same things over and over again. so i decided toput it into a book so that people couldaccess the information. not everyone can come toclinic and work with me.

and so that's whatthis book is about. i'm really interestedin helping people need as littlemedication as possible. not that medicationis a bad thing, but i think we canall agree that if we can need the less ofit, that's a good thing. right now i am workingon the next book and working furiouslyas we speak. and this will becoming out soon.

and some of theinformation that you'll be hearing from metonight is going to be in this next project. ok, so let's talk about pain. if you have chronicpain, if you experience pain on a regularbasis, then you're probably your ownpain expert, and not necessarily interms of treatments, but in terms ofyour own experience.

and every single personin this room or people who are watching overthe internet, wherever you experiencepain in your body, no matter what yourmedical condition is, your diagnosis, no matter whattreatments you have tried, the pain that you experienceis processed in your brain. and so that is justa basic foundation for how psychology fitsinto the experience of pain. everything is processedin your brain.

so think of your brain asyour pain computer of sorts. so if i were to prick myfinger right now with a needle, well those signals wouldbe-- the nerves in my hand would feel that. it would transmit signalsultimately through my arm and ultimately to my spinalcord and into my brain. and so then that wouldregister as ouch. that hurts. i want to get away from that.

and that's sort of intuitive. that's how we think about pain. but once we have chronic pain,it gets a little more complex. because when we feel pain, andwe want to get away from it, we feel that ouch,it's not so easy to do when we have chronic pain. we can't get away from somethingthat we're experiencing from inside of ourselves. the other thing to knowabout the experience of pain

in that examplewhere i prick myself on the finger andthose signals travel up to my brain, whatever isgoing on with me in this moment emotionally is going toinfluence my experience of pain in the moment. so whatever i might beexperiencing in my life emotionally isgoing to influence my experience of pain. and then, how irespond to that prick

is also going to influencehow i experience that pin prick, the levelof pain that i have and my suffering around it. so there's a big, big rolefor psychology in pain. and let's just talk aboutthe definition of pain now. because we think about pain,like yeah, i know what pain is. it hurts. it's the thing i wantto get away from. nobody wants more pain.

this is the actualdefinition of pain. this is from theinternational association for the study of pain. pain is an unpleasant sensoryand emotional experience. and so this iswhere i really want to draw your attentionto that word emotional. so believe it or not,psychology is built into the definition of pain. we just don't tend to thinkabout it all the time.

we tend to think aboutthe pain as being the sensory experience. what we feel in our body. and it's not intuitivefor us to think about the emotionalaspects of pain and how important they are. but it's half ofthe definition here. and in my opinion, ok, i admit. i'm biased.

i'm a pain psychologist. but if we pay more attention tothat aspect of the definition, we can gain better controlover our experience. and that's really whatthis is all about. how do we put youin the driver's seat of your experience? how do we allow you to havemore control over your pain so that you needfewer doctor visits, and you need lessmedication, and you're just

better able to controlyour experience? so even if you don'thave chronic pain, what i'm going to say todaywill be relevant to you. this emotional experience is apart of the definition of pain. we were just talking about that. but then when weexperience pain, we're going to have anemotional reaction to it. and that reaction feeds rightback into our pain experience and can determinehow much we suffer.

so it's hard to thinkabout pain as being anything other than bad. isn't it? because pain is,by its very nature, is-- think of itas your harm alarm. pain is there to warn you. it's the danger signal. it's there to motivateyou to get away from whatever is threatening.

pain is threatening. and so it really motivatesus to change our behavior to want to get away from it. but again, thatworks really well when it's just aneedle, or a pin prick, but once we havechronic pain, how do we get away fromsomething that's coming from inside of us? whether that's migrainesor fibromyalgia, or maybe

you have back pain. it's hard to justescape that, right? and so we really can't. we can't just escape it. but those signals and theseprocesses are still happening. we're still gettingthe same sense of, i want to get away from this. this is bad. it's, of course, it'sgoing to be there.

and if we don't learnskills and techniques to manage thisautomatic process, then we can be leftfeeling-- the process can lead to a lot ofconfusion, and some helplessness, and hopelessness. so pain is there for a reason. and it's very adaptive,and it helps us survive. it's a good thing. but once we have chronicpain, it's a different story.

and that's when we reallyneed to learn more and learn how to control it. so i'm going to take what willappear to be a little side trip, but it's not. i want to talk aboutsomething related to pain. this is the experience of dread. dread is to anticipate withgreat apprehension or fear. and sometimes people-- we alldread something in our lives, right?

i mean we all do. you could think aboutdread as being painful. so let's talk aboutthings that are-- where we use in our language. we use pain to describereally what we dread. so uh, traffic, traffic gettinghere tonight, it was painful. taxes. most people dread taxes. i don't know ifyou do, but i do.

and i'll tell you, this one. this is really funny. math is painful for somepeople, not everyone, but for some people. and it was for me yearsago when i was in school. and it's interesting. so in our everyday language,we use dread to almost to describe what'spainful for us. and there's actually ascientific basis for this.

it's not just linguistics. and so there'sinteresting research that was done onpeople who dread math. and so these researchers,doctors blaylock and lions, did a study on peoplewho had math anxiety. but they really characterizedthem as math dreaders. and this was a study wherethey used fmri technology. so they scannedpeople's brains and were able to see in real-time whatwas happening in their brains

as they were thinking about mathand as they were approaching math tasks. and remember, math was painfulfor these math dreaders. and so what they found was thatpeople who really dread math, when they look attheir brains, it's activating the same regionsof the brain that's associated with pain processing. that's associated with physicalpain and physical threats. and so literally, the thingsthat we describe as painful,

or when we aredreading something, it's lighting upthose same areas. it's activatingregions of our brain that indeed are associatedwith the experience of pain. and so it sets astage for us to begin to understand how some of thosethings in our daily lives, that maybe we dread or areparticularly stressful, it has implications for howthat might impact our pain. if you have chronicpain, a lot of people

notice an associationbetween stress and pain. and there are clearconnections for this. and what i'mputting forward here is how this idea ofthe experience of dread relates to pain. so what's worsethan physical pain? the dread of physical painis worse than pain itself. and this was shown recently ina series of different studies. this is a field ofneural economics.

and this field ofneural economics is concerned with the valuethat we ascribe to things because the value thatwe ascribe to things determines the decisionsthat we make around it. and so this is studiedin the marketplace. so the field of neuroeconomics,there's classes on it. there's degrees in this area. there's books on the topic. i just pulled a few ofthese off the internet.

this one, how the new scienceof neuroeconomics can help make you rich. so there's a lot on the topic. but what's interestingis that some researchers were really interested inunderstanding how dread influences decision making. how does dread influencedecision making? and they do this in experimentswhere they use pain. and so they bring peopleinto the laboratory.

and i don't know if you'refamiliar with pain research. but we do bring peopleinto the laboratory, and we do inflict pain. and i promise it's not severe. but you do experience some pain. and then we studyreactions to pain. and we study what happens in thebrain when you experience pain. and in this particularset of experiments, people came into the lab.

and they put them into an fmriscanner to study the brain. and they had themexperience foot shocks. so that was the paradigm,little shocks on the foot. and they're low voltage. so nobody was harmedin these experiments. but people experiencedlow voltage foot shocks. now, classical theoryof decision making would hold that wewould want to put off tomorrow things thatare painful or things

that we don't want to do. and what we will choose to dowhat are the things that are more rewarding and comforting. and so we want pleasurenow, and we'll put off the things that are painful. that's why we delay onour taxes and so forth. so that's a basic logic for it. but what they foundin this experiment was that when they set peopleup to experience various foot

shocks, they were concernedwith the amount of time that people had before theyexperienced the foot shocks. so they gave people choices. and they said, you canexperience this moderate level of pain now, or you candelay, and you can experience that same amount of pain later. and so while we wouldsuspect that people would want to delay andnot experience that pain. in fact, people preferredto experience the pain now

to get it out of the waybecause the delaying the pain, it just engendereddread about it. then they're thinking aboutit and worrying about it and dreading it. and so that was actually worsethan experiencing the pain sooner. so that was the idea. people would ratherexperience pain sooner to get it out of the way.

another set of scientistsstudied it further, this concept of dread andpain and how they relate. and in this nextexperiment, they were also playing withtime and decision making. and they gave people a choice. they said, you can experiencethis moderate level of pain in the future, or youcan experience it now, but it's going to be morepainful if you experience it now.

so the choice was pain inthe future or more pain now. and what they found was isthese people particularly high on dread, they'lltake more pain now because that period of dread ismore painful than pain itself. and so this, again,allows us to begin understanding how ourperceptions and our experience, or emotional experience,really characterizes our pain experience. they took it evenone step further

where they studiedhow framing the pain changed people'schoices around pain. and what they found waswhen they used language where they talkedabout, ok, you're going to experience ashock soon, it's about 30% less than that oneyou had earlier. when they framed it asa reduction in pain, people were much more likelyto experience the pain, even the same amount of pain,than when they framed it,

either in a neutral way, orin a way that made people-- where it cued them that somehowit was an increase in pain. so even the language andthe framing around pain is very powerful. this is just further evidenceabout how our psychology influences our experience. now there's other factors, ofcourse, that influence pain. i'm going to talkabout a lot of them. some of them we can change,and some of them we can't.

if you are female, you're morelikely to have pain than men. you're more likely toacquire chronic pain. and once you have it, it'smore likely to be more severe. you're more likely to havemore frequent episodes of pain and for them to be more painful. and there's differentreasons for that. there's a lot ofreasons for that. and what it boils down tois that in a lot of ways, female physiology ismore primed for pain.

and it just makes itthat much more important that we learn variousskills and techniques so that we can ensure we havecontrol over our experience. now other factors emotions. anger is, of course, an emotionthat we've all experienced at least from time to time. well, it turns outthat persistent anger is particularly problematicin the context of pain. and a lot of research hasbeen converging in this area.

a lot of it doneby dr. john burns. and what his work and what thework of other people is showing is that the experienceof anger is associated with more severe pain. and not only justmore severe pain, but it's also linkedto our ability to function, how muchare we able to do and our quality of life. and so this has beenshown in different ways.

in our own lab, at theneuroscience and pain lab, there is a colleague,chloe taub, who has been lookingat the role of anger and how it influences theemotional experience of people who have a history of trauma. now we know that whenwe experience trauma in childhood, or even atany point in our lifespan, but particularlyin childhood, it's well studied, thatthis history of trauma

sets us up to developchronic pain later in life. it's almost like itcreates a vulnerability. we're more likelyto experience it. and one of the things thatchloe's work is showing is that anger has aparticular role in people who have experienced trauma interms of how they will respond to pain later on. so again, reallyidentifying anger as an importanttherapeutic target.

this next study, weactually treated anger in an intervention, compassionmeditation intervention study. so this compassion interventionwas developed at stanford at a ccare at stanford. and we studied how thiscompassion meditation intervention would helppeople with chronic pain. and so what wefound is that when people took thisnine-week compassion course, that not only did theirpain intensity reduce, but also

they had concomitantreductions in anger. and this is reallyimportant because when we have chronicpain, often anger can be a common experience. it can be a commonexperience for people to even feel angry at their own bodies. my body's notallowing me to do what i want to do, to befrustrated, to be angry, or maybe we're angry at otherpeople from time to time.

but it is importantto identify if you have those persistentemotions and to know that it's important totreat it specifically because it will help your pain. related to this is aconcept of injustice. injustice andanger also combined to be a very potentinfluencer of pain outcomes. they basically serveto make pain worse. and this is important inthe context of chronic pain.

how many people askfor chronic pain? nobody asked for it. nobody signed up for it. it's not fair. and then on top ofit, sometimes people have chronic pain because theywere involved in an accident. let's say you were in arear-ended on the 101, and you had whiplash, and then,you developed chronic pain. certainly, there'sinjustice there.

let's be real. i mean nothing is fair here. but if we harborfeelings of injustice, if we feel victimizedby a circumstance, that turns out towork against us. the data are reallyclear, that when we have feelings of injustice,that they impede our ability to focus on what we cando to help ourselves. and that's reallyimportant to be mindful of.

the idea is that sure,there's a lack of justice, and i have been a victimof a circumstance. but really holding on tothat will not serve you well. and so the idea is toaddress that and treat it, so that your pain can improve. this was a studythat i conducted with dr. halawa at oregonhealth and science university back when i was there. and this was interesting.

it really gives usa snapshot into how our beliefs about painand pain treatments influence our experience. and in this study, wewere interested in looking at people in themiddle east compared to people in the united states. and we were studyingpeople with lung cancer. and people with lung cancer whohave pain and their willingness to engage in treatments.

and what we found wasthat people, americans, are fine with takingmedication, especially in the context of cancer. if they have pain, they willtake the opioid medication to reduce it. but in saudi arabia, peopledo not take opioid medication, even if they're offered it,because they perceive pain as being a test of god. and it's a sign ofstrength and endurance

for them to experience pain. and so they do that. and it's very difficult toget people to engage around pain treatments becauseof their beliefs around the meaning of pain inthe context of their culture and in their religion. when we have surgery,we're generally given pain medication. we take it for a period of time.

some people take it for longerperiods of time than others. even if all of the otherfactors are the same. some people need more painmedication than other people. we've been looking atsome of the reasons why some people needmedication longer. this was a studythat was conducted by dr. jennifer hahand dr. shawn mackey here at stanford and colleagues. there's a big list of colleaguesinvolved in this study.

but what they wereinterested in was what are some ofthe factors that predict how much medicationwe need after surgery. and what they found, thepunchline on this one is that when we havecertain factors, some depressive symptoms,when we don't feel good about ourselves, there's asub-scale in depression that's related to self-loathing. when we don't feelgood about ourselves.

when we feel worthless. that was a strong predictorof whether someone goes on to continue to need moremedication over time. again, testament tohow are psychological experience influencespain and also our response to pain treatments. so i'm going togive you a second to take a look at this comic. and i'll just read it.

"the pain starts in myhusband's lower back. travels up hisspine to his neck. then it comes out of hismouth and into my ears. and that's why iget these headaches. and we're poking some fun here. i'm poking some fun here. we can all relate in some aspectof this at different times in our lives. but at the core, whatthis is illustrating

is that there are socialdimensions to pain. pain can be transmittedin various ways, and we're learning moreand more about the impact of social factors onthe pain experience. there is a researcher downsouth in california, naomi eisenberger. and she's been studying theconcept of social rejection and how it relates to pain. and we're makingless of a distinction

between social painand physical pain, frankly, becausewhat we're finding is that social pain primes usto experience physical pain. so what's the antidoteto all of that? well, it turns out thatromantic love is an analgesic. that love does kill pain. it is a natural painkiller. this was shown righthere at stanford. this is another one of dr.shawn mackey's studies.

and this was a fun one becausea lot of the pain studies are like we're goinginto the vortex and studying negative emotions. and this one was studying love. and so they recruitedpeople, students right here at stanford,who were in an intensely loving, romantic relationship. so they're like deeply in love. they sign up for this study.

and you bring theminto the pain lab, and we'd do somepain testing on them. and then, part ofthe experiment was they would look at apicture of their beloved. and then, we would see howthat would influence their pain testing while they're viewinga picture of their beloved, compared to a picture of astranger who was theoretically equally attractive. and what theyfound was that when

people are looking at apicture of their beloved, they feel less pain. it is your body'snatural painkiller. so you can almost think ofit as an androgynous opioid. that they didn't reallytest for opioids, but we do know for a factthat there's some mechanism to explain that romanticlove, and just even viewing a picture of yourbeloved, does reduce pain. so we could prescribe thatfor every one as a painkiller.

so going furtherand taking a look at some of the social factors. how social factorsinfluence pain? this is another studydone here at stanford. this is spearheaded by mycolleague, dr. drew sturgeon. and he was reallyinterested in how social factors influencepain intensity and also emotional distress. and it's more typicalthat we think about well,

yeah, i have pain,and then i can't do the things i want to do. and that's why i feel this way. that's why i haveemotional distress. i can't do thethings i want to do. but what drew was actuallyshowing in this study was that it wasn't so muchwhat you could or couldn't do that explained how muchemotional distress you had. he found that theextent to which you

had this reductionin your ability to engage socially thatthat is what made pain lead to emotional distress. so it's coming moreinto our awareness. it's appreciating theinfluence of social factors, how important it is for treatingpain and reducing our pain. so this gentleman says, "ikeep getting pins and needles in my arms." and this is one of myfavorites of all time.

and why i love thiscartoon-- it's so human. i mean we all do this. but really, it's suchan eloquent metaphor, in my opinion, for psychology. it's in the background. and if we're not aware of ourthoughts and our emotions, if we're not awareof our feelings and what's triggering usin feeling a certain way, then, unwittingly,unbeknownst to us,

we're probably contributing tosome of our pain and suffering. because our brainsand our bodies are designed in a way whereit's going to bring up some of these emotions, some ofthese thoughts that can trigger more pain, someof these emotions that can trigger more pain orprime us to feel more pain. so if we're not awareof what's happening, we might be this guyfrom time to time. and that's the whole purposeof bringing more awareness

to how these pieces fittogether, how psychology fits into this picture. oops. ok, so the underlying idea,no matter what kind of pain you have, no matterwhat your diagnosis is, no matter what kind oftreatments you have had, you are participating withyour pain, with your thoughts, with your emotional experiences,and with your choices. this does not mean thatit's all in your head,

or that you're making it up,or that it's all psychological. you have a medicalcondition, and you have pain. and your psychologicalexperience will influence howmuch pain you have, how much you suffer from pain. so it's almost likeyou have the ability to dial it up or dial it down. and by paying attention tothese psychological pieces and learning skills andtools and information,

you can harness some potentialthat's available to you to turn that dial down. so pain catastrophizing,this is something that i spend a lot of timestudying, researching, and even treating in the pain clinic. so you may have heardthis term before. pain catastrophizing iswhen we focus on our pain and have a hard time focusingon anything but the pain. it really grabs ourattention and holds it there.

and so we might be thinking,uh, my pain, it's awful. i might be thinking there'snothing i can do about my pain, focusing on how helplessi am about my pain. and i might beruminating about my pain. so it's when we magnifypain, ruminate about it, and feel helpless about it,sort of a trifecta there. and we all catastrophizefrom time to time. maybe we catastrophizefinances or relationships or different things.

but in the context ofpain, it's particularly toxic to overfocus on pain andfeel very negatively about it. and hopefully some ofthose previous slides are setting the stagefor you to understand how that all fits together. so how do know if you'recatastrophizing or not? well, we measure itwith, typically, there's different questionnaires. but one of the easiestto access is just online.

you can google it, thepain catastrophizing scale. you can take thismeasurer, and you can see where you fall on the spectrum. you can take this scale evenif you don't have chronic pain because it willreference-- think about when you do have pain. maybe going to adentist office or if you had a medical procedure, howdo you tend to think and feel in the context of pain?

well, it turns out that thisis a really important factor to pay attention to. pain catastrophizing has beenstudied for more than three decades now. and the research is reallyclear, that the idea being, that when we catastrophizeour pain, well, there's overlap in theneural circuitry between what is activated whenwe catastrophize and what happenswhen we experience

sensory pain, physicalpain, in the laboratory. so think of it as that it sharesreal estate in your brain, basically. and as it turnsout, catastrophizing is when we-- that'show we respond to pain. i feel pain, and then ican't stop thinking about it. and then i start thinkingabout how terrible it is. and it's probably notgoing to get any better, and what's going to happenas a consequence of it

not getting any better. that's catastrophizing. that's how i'mresponding to pain. it turns out thathow you respond to pain, if you'recatastrophizing, it shapes your brain patterns. and we can see thisin the scanner. we could put you inthe scanner and see how your brain is activatedwhile you're catastrophizing.

that's easy. but here's theinteresting thing, that people who catastrophize,their neural patterns look different even atrest, even at rest. and so it shapesyour neural patterns, and it primes youto feel more pain. so the more weget on this track, the more we stay on that track,and the deeper the track gets. now, but just like thegentlemen with the tattoos,

we can learn to not get tattoos. and you can learn howto stop this process. but the importantthings to know, it does prime yournervous system for pain. and it sets the stage foryou to have a poorer response to any of the treatmentsthat your doctors will try. so this is the way i explain itto the people that i work with, and i teach classeson catastrophizing. and i say, imagine that thisis your pain, this campfire,

and it's contained, and youknow it, and you live with it. and there it is. when we catastrophize,it's the equivalent to picking up a can of gasolineand pouring it on that fire. and so we can learn howto stop catastrophizing. it's not going to takethe pain away though. but we can get you back here. and this is the goal. this is the idea with painpsychology and learning

how to use some of theseskills and information. it doesn't take it away. but if we can get you backhere where it's manageable, that is gold. that is a huge win,and hopefully, you would agree with that. ok, so how doescatastrophizing impact pain? all kinds of bad stuff, morepain intensity, worse function. it's associated with disability.

it actually predicts thedevelopment of chronic pain. so let's say none of ushave pain in this room, and we take thiscatastrophizing scale. and then we go a wholeyear out into the future. and then we see, well,who in the past year developed chronic pain? the people who scoredhigh on that questionnaire are significantly more likely todevelop chronic pain later on. this has been shown inprospective studies.

it's fascinating. that's how powerfulyour mind is. so what predictstreatment response? what predicts who getsbetter after surgery and how quickly peopleget better after surgery? it's an interesting questionbecause lots of people get the same treatments,and we respond differently. what makes the difference? well, it turns outthat catastrophizing

is one of the most potent,prognostic indicators of recovery after surgery. and so people who scorehigh on this questionnaire before surgery are more likelyto need higher doses of opioids after surgery and to take themfor a longer period of time, more likely to develop ongoingpain after surgery, more likely to stay inthe hospital longer, to have a poorer rehabilitation,poorer functioning. so it delays recovery.

and it can lead to pain lastingfor a much longer period of time. and so the idea isthat our doctors can try lots of interesting things. and we have some goodmedical tools available. but if we're notaddressing how we're responding to pain and someof these other factors, we might not have asolid enough foundation. and i want to bevery careful here.

this is not to placeblame on us as patients. we're all patients atsome point or another. it's not to placethe blame on us. it's to highlight thatthere are opportunities for us to optimize ourresponse to medical treatments. and i think it's in all of ourbest interest that we do that. so i have dedicated asignificant amount of my career to studying this thingcalled catastrophizing. this is so powerful, so potent.

it exerts a hugenegative influence. can't we just treat it? and of course we doin pain psychology, in health psychology. we do identify catastrophizing,and we do treat it. and we typicallytreat it individually. you work with a psychologistover a period of time, or you attend these grouppain psychology classes, cognitive behavioral therapy.

and it's typically eightsessions, two hours at a time. so over a course of a coupleof months, this is treated. but it's treatedwithin the context of a lot of different factorsthat we look at with pain. so we might befocusing on pacing and how our mind andour mood influence pain. and catastrophizing is oneaspect of that treatment. but there wasn't any quickway to address and treat catastrophizing.

so i was inspiredby this study here. this was conducted-- the secondauthor here, katie martucci, is now at stanfordin our pain lab. and she and fadelzeidan, and colleagues conducted a reallycool study in 2011. and in this study,they took people who did not meditate, didnot meditate, brought them into the lab, and they didsome pain testing on them. and then they taught them somebrief meditation techniques.

and i mean brief, 20minutes, but 20 minutes for over the course of fourdays, so a total of 80 minutes. 20 minutes, eachday, quick coaching on meditation techniques. and then they had them dothe pain testing again inside of a scanner, an fmri scanner. and what they found wasthat when people learned these meditation techniquesvery quickly-- remember, it was only 80 minutes thatthey invested in this--

they were able to reducetheir pain by 40%. and they were able toreduce the bothersomeness, the unpleasantness,of pain by almost 60%. so this is amazing, thatsomething that's basically free can really modulate, reallyreduce, pain so quickly. so i was thinking, how can weapply this to catastrophizing? so in 2013, i developeda two-hour class. it's a single sessionclass that focuses only on catastrophizing.

what is it? why you should care about it? and what you cando to reduce it? so it's information,and it's skills-based. one of the foundationsis learning how to calm your nervoussystem in the context of pain and stress. this is what happensautomatically when the harm alarm goes off.

and this is what happens when welearn the relaxation response. so this is a clearskill that is taught, and it's used regularly. and there's othercomponents in the class as well, differentinformation where people identify what are thetriggers for catastrophizing? and they put together apersonalized plan to treat it. and so what we foundis that people really enjoyed the class.

they found thatit was acceptable and were satisfied with it. but more importantlythan that, what we found is that their catastrophizingscores reduced significantly. and this was really interestingto us, that in two hours, you can teach peoplehow to gain control over their mind-body connection,reduce catastrophizing. and this potentiallycould then lead to very important improvementsand health outcomes for pain

and also for surgery. and we found that even if youwere depressed or anxious, that you still got a niceresult from the class. so we found very large effects. and this is just a highlight,that the majority of people in the class experiencedeither a moderately important reduction or a substantiallyimportant reduction in catastrophizing justfrom this two-hour class. and we submitted agrant to the nih.

and fortunately,they agreed with us. and we were given amultimillion dollar award to study this classin more detail to better understandwhat are the mechanisms by which this treatment works? and how psychologyworks, and how can we use that to help people? because we can simplytake medications, or we can alsolearn various skills

that help us need alittle bit less of that. not that medicationis bad, but we do want to optimize everythingwe can do to gain control. and so this is a topic thati speak about frequently is empowering people toreduce their own pain as much as possible. ok, so how do you open themedicine box in your mind? one way we couldthink about it is how do we empower ourselves,each and every one of us,

to change our pain,to change our brain, and also to change our behavior? and so self-regulation ofcognition, emotion and arousal is paramount. let me put that in english. learning how to better controlour thoughts, our feelings, and the amount of stressthat we feel in our body and in our nervoussystem is the key. and we can learn how to do this.

ultimately,developing confidence in your ability to calmyour own nervous system is the key tosuccess, to gaining as much control as possibleover your pain experience. ok, so let's openyour medicine box. what are beth'stips for doing this? i do have a listof tips for you. number one, and theseare based on the science, learn mindfulness-basedstress reduction,

if you haven't already. because there's great datato support that it works. for improving, ithelps reduce pain. but when we thinkabout everything that i've been talkingabout, it helps put a containeraround our responses to all of those emotionsand factors in our life. the stress, or anger,or catastrophizing, all of these things thatamplify pain processing

in our nervous system, theseare skills and techniques that help dampen that processing. so meditation is great. work with a painpsychologist, a psychologist who works with peoplewith chronic pain, has very specifictraining in treating chronic pain, who is acognitive behavioral therapist. work with someoneone-on-one to make sure that you're reallyoptimizing everything

you can from apsychological perspective. determine if you'recatastrophizing and get it treated if you are. if you happen to be a patientat the stanford pain management center, i teach free classeson how to stop catastrophizing, how to treat it. and so you can ask about that. you're more thanwelcome to come. the trick is to use the skillsdaily because what we're doing

is we're conditioning ournervous system away from pain. so if you just use themevery once in awhile, it's not going to do the trick. that'll help you have a littlebit of comfort in the moment, but it's not going to alter theway you are processing pain. it's not going to alter someof these patterns of thinking and feeling. so you want to use the skillsdaily and really cultivate this belief.

this is criticalthat you're changing your brain and yourexperience because you are. exercise regularly. well, that's a funny onefor me to put up there because i haven't saidanything about exercise so far, however, exerciseis known to be some of the best medicine for pain. it's great pain management. it also improves your mood.

and when our mood is better,it improves our pain. so there's differentpathways by which exercise is excellent mind-body medicine. and if you're not sure, if youfeel like it might be unsafe, work with a physicaltherapist, get checked out, find exercise programthat's appropriate for you. and there's lotsof professionals who can help with that. if you have sleep problems,learn about sleep hygiene.

one of the best predictors ofpain intensity on any given day is the quality of yoursleep the night before. lots of people with painhave sleep problems. there's a great sleepclinic at stanford. there are lots of expertswho can help with this. i encourage you toseek out that help. there's even professionals herewho are sleep psychologists. and they help unravel someof the stressors or anxieties or how our psychologymight be interfacing

to work against us inthe realm of sleep. and so there are professionalswho can help with that. nurture positive andsupportive relationships because we know how importantthese social factors are. ah and this one, learnto nurture yourself. and we talked about how love,intense love, romantic love, is analgesic. what if we learnedto love ourselves and learned to bekinder to ourselves?

and so if you know thatyou're struggling with that, that's where the compassiontraining can be so effective. if you have any angertake the compassion course to foster releaseand forgiveness. these are taught righthere at stanford. every day focus onwhat you can do. so critical, so critical. and lastly, sourcegratitude because it will help you shiftyour mindset away

from some of those factors,feelings of also anger, injustice, some of the factorsthat we know worse than pain. and it helps shift us intoa state of expansiveness. so sometimes people will say,yeah, beth, that sounds great, like the exercise, or go takea course, or be more social. but i have chronicpain, and i need to feel better beforei can do those things. and we get into this chickenor egg dilemma with this. know that you're not going tofeel like doing these things.

you're not going to wakeup wanting to exercise. or sometimes you'rejust not going to want to get outand see people. we have to encourageourselves to do it anyway because that is the medicinethat helps us get better. but if we just know, expect thatyou're not going to want to. if you wait forthe day, when you want to do some ofthese things, you're going to be waitinga really long time.

so the way to take controlis just to know, yup, i'm not going to want to,and i'm doing it anyway. because i am goingforward, and i am determined to have abetter quality of life. and this is how i seeeach and every one of you. and i just want to say thankyou for your time and attention. i also want to say thanks to mycolleagues and collaborators, people who are doingsome really amazing work. and i'm just lucky toget to work with them.

so thanks again. [audience clapping] i think we have sometime for questions. is that right? any questions? yes? one thing you didn't mentionwas the power of laughter and positive thinkingand seeing the glass half full versus half empty.

but laughter alone, you talkedabout romantic relationship, and that's if you'relucky enough to have one, of a meaningful one,is the endorphin that your body, yourchemical-- your own chemicals that are working onyour pain receptors. and i think laughteris a lot more-- so much endorphin release and[inaudible] exercise. those two are very [inaudible]. absolutely.

great point, great, great point. and for those of youwho couldn't hear, she was saying that laughteris excellent medicine for pain and absolutely. a really nice basicway to think about it, if we want to be reallyreductionistic here, things that bring usjoy are analgesic. they're painkillers. and the things that whenthey don't feel good,

that we woulddescribe them as being kind of painful in theway, they are painful. they do prime usto have more pain. and so it's anopportunity for all of us to put our lives andour relationships and our choicesunder the microscope and to determine is thisbringing us joy or not? and do we want to maybemake some different choices? or how can we steer ourselvesmore in the direction

of joy and laughter and love? yeah, absolutely. question? yeah, is anybody doingresearch on the notion that there are formsof chronic pain that are analogous totinnitus, which is something that nobody understands? but my understandingthat i have of it is that it's psychological.

perhaps. and you're a psychologist. is [? somebody ?]working on this notion that chronic painsomeplace else in the body is literally thesame kind of process but just involving differentnerves and auditory nerves? yeah, so it's an interestingquestion and really hitting on the idea ofsomething like tinnitus, which is the persistentringing in the ears,

that they don't have goodunderstanding of the mechanisms or why that's there, but thatthere is overlap, actually, with chronic pain indeed. and we find that there'soverlap as well with other types of conditions wherethere's something of a stuckness in thebrain and the body. so an example of that is posttraumatic stress disorder. well, we experience atrauma, a horrific trauma. the whole nervous systemgoes into high alert,

and it never goes away. and so maybe i had a caraccident 10 years ago, but i'm still living everyday as if the accident just happened. it's stuck in the nervoussystem, and why is that? and the same with pain. those pain signals are no longerserving a useful function, and yet they're there. and so some of thetreatments are similar.

i mean we look forways at a minimum to manage these-- theflares associated with it or the bothersomeness around it. so for tinnitus, for example,and even for chronic pain, some of the besttreatments involve learning how to harness themind-body connection, how to de-escalate and dampensome of the high alert that your systemis experiencing. another question?

yes, did i understand inthe beginning of your talk, you said when they do functionalmri, the part of the brain that lights up is same asperceived kind of a pain? what did you say exactly? i had a littledifficulty with that. so i'm not exactly surewhat you're referencing. was it about the dread part? or was it-- when you first talkedabout when they looked

at functional mri,the part of the brain that lights up actuallywith physical pain, actually same as. got it. yes. so i think the partthat you're referring to is that there are manydifferent studies that look at how the brain isactivated during pain. and when we experiencecertain negative emotions,

for instance, there's a lotof overlap between what we're experiencing emotionally andthis map of what we experience from pure sensory pain. my difficulty was when,my understanding was there's psychosomaticpain and then there's truly mechanical,physical pain. a bulging disc pain isa bulging disc pain. there's nothing perceived. yes, yes.

because you're upset, it'sjust daunting is there, and nothing is goingto relieve it until you get the adequate pain relief. but with the emotions,that's the difficulty i have. i'm sure the part of thebrain that is lighting up is different. oh it's a greatpoint that i want to spend a little more time on. and thank you forbringing it up.

so the idea thatyes, you could have pain in your spine,the bulging disk. we can image thatand point at it and say, yeah,that's what hurts, and that's why that hurts. but even so, evenwith all of that said, our psychology, theoverlay of psychology, can either make itworse or make it better. now we can do allof the treatments

in the world to help youdampen the pain processing. it's not going tofix the bulging disc. there is a level of painthat will be there, if you have that medical pathology. there's definitely there's anemotional psychosomatic part of it also, even with thebulging disc. [inaudible] the definition ofpain, no matter what the cause of the pain, isthat it is a negative sensory and an emotional experience.

and it's all in thisspectrum to what extent this is really influencingyour pain experience. but the exciting thingfor me is that there's beautiful, wonderfulopportunity for us to take a look at wherethose opportunities lie to gain more control. and to me that's reallyexciting because it puts you in the driver's seat ofhelping make things better for yourself.

it's not going to takeaway the bulging disc. nobody's saying that. but also, i'm notputting forward that all pain is psychologicalor just in your mind. what this is aboutis recognizing that there ispower in psychology to alter our experienceeither for the better or for the worse. and of course, we wantto make it better.

so we use some of these skills,techniques, and formulas to help ourselves suffer lessand to get more out of life. question over hereand then over here. yeah. so you [inaudible] aboutpain catatrophizing and how that canactually magnify your experience of pain. what are the potentialbenefits and risks of potentially promptingthat pain catatrophizing

by asking about to monitorit at different doctor's appointments. so you're trying tomonitor it to make sure your pain goes away. could that potentiallyinfluence the way they experience the pain? do you mean what isthe potential downside of monitoring painor of monitoring pain catastrophizing?

could the potential-- soby trying to monitor pain, could you actually be sparkingthis pain catastrophizing? even if you're trying to help. no, it's a great question. yeah, yes, so thequestion is you know now that every time yougo to the doctor, they ask us about our pain. and so we're constantlybringing our attention to it. and you hit on areally great question

because it's onethat we actually struggle with in pain research. because how do we studyit without asking people about it a lot? and we don't want to beasking them all the time because that's anegative intervention, just asking peopleto think about it. what we really want is forpeople not to think about it. but it's a catch-22 in pain.

we were literally talking aboutthis this week in the lab. it's like how do we studyit without priming people to pay attention to thenegative aspects of it. so my personal belief isyeah, it can play a role. it can. and we just need tobe very mindful of it. and there's no great solutionsthat we have right now. ask about it alongwith everything else. what's that?

yeah, well, and nowthat you mention it. when you come to a pain clinic,when you're working with people who really only workwith pain, whether that's a psychologist or a physician,often they won't even say, they won't even askabout your pain. they'll just say,how are you doing? how are you doing? and just ask it open-endedly. because usually when peoplehear that they might think oh,

i had a great week. or today, blah, blah,blah, blah, blah. so not asking aboutpain, ultimately, we want to be in that direction. and then there wasa question here. i just want to know if it'spossible to see the web addresses again. i wasn't fast enoughto copy them down. let me see if i canget to the first slide.

so we have thefirst-- here we go. this is the one. let's see if i canget it to work. i might need techsupport to help me get it up at this point. sorry. so let me do this. let me just give you theaddress or the name of the lab. so it said stanford--

there's one in the onewith the back pain. the back pain. that one. ok, so what you'llwant to do is you want to go to the stanfordsystems neuroscience and pain lab. so if you just goto that website, you will then find the tabfor the center for back pain. so it's housed underthe neuroscience

and pain lab-- the systemsneuroscience and pain lab. that's where you findthe center for back pain. so stanford systems pain-- neuroscience and pain lab. i can write it down for you. come see me afterwards. i'll write it down for you. i'll make sure you get it. it's long.

it is long. you're right. and also the stanfordcenter for back pain, that will get you there. and you fill out an online form. and we can automaticallysee if you're eligible for thisfree treatment study. and even if you're notavailable for that one, we have other cool studiescoming up all the time.

we do a lot of different things. and so you will be contactedwhen there is a study that it appears that you qualify for. then we bring you intothe lab, and we'll do ask more questions tofind out what's appropriate and what's interesting to you. yeah, another question. so you had mentionedthat there's a cultural difference in theway that people perceive pain

within cancer populations. in your experience, or perhapsthere's research on this, is there a differencein different cultures and how people experiencepain in general? it's a great question. and did you wantto chime in there? i'm from iran, persian, and myfather, of course, very much pers-- wants to be perceived. so he had done somewoodwork, he's retired now,

so his shoulder was achingand very much, i think, because he stopped doing it. and i said, dad, well,you need to stop. you're doing too much. i'm going to show it. it has no right to hurt. he basically, he does nottake any pain medication. and yes, very much, i thinkcultures and men especially, they don't--

but it's interestingbecause there's also a gender effect there. and sometimes there canbe an age effect too. i mean back in the day, peoplewould just be like suck it up, and they would justsuffer or get through it. and so there's manydifferent factors. so culture, age, sex,gender, it all plays a role. the one thing that iwill say without being a cross-culturalexpert on the topic

is that many studieshave looked to see well, do we just have more pain here? is there somethingabout our culture where we're more sensitive to it? and the answer is no. the answer is no. that we had thissurprising statistic that 100 millionamericans experience pain on an ongoing basis.

that's almost onein three adults. but really, when you look atthe data for the other countries in the world, it's all similar. it's all similar. so i think there'spockets of differences from here and there. but actually, theprevalence of pain is-- it's pretty standardacross the globe. we're just lesspatient with the pain.

we want a pill right away. a pill. just give me a pill. i'm hurting, give me a pill. i just want to cure it quickly. yeah, yeah. question back here. i just want toclarify something. you had said that angeris a therapeutic target

and that also thatcatastrophizing is this therapeutic target. is the compassiontraining the treatment on both of those targets? so interestingly, well,that is a great question because i have not seenany data for a study that has looked atcompassion training as a treatment forcatastrophizing. our study looked at compassioncultivation training

and found that it reducedpain and anger concomitantly. and so it's veryuseful for that. now i would suspectthat it would be useful forcatastrophizing as well. and what we're reallyfocusing on now is briefer treatment,specifically, for catastrophizing. the idea thatwell, gosh, if this is such a powerful negativefactor, what if we identify

people early on andrapidly treat them, so that they canhave an-- optimize your response towhatever treatments your doctors will try with you? so i have thisfantasy in the future that when you set footin the pain clinic, or maybe even in primary care,that they could screen you and give you a linkto a video, where you could get all of theinformation and start

self-treating. and in fact, here atstanford, we adapted the class that i developed. we put it on videoand adapted it so that it'sappropriate for people who are about to have surgery. because remember one of thebig indicators of how well you do after surgery is whether ornot you're a catastrophizer. so what if we treatcatastrophizing before surgery?

and that leads to quickerrecovery, less medication, better function. so that's the hypothesis. we're studying this right now. we're doing a randomizedcontrolled trial in women who are undergoingsurgery for breast cancer. some of them are getting amastectomy, but some of them are not-- it's not mastectomy,but they are undergoing a surgical procedure.

and so we're looking to seecan we help people remotely? because they're justwatching this online and going throughthe treatment online. but i think now becausewe know that pain is so prevalent in this country,and we've all seen the stories on pain treatments. and we need solutionsthat can help people. and we have tofind ways to treat big masses of people efficientlyand in a manner that's

cost effective. and so part of what we'retrying to do here at stanford is develop theseinnovative treatments that can be part of the solution. how many of these treatmentsthen get to a surgeon, for example, out in the realworld, not in this academia setting, so that his breastcancer patients would be aware that they could takea video or that they could-- who does that?

when you say we, who does that? who delivers that? totally, no, it'sa great question. so first we study it inan academic environment. and the end goal isjust to have these free on the internet and available. that is the goal. one excruciating aspectof science and research is that we have to studyit for a period of time

before we can just make itfree and widely available. and there's ways thatwe get around it. i mean i put this informationin my book, for instance. but when we just develop it,we have to learn how it works and for whom, so that wecan basically give people more information about it. but i will share with youthat my goal is to get it out and for it to becompletely free. and it won't be this year, andit probably won't be next year.

but sometime in the near future,that is absolutely the goal. so that you, or any of us,could just google that. download it. download the app. the app will be free. the video is free. everything, all ofit, widely accessible. because there's no point in justdeveloping things in our lab, and then we help 30 people.

the point is to helptransform pain care and to give people thetools and the resources, so you can self-treat at home. but my point is that informationis out there, much of that's out there right now. but how would manypatients who have surgery, would their surgeon,for example, be alert enough to thisto say go to this website, or here's some research--

well, it's a good question. and we're moving things in thedirection of educating more on this topic. so just this month i hadan article published. it's basically in ajournal read by surgeons. it's a surgical journal. so it starts therewith really educating medical providers who don't livein this world of psychology. i mean they just--no fault, no harm.

but it's a new concept for them. we're working to introducethe concept, draw attention to the importance oftreating it and also to connect to themwith resources. because as you mentioned,even though, for instance, this whole video packageisn't available now, there are things thatare available today that people can use. so those are the thingsthat i write about.

yeah, another question? i just thought about something. it goes to yourquestion of dreading. have they done a study to,perhaps, choose two groups. one, preoperatively, you tellthem, oh, this operation, this is really intense. it's going to hurt. it's going to hurt a lot. we'll do as much as we can.

and then see what happen. versus tell people, ohthis doesn't hurt at all. when you wake up, there'sgoing to be no pain. don't worry about it. and then have they donesomething like that? not exactly that,but something that i think will be equallyinteresting is that they have done studies,actually do studies where they performfake surgeries

on people, sham surgery. and so you either get realsurgery or fake surgery. but you don't knowthe difference. and people get betterfrom fake surgery. people get better from takingplacebo pills, fake pills. and we talk about placebo. it's pejorative. oh, that just shows thatit's all in their mind. to the contrary, placebois a fascinating concept.

and it really illustratesthe power of our mind and what we believeand its capacity to either heal us or harm us. and it's reallygreat you brought that up becausethat's exactly-- i'm so excited about this topic. and that's exactly whati'm writing about right now in this second bookis exactly this. this idea, the way that it'slike a pejorative concept.

oh, placebo. we need to be focusing on that. that's the coolest thing ever. and we're focusing onsomething like the big story is on the pharmaceutical. but the big storyis really on how people just believing thatthey'll get better, get better. it's fascinating, fascinating. well, unfortunately, physicians,in general want to give you

the worse scenario usuallybecause afterwards they don't want to be responsiblein case things don't-- so we do that often, i think. so one of the thingsthat's really interesting is that the power of suggestionis so potent that it often can call into question theidea of informed consent because we're listing all ofthese negative things that could happen. and then we startfocusing on them

and searching for evidence. and we can actually start tocreate some of those symptoms. this is exactly what i'mwriting about right now. and so this effect is soparticularly powerful in cancer that some doctors-- imean there's actually been medical literature wherethey say where they're having debates about whether it'sethical or not to inform patients about someof the side effects and to get them thinking on itbecause they can create them.

so there's a debateon that actually. kathleen. [? you can't use morphine and alot of ?] things like cortisol and [inaudible] insome of your studies. i didn't really seethat in any of these. i didn't put that up. so kathleen's raisinga great point. i have done prior researchlooking at how catastrophizing

influences the immune system. and this was a pilot studyi did back in oregon. and it was a bit of apainful study for me because i broughtpeople into the lab. and we placed acatheter in their arm because we weredrawing blood samples over the course of hours. and what i had them do wasi had them catastrophize. i actually asked themto catastrophize.

so focus on yourpain, how bad it is, and imagine it worsening. and then i want you to talkfor 10 minutes about the worst parts of it, whatyou see unfolding if your pain gets worse. so i actually guidedpeople to catastrophize. and this was reallyhard because it goes against my fiber of my being. and i want to help people.

but sometimes we have tostudy the negative stuff so that we can better help people. and this was that study. and so then we drew bloodat various time points and measured thecytokine response. cytokines are a markerof the immune system. we were trying to measure theamount of inflammation that would be expressed in theblood as a consequence of catastrophizing.

and what i found werea couple of things. one is that women gota pretty good response, whereas men did not. and we could interpret that. and we could say, well, it'smore stressful for women or all of these things. well it's true that the immunesystem is often a little more overactive in women. they're more likely to acquireinflammatory conditions,

for instance, we are as women. but there was somescientific confounds. i mean i was in the roomas the experimenter, so it might have been agender effect, that men were less comfortable emoting. what i found wasthat the women who had an inflammatoryresponse were the women who notonly experienced this negative emotion,but it was visible.

there was expressionof negative emotion. so it wasn't just enoughto picture it in your mind, like, yeah, that would be awful. they had to affectivelydisplay their emotion, and that was correlated withthis inflammatory response, which we couldmeasure in the blood. and so that has someimplications, then, when we think abouthealth and how stress can impact ourbodies and our physiology

and inflammation. this was a study that was donein people who had chronic pain. we know that inflammationisn't good for pain. i mean that's prettycommonly known. we often take anti-inflammatorymedication for that reason. so we don't know the fullconsequences and implications of this research. but it offered some clues abouthow we direct our thoughts. and the emotionsthat we experience

as a result of how wedirect our thoughts directly influences our immune system. and that there areimplications for pain, possibly, as aconsequence of that. so thank you for bringingthat up, kathleen. question. has there been any studieson just visual observations of people with painand then linking that with theirexperience of pain,

like their painscores and everything, with a measure ofcatastrophizing? so it seems like youhear providers talk about, well, they entered10 out of 10 pain, but they're walking andtalking and laughing, all this kind of stuff. i'm wondering if thosetypes of observations are hinting at catastrophizing. if somebody, like you said,their affect is negative.

they're-- oh interesting. --grimacing, things like that. i wonder if that's whatyou're actually looking at. is that correlated with theirmeasure of catastrophizing? yeah, so what's interestingin this specific experiment, we didn't find that theirmeasure of catastrophizing correlated with howmuch affect they were displaying in the moment.

but it was the intensityof the induction that correlated with theirexperience of inflammation. i think what you might be askingis in just everyday people, are there more objectiveways to either measure pain or to observe catastrophizing? am i-- yes, the observation,i was just interested, i'm interested in yourthoughts on the observation of catastrophizing, aside fromthe measures and the scores

and stuff like that. interesting. it's definitely somethingwe-- clinically, we see it. sometimes even when people areless willing to endorse it, but you see it, and you hear it. and then you lookat their score, and it's like something'snot connecting there. so sometimes people willunderreport for whatever reason, for whatever reason.

and there's no blame there. it's just sometimespeople score lower. they just tend to. but when you'reworking with them, you identify, no, thisis actually happening. this is something that weneed to address clinically. so that does happen absolutely. any other questions? one in the back.

this is out-of-the-boxand on the other side, but with people that are verymindful and that are very in control of their pain, andthen stepping into an emergency room or in a doctor'soffice, and you have pain, but you're not very sureof what that pain is. and most recently,a lot of people with cardiovasculardiseases, it's on the rise, and those areprobably most things that are undetected andfeel very flu-oriented more

than feeling like heart attack. i mean especially ifyou've never been sick, you don't know whatthose things feel like. going in with controlledpain, you feel like bad. you always make it more. ok, because you looknormal, you feel normal, and you could controlyour pain, and you're just going through so many tests. and by that time,it's just too late.

by that time, they diagnoseand it's almost too late. right, right, so she raisesan interesting point, sort of at its core, is if we'revery mindful of our pain and mindfully controlling itand really have a nice container around it, that it might insome ways impede access to care. i think-- i feel like througha-- for instance, i'm a very perceptive person, soi'm very in tune with my body. i'm very in tune.

so i can control pain. i can divert it. i can do yoga. i can do all these things. but then when you step in afteryou're going through something very serious, it's almost-- ittakes a long time for someone to be like, areyou really in pain? to be believed. you look really healthy.

right, to be believed,because yeah-- by that time it's like theycouldn't diagnose someone earlier and [inaudible]. yeah, it's a good point. and that's one of theissues with chronic pain is that you don'tsee it, and so people assume that it's not there. they'll just assume that you'rehealthy or that you feel good. and people have noidea what's happening,

and that can be acomponent of the suffering and isolation of pain. and so we actuallytalk about that, when we're working withpeople that-- letting people know that you have painwithout it becoming the focus of the relationship. but letting people know thatyou have it can be important. and also, know thatpeople will forget. and so having to bring itup or remind them or have

productive conversations sothat the relationship can move in a way where youfeel like you're being heard and also seen. because it is hidden, and peoplewon't-- they won't remember. they won't, and so itcan be in the background and, especially, for folks whoare younger, in particular. i was wondering ifthere are studies out there with actual doctorsthat when patients are going through this kinds of thingswhat they're actually looking

at, compared to someonethat's coming in-- i'm more talking aboutcardiovascular health because it's so undetected. you know that you're going in--because they ask you questions, like, what's the pain? and do you felt that. you don't know what aheart attack feels like. [inaudible] you're breathless. it could be asthma.

it can be like, you'vebeen exercising. it can be a lot of things. i'm not familiar withthat specific literature and, in particular,this aspect of what are physicians perceptionsof a patient's symptoms in the moment of likecardiac symptoms and whatnot. but i think that that'san interesting literature, i'm sure. i think what she's describingas acute pain in the chest

is emergency right away. i mean when you walk into er,if you say my chest hurts, they usually are notgoing to ignore you. and you said acute, you'll know. believe it or not, people thatare even relaxed in general, the cardiovascular disease,when they have chest, they also describe havingthis impending doom, the feeling of impending doom. and they're not doomy people.

they're very happy,joyous, but when it comes to the chestand the heart pain, they have that senseof impending doom. i agree. [inaudible] you have to be thevery assertive client. when you walk into theer, you have to say, i have history of heartdisease, and my chest hurts. believe me, you'll bethe first one to be seen. so any other questions?

does it feel complete? ok, well, thank you all foryour attention and time. thank you.