Book Review: Unlearn Your Pain

[Content warning: discussion of chronic pain and related conditions, and the debate over whether some of them may be psychological in origin. None of this is medical advice or a recommendation to start or stop any form of therapy. Low confidence in my conclusions here.]


Some of the most interesting lectures in medical training are the ones that start with “Okay, you’re all going to think I’m a quack, but…”

This was how Dr. Howard Schubiner started the lecture he gave at the hospital where I work. Dr. Schubiner isn’t an obvious quack – he’s a professor of medicine at the local university, directs a clinic at a reputable hospital nearby, and is on the editorial boards of a bunch of medical journals. And although his lecture raised what we will generously call a few red flags, there was also just enough interesting stuff there that I couldn’t resist buying his book Unlearn Your Pain to learn more.

Dr. Schubiner’s specialty is psychosomatic complaints – bodily symptoms that don’t come from any obvious disease and seem to reflect psychological stress. Everyone agrees that this category exists. Most doctors have stories about conversion disorder – usually patients who become “paralyzed” in previously healthy limbs after some life crisis. One of my medical school professors had a pretty good diagnostic test for this – feign a punch at the patient’s face, really quickly, without warning her. If she instinctively uses her “paralyzed” limb to block it, it’s conversion disorder. The same sort of thing works for pseudoseizures – apparent seizures not associated with objective seizure EEG activity. There’s a legend about a neurologist telling a medical student that a certain patient’s fit was a pseudoseizure, and the patient interrupting his seizure to protest “No it isn’t!”.

Most people who have worked with conversion or pseudoseizure patients don’t doubt their inherent honesty. These patients aren’t faking, per se. Such a person genuinely can’t move their limb, can’t just decide not to have seizures. Often they’re very distressed at what’s happening to them (although sometimes they really aren’t). Psychologists like to say that it’s subconscious – whatever that means. Just like somebody crippled by panic attacks, the symptoms are real and involuntary, but they’re also psychologically produced.

The existence of this category isn’t controversial, but its size definitely is. Some people propose a long list of conditions – fibromyalgia, irritable bowel syndrome, chronic fatigue syndrome, chronic Lyme disease, tension headaches, interstitial cystitis, et cetera – that they think of as mostly or entirely psychosomatic. On the other hand, patients’ rights groups get very upset at claims that their conditions are “all in their head”, accuse doctors of thinking that they’re lazy or making up their symptoms, and pass around stories with titles like RE: RE: RE: FWD: RE: THE MEDICAL PROFESSION about some guy whose doctor dismissed him as making up his symptoms but who was later diagnosed with zebra-itis and cured with an experimental gene therapy treatment.

Dr. Schubiner is a psychosomatic complaint maximalist. He thinks that just about anything that can’t be traced to a well-understood physiological cause is probably psychosomatic – in his language, Mind-Body Syndrome or MBS. He quotes a fascinating theory by Edward Shorter that this all dates back to the invention of the tendon hammer, ie that little thing doctors hit your knee with:

An important advance in medicine was the discovery of deep tendon reflexes. The simple test of striking a tendon with a reflex hammer can quickly distinguish pathological from psychological paralysis. Amazingly, once doctors could do this test, the number of people with this type of conversion disorder decreased substantially, and now the condition is rare. When doctors and the general public come to view a medical condition as psychologically induced, it is less likely to occur..the subconscious mind is unlikely to produce symptoms that will be easily seen as psychological. But since humans continue to experience great stresses and strong emotions, paralysis has been replaced by chronic back pain, fibromyalgia, fatigue, irritable bowel syndrome, and many other symptoms.

When Schubiner talks about fibromyalgia and fatigue, he’s not so far outside (one edge of) respectable medical opinion. But he goes further and lists migraine headaches, heartburn, carpal tunnel syndrome, tinnitis, postural orthostatic tachycardia, repetitive stress injury, and reflex sympathetic dystrophy as likely Mind-Body Syndrome as well. And most explosively, he says the condition explains almost all pain.

Schubiner admits there is such a thing as anatomically-caused non-psychological pain. It tends to be associated with very obvious injuries like dropping an anvil on your foot, and it tends to go away after a couple of weeks at most. Anything more mysterious and chronic – facial pain, TMJ pain, joint pain, abdominal pain, neck pain, shoulder pain, tendonitis, and especially back pain – is probably Mind-Body Syndrome. After a medical workup has failed to reveal obvious cancer or infection, these are almost certainly psychosomatic and continuing to treat them as potentially medical just makes them worse:

When patients with Mind-Body Syndrome are labeled as having degenerative disc disease on the basis of an MRI….symptoms can be exacerbated and patients harmed by medical diagnoses. This occurs because the diagnosis creates fear and the belief that there is something seriously wrong with one’s body. These emotions activate the anterior cingulate cortex, which creates even more pain by ramping up the learned nerve pathways of MBS.

If this were true, it would be really important. Surveys suggest that between 40 million and 100 million Americans have chronic pain; the former study finds 67% of them say their pain is “constantly present” and 50% say it is sometimes “unbearable and excruciating”. The financial cost is between $60 billion and $600 billion per year. I’m not sure what to think about all these estimates that differ by orders of magnitude, but the point is that there’s a “chronic pain epidemic” and it’s really bad. The mainstay of treatment for chronic pain is opioids, and by non-coincidence there’s also an opioid addiction epidemic and an opioid-related death epidemic. To some degree the government can use regulation to trade off pain burden against opiate deaths, but no point at that curve is very palatable and we desperately need some kind of real solution.

Schubiner says he has it. It’s time to admit that all of this pain that’s getting all epidemicky is almost entirely psychosomatic. It might start with a real injury, but after that injury heals the brain “remembers” the relevant pain pathways and exploits them as a way to express psychological stress. He presents some fascinating and delightful evidence for this.

A guy named Harold Schraeder studied prevelance of chronic whiplash in Lithuania, of all things. He found the prevalence was zero. In most Western nations, a certain subset of people who get in car accidents suffer chronic disabling neck pain, presumably related to having their neck get suddenly jerked by the force of the impact. But Schrader found that this never happened in Lithuania, even though they had a lot of accidents and their cars were no safer than ours. Simotas and Shen found that there was zero whiplash in demolition derby drivers, even though they got into crashes all the time and it was basically their job description. Further studies found that accident victims with more neck injury were no more likely to develop whiplash than victims with less neck injury. Perhaps, they argue, chronic whiplash isn’t a bodily injury at all, but a culture-bound syndrome in which people who expect whiplash to exist use its symptom profile as a way of expressing their psychological tension.

Then there’s back pain, one of the most common and disabling types of chronic pain – Medicare back-pain related costs have grown about 3-4x in a decade. Standard medical workup for back pain usually involves getting an x-ray or MRI, finding some problem with the discs in the spine, and treating with painkillers, steroids, or surgery. Schubiner is not convinced. He notes studies that find that radiographic findings of disc degeneration or herniation do not accurately predict future back pain. Yes, most back pain sufferers will have problems visible on MRI, but most perfectly healthy people pulled off the street will also have problems visible on MRI – for example, this study finds that half of all 21-year-olds in Finland have a degenerated disc, and a quarter have a bulging disc. The book quotes an NEJM article as saying that “neither baseline MRIs nor followup MRIs are useful predictors of low back pain”. However, studies (1, 2) find that a patient’s job satisfaction does predict their future back pain. Books and studies called things like Time To Back Off?, Back In Control and Watch Your Back point out that many surgeries and injections for back pain work no better than placebos in controlled experiments, with a review article in the Journal of the American Board of Family Medicine concluding that “prescribing yet more imaging, opioids, injections, and operations is not likely to improve outcomes for patients with chronic back pain” On the other hand, Schofferman et al found that childhood trauma correlates heavily with success of back pain treatment: 95% of patients with a happy childhood got better after back surgery, but only 15% of patients with multiple childhood traumas did.

Based on these studies and others like them, Schubiner concludes that chronic back pain is psychological rather than physiological. He thinks there may have been some original minor injury, of the sort that most people would get over in a couple of weeks. This causes the nerves to “sensitize” – ie the brain is primed to think about and remember this form of pain. Then, when people recall their subconscious tension over childhood trauma and the stresses of life, they express it as back pain through the sensitive nerve pathways.

Extend this model to headaches, irritable bowel, chronic fatigue, and everything else, and you have Dr. Schubiner’s theory of pain.


If all of this pain has a psychological cause, then it should have a psychological solution. But psychological solutions to chronic pain are no more effective than physical ones. For example, Cochrane Review finds that cognitive behavioral therapy for chronic back pain has a moderate short-term effect which fades quickly. There was a similar effect for neck pain which Cochrane found “could not be considered clinically meaningful” and which also faded quickly.

Dr. Schubiner says this is because cognitive behavioral therapy is inappropriate for this condition. It’s caused not by negative thoughts and dysfunctional behaviors, but by unresolved childhood traumas. He recommends a therapy designed to help resolve such traumas called Intensive Short Term Dynamic Psychotherapy.

Freudian therapy (“psychoanalysis”) usually takes several years to get anywhere, and may take ten years or longer to complete. Around the 1960s, some psychiatrists got tired of waiting and invented a high-speed version called “psychodynamic therapy”. Schubiner’s version, which derives from the word of a guy named Dr. Davanloo in Montreal, promises results in as little as four weeks. It involves a lot of stuff, including some kind of silly-sounding things like writing affirmations, finding your acupuncture points, and putting your body in very masculine “power poses” and raising your fists and shouting “I AM GOING TO OVERCOME MY PAIN!”. Dr. Schubiner demonstrated this last in front of us and he did indeed look very masculine and determined; if I were chronic back pain, I would definitely put him on my list of people to avoid.

But the heart of the therapy is a technique for returning to traumatic childhood moments. You try to figure out what your traumatic childhood moments were – for example, maybe your father got drunk and beat you up. So you go back to the incident, either as a solo visualization or in a conversation with a partner. It goes something like this:

Doctor: Tell me what’s happening

Patient: I’m in my childhood home. My father approaches me, beer bottle in hand, looking really angry.

Doctor: How do you feel?

Patient: Really scared.

Doctor: But also?

Patient: Angry.

Doctor: Good! You have every right to! Tell your father that!

Patient: Father, I’m really scared and angry!

Doctor: Now what does your father do?

Patient: He doesn’t care.

Doctor: And what would you like to do now?

Patient: Beat up my father.

Doctor: Then go back into that experience and beat up your father.


Doctor: How do you feel now?

Patient: My chronic back pain is gone!

There are enough variations on this to make it a four week course, but in Schubiner’s examples (which he takes from real clinical practice), even something as simple as this can be enough to make chronic pain go away near-instantly. He has about a dozen anecdotes from his own practice where this happens. Then the rest of the course is just solidifying that gain and making sure it doesn’t come back.

I talked to a professor of psychoanalysis I work with about this. She says that Davanloo is well within the psychoanalytic mainstream. She says that she herself is not a big fan of his work, because she thinks it’s important to spend those several years unpeeling a patient’s defenses instead of just smashing them with a sledgehammer. But she says chronic pain patients may have unusually strong defenses and that maybe the sledgehammer approach is the right one. So overall she cautiously approves.

On the other hand, my more cynical readers might note that “well within the psychoanalytic mainstream” isn’t exactly equivalent to “definitely not a quack”. Schubiner is aware of this and has tried to get some evidence for his method. Along with a case series, he has published a study on the psychological treatment for fibromyalgia, in which 45% of the intervention group experienced significant pain relief compared to 0% of the controls. He also tested the full version of his therapy in a preliminary trial in which “two-thirds of the patients improved at least 30% in pain”.

So, should we believe him?


I tried to verify some of the claims in this book and discovered things were much more ambiguous than it let on.

The idea of whiplash as psychosocial is still controversial in the literature. It’s true that some studies in Lithuania and Greece show almost no whiplash. But some critics say that these studies lacked enough power to find a difference in whiplash rates among countries even if such a difference existed. There were also extremely weird fluctuations in the data – for example, the same team in the same city doing two studies a few years apart found neck injury rates of 15% versus 47%. Here’s a long and acrimonious debate in a medical journal about this. But interestingly, even the pro-psychosocial side doesn’t seem to want to say there’s no biological component. And such a claim would be difficult to sustain given studies that show significant effects of things like head position during an accident on future whiplash rates. You can find a good summary of some of the points on each side here. Here’s another review by Dr. Arthur Croft, Ph.D., D.C., M.Sc., M.P.H., F.A.C.O., and Emmy award nominee (really) – who says, brutally:

Ferrari, et al., have recently promoted the so-called biopsychosocial model in the context of whiplash, making numerous excursions into the literature in support of it. The lynchpin of their theory relies on two studies conducted in Lithuania which purportedly followed the natural history of late (i.e., chronic) whiplash in a population of persons exposed to rear-impact motor vehicle crashes – the putative injury mechanism for acute whiplash injury. Unfortunately, “fatal” errors in study design in both cases prevented meaningful interpretation of their results, not the least of which was that only a small portion of their cohort actually had an acute whiplash – the necessary precursor for late whiplash. Our post hoc power calculation revealed that their cohort was inadequate to support any of their conclusions.

Unfortunately, many authors – since these flaws were pointed out – have failed to be dissuaded from citing this literature in support of the biopsychosocial theory, particularly those authors from the camp of the nonbelievers. These Lithuanian papers, it should also be noted, stand alone as outliers to more than 50 other published reports of outcome over the past 45 or so years, and arrive at some rather improbable conclusions that almost immediately beg some questions. In the first paper, the results suggested that persons exposed to whiplash mechanisms would have about the same long-term neck pain as age-matched uninjured persons in the population. In the second study, acute whiplash trauma exposure seemed to actually have a protective effect, somehow immunizing these people against future neck pain. Again, these findings would be particularly interesting if the studies had the added virtue of being valid on a statistical and methodological basis.

To these I would add that even if a US-Lithuania whiplash rate difference existed, it wouldn’t necessarily have to be psychological. Some people bring up Americans having bigger cars; other people bring up differences between American and European car seat headrest design, and still others bring up differences in US and Lithuanian diets and lifestyles which might affect pain and healing.

The book’s treatment of back pain also raises some concerns. It is definitely true that the relationship between back pain and radiographic findings is way lower than anybody wants to admit, and that MRI isn’t very useful for diagnosis. That having been said, the relationship is not zero. For example, in this study, patients with the highest level of radiographic degeneration were 4.5x more likely to be in the highest back pain category compared to patients with the lowest level of radiographic degeneration. The correlation is not one, but neither is it zero. Some people with lots of back pain will have no radiographic findings, and some people with lots of radiographic findings will have no back pain, and the relationship is weak enough that using MRIs for diagnosis is heavily discouraged, but in general the two have a positive and significant relationship. See for example here, here, and here. I don’t know to what degree this affects the book’s thesis, but it seemed important to point out.

Nor is there any more clarity about the relationship of back pain to job (dis-) satisfaction. I was able to find three meta-analyses on it. One of these, Linton, said that:

The available literature indicated a clear link between psychological variables and neck and back pain. The prospective studies indicated that psychological variables were related to the onset of pain, and to acute, subacute, and chronic pain. Stress, distress, or anxiety as well as mood and emotions, cognitive functioning, and pain behavior all were found to be significant factors. Personality factors produced mixed results. Although the level of evidence was low, abuse also was found to be a potentially significant factor.

But Hartvingsen et al concluded:

According to recent epidemiological literature we found moderate evidence for no positive association between perception of work, organisational aspects of work, and social support at work and LBP. We found insufficient evidence for an association between stress at work and LBP. Regarding consequences of LBP, there was insufficient evidence for an association between perception of work in relation to consequences of LBP. There was strong evidence for no association between organisational aspects of work and moderate evidence for no association between social support at work and stress at work and consequences of LBP. There were major methodological problems in the majority of studies included in this review and the diversity in methods was considerable. Therefore associations reported may be spurious and should be interpreted with caution.

Finally, Hoogendoorn, Poppel and Bongers, who sound like a band for very young children, are very ambivalent. They do find some effects, but they all give off an air of desperation, eg “Low job control was found to have a statistically significant positive effect on short and long absences due to back pain, except in men in lower grade jobs and women in higher grade jobs, in whom the effect was reversed”. They are very open about this, and conclude:

“Evidence was found for the effect of some of the psychosocial work characteristics, but there is no psychosocial work characteristic for which evidence was found in all reviews…the conclusions drawn in the various reviews appear to be rather heterogenous”.

And, very significantly for our purposes:

“Having evaluated the strength of the evidence for both physical and psychosocial factors as risk factors for back pain, using the same methods, the question arises of whether the findings indicated a difference in the evidence for physical and psychosocial factors. Strong or moderate evidence has been found for heavy physical work, lifting, bending, and twisting, and whole body vibration at work. Unlike the results for psychosocial factors, these results were rather insensitive to slight changes in the assessment of the findings and the methodologic quality of the studies and in agreement with the results of previous reviews on physical load. This indicates that the body of evidence supporting the role of these physical load factors as risk factors for back pain is somewhat more consistent than that for the psychosocial factors)

The consensus in pain medicine is that pain depends on both psychological and physical factors working together. Schubiner is trying to shift that consensus to say pain is almost entirely psychological and based mainly on childhood trauma. But the studies, while not ruling out a psychological cause, are very emphatic that physical causes definitely matter. And even the papers supporting psychological causes say that, among all such causes, there is unusually little evidence for childhood abuse as a factor.

But the part that bothered me most was the use of Schofferman’s study showing that childhood trauma predicted back surgery success rate (I should note that he doesn’t cite this explicitly in the book, but he implicitly works off it, and he discussed it explicitly during the lecture). This was a surprising study that cried out for replication – and which was in fact re-tested in 2002 on a larger sample by Nickel, Egle, and Hardt. They were unable to replicate the findings. Chronic back pain patients, surgery-failing and otherwise, were no more likely to have childhood trauma than anybody else. This bothered me because Schubiner played up Schofferman’s 1991 study that supported his hypothesis without even mentioning this one. People have a right to present their case the way they want, but when someone clearly ignores better and more recent evidence, it makes me a little more skeptical of everything they say.


What about the psychiatric part of Unlearn Your Pain‘s program?

The psychodynamic therapy literature is even more of a mess than the back pain literature. I’ve been there before and don’t want to go back. You can read Jonathan Shedler and Jared DeFife in support and James Coyne and Michael Anestis in opposition. I find myself more sympathetic to the “doesn’t work very well” camp, but the field is muddy enough, and my biases against it strong enough, that I place little confidence in that judgment.

So let me try to cut through all of this with my favorite weapon for these kinds of things: behavioral genetics. Of the five behavioral genetics studies on back pain I could find, four (1, 2, 3, 4) found no shared environmental effect on back pain, with only one dissenter. This is in common with a large literature finding little shared environmental effect on a host of psychological problems including depression, anxiety, and bipolar disorder – and indeed, it would be very strange if chronic pain were more related to childhood experiences than those were.

Psychiatry tried really hard to give the “childhood trauma causes everything” thesis a go for fifty-something years. Sure enough, psychiatrists found loads of childhood trauma, because, much as pretty much everybody will have something weird with the discs in their backs that can be detected on MRI, pretty much everybody will have something weird with their childhood that can be detected with psychotherapy. Using the kabbalistic method, you can always find suspicious coincidences linking their childhood trauma with their current pain. Schubiner writes – as far as I can tell, 100% seriously – that:

When someone develops a pain in the buttocks, there may be someone in their lives who is ‘a pain in the butt’.” Someone who develops difficulty swallowing may be reacting to a situation in life that is ‘hard to swallow’. I evaluated a woman with pain in the bottom of her feet. While waiting in line one day, she realized there was a situation in her life that she ‘just couldn’t stand anymore’

I want you to appreciate how much willpower I’m showing here. There is form of psychiatry based around corny puns, and yet instead of emailing these people my resume immediately I’m trying to maintain a cautious skepticism.

And when I do, I just can’t believe it. The early psychoanalysts weren’t doing science, they were taking Sofer’s Law and running with it. Eventually we realized that talking about childhood traumas wasn’t predictive, wasn’t especially curative as per rigorous studies, and we moved on.

There’s a lot of controversy around this decision, but I think behavioral genetics has made the childhood-trauma side increasingly untenable. Assuming twin studies aren’t entirely fatally flawed – something thousands of people have looked for and nobody has found – childhood shared environment, which presumably includes things like abusive parents, just doesn’t affect adult outcomes very much. I can’t see a way to reconcile that with psychoanalytic theories and I don’t think we should keep trying.

I don’t deny that there are a lot of suspicious coincidences. But I think if we look harder, we can find that those suspicious coincidences all have more reasonable explanations. Like, yes, people with a lot of psychological problems tend to have a lot of back pain. But again, when you do twin studies:

On initial analysis considering the participants as individuals, rather than twins — and therefore not accounting for genetic and familial factors — the odds of having back pain were about 1.6 higher for those with symptoms of depression and anxiety.

On further analysis of monozygotic twins — who are genetically identical — the association between symptoms of depression and low back pain disappeared. This suggested that the strong association found in non-identical twins resulted from the “confounding” effects of common genetic factors influencing both conditions. For example, genes affecting levels of neurotransmitters such as serotonin and norepinephrine might affect the risk of both conditions.

Previous studies have shown a “consistent relationship” between back pain and depression — a combination that may complicate diagnosis and treatment. However, the nature of the association remains unclear. The new study is the first to examine the relationship between depression and low back pain using twin data to control for genetic and familial factors.

When you control for genetics, WHICH YOU SHOULD ALWAYS DO AND I AM SO SERIOUS ABOUT THIS, this explains the entire psychological problem/back pain link. Combined with the previous twin studies showing no effect of childhood environment, this is a very strong challenge that theories claiming a psychogenic origin of back pain based in life events will have trouble surviving.


So in the end, what do we make of chronic pain?

Many, many, many people report using the techniques in Unlearn Your Pain (or the closely related techniques of Dr. John Sarno) and having good success. I don’t think this is entirely coincidence or bias. But I’m also not willing to entirely buy into this repressed childhood trauma theory.

There are definitely some types of pain which are not related to bodily injury. My best evidence for this, which Dr. Schubiner talks about too, is the people who have pain which is anatomically implausible or “migrating”. By “anatomically implausible” I mean pain that cuts willy-nilly across the body’s neural regions; pain in the distribution of the ulnar nerve may be an ulnar nerve problem, but if it has half the distribution of the ulnar nerve plus half the distribution of the median nerve, while leaving the other half of both distributions pain-free, it’s a little harder to figure out what could be causing it (especially if it’s on both sides equally!) By “migrating”, I mean that somebody has right hand pain, the doctor gives them some kind of treatment, that goes away, the next day they have right foot pain, another treatment, it goes away again, and the next day they have diarrhea. While there are very rare processes that can do something like that, when it goes on long enough that’s good evidence that the pain isn’t anatomical.

But I think the way in which pain isn’t anatomical is more complicated than the simple model that Unlearn Your Pain uses. Instead of the brain “using” pain to express repressed emotions, maybe gating and modulating pain sensations is just really hard.

Let me give an example [trigger warning for inducing mild bodily discomfort]. Right now, you’re suddenly aware of the feeling of your tongue in your mouth. And right now, the top of your head is suddenly really itchy. Also, right now something is wrong with your saliva and you’re swallowing consciously, but it feels awkward and you’re worried something might be wrong with your throat.

This isn’t because I have magic powers inflicting these things on you, it’s because you’re constantly receiving all sorts of sensations and your brain effectively gates and modulates them. You’ve always got micro-itches and micro-pains going on everywhere – no part of your body is one hundred percent optimal and even if it were there are still variations in neural noise – but your brain usually correctly decides these aren’t worth your time. It’s only when something forces you to focus on them – whether worry about a back injury, or an annoying blogger – that they make it through.

All psychiatric disorders are heavily comorbid. People with one or more of depression, anxiety, OCD, anorexia, autism, gender dysphoria, PTSD, et cetera are many times more likely to have all of the others, and it doesn’t just seem to be in a boring “OCD is depressing and makes me anxious” sort of way. All of this seems to relate to a general factor of neural messed-up-ness. It wouldn’t be surprising if this correlated with some kind of messed-up-ness in the neural systems that are supposed to process and gate pain.

Remember also that stress can cause relapses of many very biological and serious diseases like ulcerative colitis, multiple sclerosis, or epilepsy. Also, inflammation seems to be a shared and complicated factor between various bodily illnesses, stress, and depression. So for stress to cause a “relapse” of chronic pain, all we’d need is for it to put extra pressure – whether through inflammation or some other method – on an already slightly messed-up pain-gating system in the brain. And then there’s muscular tension, which I inexcusably forgot to mention until now but which is also a relevant system by which stress affects chronic pain.

We know that pain is very sensitive to the placebo effect – I’m generally a placebo effect skeptic, but even arch-skeptics Hróbjartsson and Gøtzsche agree that pain is one of the few places where the placebo effect really dominates. This is why we so often see faith healers and saints and miracle water from Lourdes treating pain so effectively – at least briefly. It’s why homeopathic treatment for pain shows such an amazingly good effect size.

And, I will say cynically, it’s why so many people have reported (genuine) success from Unlearn Your Pain and related programs. It’s why Schubiner writes:

I believe that each and every person with Mind Body Syndrome can get better because it is possible to overcome MBS by using this program. Those people who are unable to accept that their symptoms are due to MBS, or who do not develop positive expectations of relief, or who are unable to believe that they can make changes in their health and in their lives are the people who are less likely to improve.

Part of me wants to say that we have a word for medical treatments that only work if you believe that they will, and it rhymes with “gazebo”.

Another part worries this is unfair. If the placebo effect comes from the brain’s ability to gate pain, then saying “You’re not really affecting the brain’s ability to gate pain, it’s just the placebo effect” stops making sense. It’s not that it doesn’t work and is just placebo – it’s that it does work, via placebo.

There’s something to be said for glorifying in the placebo effect, laying it on as hard as possible, putting on the fanciest robe and wizard hat you can find and saying “I CAST YOU OUT BY THE POWER OF PLACEBO, GO FORTH AND SIN NO MORE!” I think in some ways there can be better and worse placebo therapies just as there can be better and worse real therapies, placebo therapies that activate the placebo effect only a little and don’t help much, and placebo therapies that activate the placebo effect really strongly and use it to work miracles. Maybe we should give more status to the best placebo therapies, to view them as highly perfected works of the placebomantic arts in the same way that powerful medications are triumphs of psychopharmacology. I think psychodynamic therapy and everything descended from it would have a high place in that pantheon.

In that sense, I think Unlearn Your Pain might be a useful book. I think that even if I accept what I consider the consensus theory of chronic pain – genuine (if small) lingering injuries (or nerve sensitization from such) interacting with a poorly-wired pain gating system in the brain which is highly susceptible to placebo effects – Unlearn Your Pain remains a useful book, as the distilled wisdom of many years of work trying to activate those effects as strongly as possible.

Another possibility is that the active ingredient isn’t the intensive psychotherapy, it’s the belief that the pain is caused by Mind-Body Syndrome. It seems just possible that this belief could break the cognitive loops that seem so relevant in all of these processes.

So I guess I’m in a weird spot in terms of what I think of Unlearn Your Pain.

I think it’s definitely right that a lot of pain has psychosomatic components. I think it probably helps treat psychosomatic pain, maybe really effectively, and partly for the reasons that it thinks it does.

But I’m not convinced by its more sweeping claims that physical injuries play little-to-no role in chronic pain. Along with Schubiner’s talk of nerve sensitization, one can imagine a scenario in which alternatively apparently-healed physical injuries may leave very small irritations on local nerves, and that the degree of irritation a nerve is able to bear without giving you chronic pain is related to your general neural-non-messed-upness and stress level. In such a scenario psychological factors might play a role in gating the pain, or in tensing or releasing muscles around the pain, but would not entirely explain it.

I’m also not convinced by its claims that childhood trauma has any interesting relationship with pain, nor that trauma-related therapy has a unique non-placebo ability to deal with such pain. I think that childhood trauma is overemphasized throughout psychiatry and that this theory of pain represents a step in the wrong direction. If trauma-related therapy works, it works by a nonspecific process of making people feel like they’re doing something useful and taking their attribution for their pain off of bodily processes.

Niels Bohr used to hang a horseshoe above the door to his office, saying “I’m not superstitious, but I hear this works whether you believe in it or not.” Part of me is tempted to recommend Unlearn Your Pain to my patients on the same principle. And if any readers of this blog have chronic pain and want to try to the month-long self-help therapy course in this book, I would be very interested in hearing back from you (please tell me before you start, so that there aren’t response biases). If the $25 price of this book is the difference between someone in that category trying vs. not trying it, I’m happy to send you the book if you agree to get back to me with your results. Contact me at if you’re interested in this.

274 thoughts on “Book Review: Unlearn Your Pain

  1. Nat Kuhn MD

    Hi Scott, as you requested, I tried to post my email to you as a comment here, but it was too long.

    Here’s the beginning, with a link to the rest:

    Hi Scott,

    My son Ben Kuhn texted me the other day about this post. At his urging I’d read some of your previous posts; I’ve enjoyed and wish I had time to read more. For this one, as a psychiatrist who practices and teaches Davanloo’s Intensive Short-Term Dynamic Psychotherapy (ISTDP), I rushed-right over when he texted me!

    Howard Schubiner is an exemplary human being; he has referred a number of patients to me and he has spent a great deal of time corresponding or speaking with almost all of them. Multiply this by a nation of 320 million and I find the implications quite stunning.

    Unfortunately, he may have set up a straw man in terms of theory of psychosomatic pain. Read the rest…

  2. Nathan B. Holladay, MD, PhD

    As a physician who treats fibromyalgia and chronic fatigue syndrome it is clear to me that the individuals I treat have very real disorders where there is often evidence of underlying pathology. Therefore, my first inclination is to toss it out the window when I hear anyone talk about psychosomatic illness. Of course if you consider something like migraine to be psychosomatic simply because you can alter it with psychological therapy, then you are casting a broad net. But it is important to listen to all sides. By saying is it psychosomatic or is it physiologic, we may be working with a sort of false dichotomy – there are plenty of people who have predisposing underlying pathology that could still benefit from whatever kind of therapy Schubiner does – not because there isn’t something going on due to a physiological abnormality, but because the therapy may help to ameliorate it or reduce behaviors and stressors that promote ongoing disease. It also may be worth noting that there is probably an intrinsic bias in virtually any physician’s conclusions as to what is causing symptoms based on the patients coming to them.

    In chronic fatigue syndrome there is clear evidence of underlying infection being related – and evidence that treating these underlying chronic infections can sometimes help in a way that extends beyond the placebo effect. Some also manifest autoimmune abnormalities. But if you just test for the basic markers that you might consider based on what you learned in medical school, then you wouldn’t always find much. I feel from evaluating many so-called fibromyalgia patients that there are different types (consistent with fibromyalgia’s classification as a syndrome rather than a disease), and in some of these there is also an underlying infectious cause (eg, systemic infections with atypical bacteria, including Chlamydia and Mycoplasma species – the clinical data for this is better in the area of arthritis).

    On the matter of conversion disorder, which was brought up in the article, I personally think that conversion disorder is a diagnostic zebra, not a horse. I speak from experience. When you have seen individuals who had clearly abnormal symptoms, whose neurologic exams were felt to be suspect and who eventually progressed to a very serious condition, it makes you upset that they didn’t give credence to what the patient was saying in the first place. Instead, it seems that sometimes physicians manifest a form of hubris based on an overestimation of their own diagnostic skills and of the state of current medical science.

    Attributing illnesses to psychosomatic causes or using the label ‘functional’ has at times gotten me fired up, and I have experience to back my concern up. But that having said, the mind-body connection is a part of the picture and if Schubiner in his experience has seen people respond to therapy then I need to take that into account too. So often different people have different pieces of the puzzle and each ends up rejecting what the other has to say simply because of their different perspectives. I think it would be terribly misguided to believe that every case of fibromyalgia (or other illnesses mentioned above) may be solved through mind-body techniques or that there are not underlying pathophysiologies that we should try to identify, but it has me interested in looking at what he’s doing because apparently he’s been able to help people.

    My parting thought would be that it is very important to evaluate pain, as with anything else, on a case by case basis. It is abundantly evident that different people have different causes, and therefore there is no one single blanket therapy for pain. So let’s avoid just getting into a camp and disregarding everything and everyone else.

  3. ChristianKl

    Writing about both highly positive memories and highly negative memories can have positive health effects (
    I think there a good probability that you can get stronger suggestive effects (placebo effects) if you tap into strong emotions. Childhood trauma provides a source of very strong emotions.

    I would guess that you get the same effect with past-life “memories” brought up via hypnosis.

  4. G. B. Edmonds

    Dr. Schubiner’s opening assessment is correct. I think he’s a quack.

    Okay, not really (well, not quite really), but he is certainly wrong with regard to specific pain related to spinal nerve injury or obstruction. I worked, in an emergency room/trauma center setting, with a great many patients who had acute spinal injuries for many years. The associated pain (and, when applicable, paralysis) is most certainly not a figment of patient’s imagination.

    Moreover, I’ve undergone no fewer than 12 spinal surgeries of my own (four of them for the placement, removal, then replacement of a different spinal stimulation system). I’ve had a nearly completely paralyzed arm recover as a direct result of quick surgical intervention, and I’ve lived with (usually moderate, but sometimes severe) chronic pain as a consequence.

    I can, from personal experience, assure Dr. Schubiner that there is indeed a substantive and significant difference in the chronic “backache” concurrent with overwork, and the screaming, electronic-shock, burning pain stemming from an insult to major nerve root.

    I can agree that “whiplash” is a nonstarter from the medical perspective, but is most assuredly the ambulance-chasing attorney’s very best friend in the world.

    Do pyscho-social realities play a part in chronic pain? The answer, obviously, is yes. Are they the only issues causing such pain? Equally obviously, they are not. They certainly may be in some situations, and I’ve personally treated some chronic headache sufferers with hypnotic and relaxation techniques.

    The fact is, as noted in the article, it’s relatively easy to at least form some suspicion of malingering on the part of any patient that displays false indicators of neurological damage, or who complains of chronic pain when there is no apparent physiological cause. When such a cause is evident (as in the case of damaged disc, depression or compression of the spinal chord or nerves stemming therefrom), I regard it as a physician’s duty to at least do what’s possible to eliminate the pain with standard forms of treatment.

    If there are not obvious indicators for physiological pain, then yes, the doctor’s book might be of some benefit. To suggest that even that sort of pain, however, is entirely psychosomatic, when all ready avenues of assessment are not yet realized, is the definition of cruelty. There are many people who do present with chronic pain that is of, for lack of a better obvious reason, psychological issues. These people often do benefit from psychological counseling or alternative treatments. Again, however, after a normally short span of time, such people are usually assessed and appropriately directed. The suggestion that chronic pain caused by obvious physiological abnormality, is psychosomatic in origin is, on its face, questionable. Certainly, such pain can be exacerbated by psycho-social issues in some cases, and its severity might be somewhat abated by (as previously noted) non-invasive, or non-chemotherapeutic modes of treatment.

    The suggestion that most such pain sufferers are imagining their pain, however, is simply incorrect. I wish I didn’t personally know otherwise, but alas, I am a prime example of such patients. I respectfully suggest that if Dr. Schubiner experienced such pain, he would most assuredly amend his opinion.

  5. Adam

    Interesting topic. I’ve been dealing with back issues for three and a half years, but I’ve never thought of it as “chronic pain.” On most days, if you asked me to rate my pain on a scale from 1 to 10, I’d probably say 1 or 2. It’s just background noise. The greater problem is the increasing frequency and decreasing causative threshold of back injury. At first, I tore a disc deadlifting over 400 pounds. The second and third times, the same thing. Eventually, I was feeling a warm pop and my spine locking up and not letting me move for a few days from, say, putting away dishes, standing up to get out of my car, or putting on underwear after getting out of the shower. Then the locking up happened for longer periods and became accompanied with unbearable muscle spasms. But still, even though the pain in the aftermath of a flareup is unbearable, after that, it’s just background noise. Even with visible nerve impingement and weakness, throbbing, and stabbing in my legs, it doesn’t really hurt that much. The problem is almost entirely with reduced mobility and the fact that I can’t do anything strenuous without hurting myself. I was an extremely active person before, a runner, climber, open-water swimmer, weight lifter, a Soldier even. I can’t do any of those things any more, but most people don’t do any of those things to begin with. It still beats being Christopher Reeve or Stephen Hawking.

    It’s hard to see how any of it could be psychosomatic. Are spine doctors just liars? They’ve explained in excruciating detail how intervertebral discs work and all of the ways in which they can fail by being overloaded under conditions of flexion. I see what my cats can do with a spine design that matches their body posture. They don’t have issues like this. They seem unique to bipedal creatures and surely there is a physical reason for this? Each injury definitely happened when I was in a compromising position and not being careful enough. I’ve never suffered from anxiety or depression, did not experience any childhood trauma.

    This isn’t really an issue of an unbearable everyday life. When you’ve done the kinds of things I’ve done, you learn to ignore pain as opposed to injury that risks permanent damage. It fades into the background and you keep on moving. The issue is simply my spine literally locking and not allowing me to move as an involuntary defensive mechanism to prevent a herniated disc from doing real damage to the nervous system. It’s perfectly understandable that it would do that. I had a trapped ulnar nerve permanently kill the outer two fingers on my left hand. It doesn’t hurt. There’s just no feeling at all, which was awkward for like six months before my hands reprogrammed themselves and typing/gripping went mostly back to normal. You can’t kill an entire leg or the nerve controlling your bowels and just return to normal after that.

  6. t. eadweard

    Doc –
    Your book review brought up so many interesting questions and thoughts I am not sure where to start. But I will try to be pithy and to the point. I hope don’t mean to say anything you know (and you will know all of this) it just helps my thought process.
    – The one area where I think where we may be able to learn more about psychosomatic pain is the protracted syndromes from psychiatric medicines like benzodiazepines, SSRIs, etc. Onviously this happens to the small minority of patients. And it doesn’t mean the drugs didn’t work when the invidiual took them (obviously). But the topic is controversial – I just happen to think it is controversial that it is controversial ha!! 😉
    Benzodiazepines, as you know, can have a particularly nasty withdrawal syndrome. Patients at even low doses of Ativan can be dependent and go into a relative/tolerant withdrawal after a few months and not even know they are are hooked or experiencing acute withdrawal symptoms. I am not talking abuse – but taking as prescribed.
    My point is that these protracted syndromes can have debilitating pain and psychiatric symptoms. The protracted syndrome in these individuals is often recognized as a worsening of the pre-existing condition/state as opposed to a new baseline. Because it is often referred to as “all in your head” or “there is no such thing as protracted syndrome” “You produce too much glutamate and not enough GABA” Proper context in treating – or importantly maybe NOT treating this syndrome.
    I think, humbly, that protracted withdrawal syndromes are telling us more about pain than we may think. You touched on inflammation. “You don’t produce enough GABA” argument may actually be telling us that their may be a receptor issue/mutation and not a neurotransmitter quantity issue (like insulin resistance not a beta cell issue) My point is that maybe these protracted syndromes are inflammation. The autonomic hell some people go through can last for years and look like chronic fatigue, fibro, etc. But because this is caused by a withdrawal syndrome I think it is fair to say that pain in non-protracted somatic patients (or no previous therapeutics) may be, like you said, chronic inflammation. A simple inflammatory issues like new or worsening seborhheic dermatitis that is seen in Parkinson’s patients and other nervous system disorders can be seen in protracted withdrawal patients who did not have it on their face or chest before. (Kaiser did a interesting study of Seborhhiec in senior individuals and tracked for development of Parkinson’s. Just a side)
    I will leave it at that. I have more (ha!!) but I really think these syndromes if given the attention they deserve (at least for patient dignity) can tell us a ton about the pain in some of these psychosomatic cases and the neurochemistry behind it.
    Warm regards.

  7. Agronomous

    I would be very, very careful not to glamorize placebos. A personal experience:

    Back in my twenties, I figured a good way to make some easy money was to sign up for medical trials, most of which were drug trials. So I signed up for around a dozen over the course of three or so years. By plain bad luck, I got assigned to the control group for nine or ten of them.

    Taking placebos so regularly (and in fairly high doses) eventually led to a serious dependency on them. Just as placebos can make you feel much better while you’re taking them, they can make you feel much worse when you quit. I’m not going to say the situation’s as bad as with illegal drugs, since it was easier for me to find substitutes and taper off: Tic-Tacs, Lucky Charms, and (just for a while, when I’d hit rock bottom) store-brand granulated sugar, out of a five-pound bag. (I honestly considered using a different handle for this post before including that last one.)

    The medical establishment was no help whatsoever. Some doctors figured anything to do with placebos must be all in my head. Others were, I think, legitimately confused about what to tell me to stop taking: sugar pills? the study drugs? sugar in any form? One just mumbled something, made me wait alone in the exam room for fifteen minutes, and sent a nurse to show me out.

    Eventually, with time and the power of positive thinking, I managed to pull things together again. But some nights, I lie awake worrying: “What if positive thinking doesn’t really work? What if it’s just another form of placebo?” Those nights are why I don’t keep sugar or honey or candy in the house—let alone sugar pills.

    1. Anonymous

      Fascinating. This is a story you could get published (How I Became Addicted to Placebo Pills).

  8. Thomas Jørgensen

    If backpain was mostly psycological this would either not work, or work on the placebo group.

    The obvious next step is to try giving people antibiotic epidurals, because the enormous doses and length of treatment they’re using here is due to the spinal sheet being pretty impenetrable to antibiotics..

  9. Steve Sailer

    When carpal tunnel syndrome was trendy in the 1990s, I got it. I started assuming my hands would hurt for the rest of my life and I started looking into computer aided dictation and the like. But then I noticed that I had been typing for a few months with my chair parallel to my desk for some reason that I thought was cool at the time. I went back to sitting normally at my desk and my hand pain went away in a few days and I haven’t had it since.

  10. Steel

    Just a couple days after this, one of my friends whose life is falling apart – bipolar who goes physiologically waxy/catatonic during depressive phases – also conveniently got diagnosed with lyme disease. She’s really just an internet acquaintance, and I won’t take much action, but I can’t help thinking that this is a factor in her situation, the narrative that’s emerged of her life Being Terrible.

  11. HHELLD

    But if the pain is ignored, what negative consequences can be expected? E.g. 1. From joint pain, 2. From definitely-inflammation joint pain, 3. from headache, 4. From cannot-even-focus-anymore headache, 5. etc.

  12. jimmy

    This is a super interesting topic, and I have some first hand experience playing with the stuff. I’ve “fixed” pain from genuine injuries as well as “psychosomatic” stuff, and even *created* some psychosomatic stuff – though the latter was accidental most of the time.

    On one hand, I like when “the placebo effect” gets attention (especially when it’s seen as working even without deception) because it’s really good shit. On the other though, that whole framing kinda misses the point and ends up confusing the boundaries between “psychosomatic” and “real” pain, as well as sending you off in the wrong direction about “how to hack your mind with the placebo effect”.

    It’s a super complicated topic so I can’t really even begin to explain what I know and what I’ve seen, but the fact that it’s complicated *is* part of it. For example, a huge huge *huge* part of it is that pain isn’t actually the problem. No one cares about pain. *You* don’t care about pain, even if you think you do. Even as you scream for pain killers, you’re wrong about what you want. If you haven’t had the experience of feeling intense pain while at the same time finding it about as irrelevant and easy to forget as the sensation of your tongue sitting in your mouth, then you haven’t had an opportunity to distinguish between pain, that-which-makes-you-miserable, and that-which-you-do-not-want. They’re very different things, believe it or not, and distinguishing between them grants you a lot of room to improve.

    How do I know? Well, among other ways, I’ve been there. Simply reciting “Pain is just information!” isn’t enough, of course, but I’ve had the experience of deliberately and methodically shifting from suffering and wanting the pain to go away to the same fairly intense pain as just completely uninteresting and not distracting in the least. If you’ve never been there before, it’s a trip.

    However, even that conflict isn’t really what you want to end. I’ve also had the experience of being in legit level 10 pain (and suffering), complete with inability to even crawl, and not in the least tempted by pain killers. If you’d have offered them, I’d have laughed in your face. In fact, I was already laughing at how *ridiculously* intense the pain was. It was funny.

    And still other times it’s not funny to me and I would reach for painkillers if I weren’t such a stubborn shit. Sometimes the pain has real meaning, and I’m not sure how to deal with it. Sometimes I’m not sure how to organize the information in a way that doesn’t leave me gridlocked and miserable.

    But that’s really what it’s about, not “making pain go away”. Trying to “make pain go away” can *create* suffering out of nowhere, and I’ve seen it happen. Good intent, bad results. And allowing someone to have pain without acting like it’s the end of the world can instantly turn pain from a real injury into “that funny tickling feeling” – seen that one too.

    1. Cord Shirt

      I’ve been there too. “Notice the pain, but don’t mind it,” is how a Sylvia Engdahl character explained it. That’s where I got it from. And yeah, it works.

      I wouldn’t advise doing this unless you’re pretty sure continuing to use the painful body part won’t injure it further (or it’s an emergency). Otherwise, using this technique is highly likely to…injure you further. I’m sure you can guess how I know.

      On another note, jimmy, I really wish you wouldn’t be see gee-whiz about it. Nothing personal–it’s just that *I know from experience that this technique does work*, but your gee-whiz attitude, which unintentionally gives a powerful impression of arrogance, would’ve turned the younger me off so thoroughly I might never have *realized* it works. I don’t want that to happen to anyone.

      I find this paragraph really off-putting:

      For example, a huge huge *huge* part of it is that pain isn’t actually the problem. No one cares about pain. *You* don’t care about pain, even if you think you do. Even as you scream for pain killers, you’re wrong about what you want.

      It comes off as really pushy and “I know your own mind better than you.” And I think that for someone with a cultural background like mine, it may also unintentionally make the technique sound impossibly difficult.

      So for the benefit of anyone reading who’s from a cultural background more like mine, here’s how I’d put it:

      This works. It’s not “a trip”–it’s not weird in any way; it’s actually a *completely normal and easy thing to do* as soon as you get the hang of it. Sylvia Engdahl had it right: Let yourself *notice* the pain–don’t try to shove it away–but choose not to *mind* it. If others like me and jimmy have done it, dear whoever reads this, you stand a good chance as well. (Just don’t use it at the wrong time and damage yourself.)

      1. Cord Shirt

        (I can’t edit, so: Sorry about the typo. *So* gee-whiz, of course, not “see” gee-whiz. ;))

        I should add: I agree that pain isn’t the problem, suffering–“minding it”–is.

        I edited out what made that paragraph so off-putting because I was trying to make my comment politer, but now I see that just made it unclear. So here are the reactions I’d expect that paragraph to spark in people with cultural backgrounds like mine: “Who are you to just assume others ever ‘scream for painkillers’–ever even want them at all? Who are you to tell others that they’re ‘wrong about what they want’? Who are you to just up and assume you *know* what they want?”

        (I know it wasn’t meant to be overbearing, just saying I’d expect it would strike some that way.)

      2. jimmy

        Thanks for the feedback. Especially the “less polite” part, as that really gets at the heart of the matter.

        >“Who are you to just assume others ever ‘scream for painkillers’–ever even want them at all? Who are you to tell others that they’re ‘wrong about what they want’? Who are you to just up and assume you *know* what they want?”’

        The first question is strange to me. I thought it was pretty unobjectionable that there exist experiences where people very very much want painkillers. While I’ve never personally “screamed for pain killers”, I’ve had experiences where I very much would have wanted them. Heck, I don’t think I’m past that point even now. I didn’t anticipate anyone could take offense to that part because hey, if you can’t imagine ever wanting pain to be gone, you’re pretty clearly not the target audience – good for you, and I hope I get there someday!

        The rest of the questions were kinda anticipated but I didn’t see how else to write it so as to make the point clear while preempting these questions. They are very good questions though, so I’ll answer them.

        To start with, who am I *not*?

        I’m *not* someone who knows with certainty what you do want in any given case. I’m not someone who thinks you should take his word for it. I’m not someone who thinks your experiences aren’t “valid” and informative, and I’m not someone who thinks they should be dismissed without consideration. You *shouldn’t* just take my word for it, and you *shouldn’t* dismiss your own experiences. Ever.

        But I *am* someone who has seen both sides. I’ve been there, learned more, and come to experience first hand that I was wrong when I thought I cared about “pain”. I’m also someone that has gone through the exercise of actually talking to people in pain and simply by empathetically following that-which-they-care-about, bringing them to a place where they still have the pain and just don’t care at all. It’s something I’ve empirically tested.

        >here’s how I’d put it:

        That message is actually very different in content. That may be how you go about it, but it’s different from how I go about it in important ways. In addition, I specifically don’t want to say anything that tells people what to do or even looks like directly actionable advice. I anticipate that if I tried to do that, it would just result in hard-to-see miscommunication that does more harm than good (including, for example, people “not minding” important pain even after the warning. I’ve had that outcome in the past and regret it). I don’t think I can make the point that pain isn’t the problem *and* show how to see that for yourself.

        However, I do think that I can express the simple idea that pain isn’t the problem and that there *is* something to see for yourself. And I think that point is worth expressing very strongly – because it’s not a “pain isn’t the problem maybe/sometimes/for some people unless it *really* hurts”. It’s a “pain isn’t the problem *period*”. Even when painkillers are a wonderful solution and you’re right to want them.

        1. moridinamael

          I’m going to push back against this a little bit.

          *Chronic* pain is miserable because it is endlessly persistent. It’s there when you wake up in the morning, before you’ve had a second to establish your psychological defense against it. Perhaps it’s already sapped all your “mental resistance” before you even open your eyes, by giving you a terrible night’s sleep.

          You can use complicated meditation-style tricks to fake out your nervous system. Sure. This works for minutes at a time, until you need to focus your attention on something else, and then pain is there, like a kid poking you in the eye from the corner of your peripheral vision. You can’t do high-level cognitive work while simultaneously “remembering” to find that this aversive, intrusive, persistent stimulus is actually “okay”.

          And pain can only be one “factor” in a complicated fractal of suffering. Muscle tension is unpleasant. Your body’s inflammatory response makes you feel sick. Real severe pain has ramifications on numerous other systems in your body. It is a constant background stress.

          There is an enormous difference between breaking a bone and being able to “be okay with it” versus knowing that you’ve had a headache for four weeks and you have no reason to suspect that it’s going to go away by bedtime.

          Honestly I think the issue here is that many different things are being conflated under the umbrella term “pain”.

          1. jimmy

            I’m not talking about “complicated meditation-style tricks” “faking out” one’s nervous system, or indeed any sort of “establishing a psychological defense”. There is no “remembering” necessary, as what I’m talking about isn’t a conscious level thing at all.

            I’m talking about changing the way you relate to the pain altogether. I’m talking about pain being literally so boring that it would be effort to focus on it – the same way it takes deliberate and consistent effort to meditate on your breath for minutes. I’m talking about it as something that can happen all on its own once you have new reference experiences to build on.

            And I do not discount the difficulty of doing the conscious level work of refactoring the pain while tired and under stress or the potential interference with sleep either. It might not have been clear, but the bit I mentioned where I was in too much pain to crawl was one where it was too intense for me at the time and I failed to refactor the pain, so I very much know what that’s like to fail and suffer. It’s also one where my meta-defense (which came from deliberate experimentation with pain a week or two prior) *automatically* kicked in without having to think of it. I didn’t “try” to laugh at it, it was just funny. And even without figuring out how to refactor the pain into boringness and the pain still at a 6 or 7, falling asleep wasn’t an issue at all (which kinda surprised me at the time).

            Can I imagine a pain that would keep me up and be miserable and unfunny? A pain that would cause me real problems?

            Absolutely! Again, I’ve been there. But is the problem the pain or my response to it? One path points towards some really solid solutions. The other is a false stop sign.

          2. moridinamael

            Is there any literature that someone can follow to try to replicate this? Or is this something you developed on your own?

            You’re definitely not the first person I’ve heard claim a similar ability to semi-permanently tune out the suffering component of pain, but I’ve never seen any concrete instructions for implementing the technique.

          3. jimmy

            The specific way I originally went about it was following a protocol developed by my friend Joe Fobes (links to his explanation and ‘how to’ at the bottom). It’s designed to be much more general than physical pain, but it works for that too.

            However, it’s worth noting that I didn’t just read this stuff and put it into practice. I’ve been thinking pretty hard about the stuff and developing my own ideas on the topic for the last several years – as well as talking to the guy directly and having him walk me through his acknowledgement routine a few times on other things and setting me back on the right track when I’d screw it up.

            My own writing on has touched on the subject of physical pain as example of more general principles but never really explicitly addressed it. It’s also purposely very far from a “how to” that tries to be useful with little investment, but I included the link this time in case you’re curious.


          4. Cord Shirt

            There’s another published version of this too. I’m sorry to say I no longer remember the name of it (I just spent an hour trying to find it again online, but no luck), but maybe you’d like to know it definitely exists. I remember it billing itself as something like “acknowledge the pain, but choose not to let it prevent you from engaging in the activities you wish to engage in.”

            I’ve been there too. It’s why I reinvented the wheel this method.

            For me, a large part of the “sapping” aspect you mentioned comes from minding the pain rather than from the pain itself. For example, in “knowing that you’ve had a headache for four weeks and you have no reason to suspect that it’s going to go away by bedtime,” a large part of the problem can be the focus on whether it will ever go away. That is, suffering due to the thought of there being “no end in sight.”

            It’s the same with Adam’s “Can you stick your hand in boiling oil for even ten seconds?” question from the other thread….

            I can still never imagine willingly boiling all of the skin off my hand or letting a dentist drill through my teeth into my jaw with no anesthetic, let alone doing these things over and over again forever without the prospect of one day being comfortable and bragging to my friends about how hardcore I am because I did these things. And I can’t imagine you doing it, either.

            Having no skin is *dangerous*. Having no skin over a large enough area of your body can kill you slowly over several days. Having no skin on your hand can heal so badly you end up unable to use the hand (were you ever forced to read Johnny Tremain?).

            If you had a choice between “holding your hand in boiling water for 10 seconds and then finding it perfectly undamaged” or “your hand suddenly gaining the damage characteristic of having been boiled for 10 seconds,” which would you choose?

            I would choose the first. Even if I thought I couldn’t pull it off because “the pain would hijack my brain,” I’d still *want* to choose the first.

            So ISTM the pain isn’t the problem, the damage is. The pain is only there to prevent or at least alert you to the damage. If it’s not serving that purpose, it’s not important.

            …my family/cultural background has made me big on psychological explanations for things. So this may just be my bias talking–but I’m inclined to think that if someone can’t change their relationship to their pain in this way, it might be because some part of them still thinks or fears that the pain may be a sign of ongoing damage. I’m also inclined to think that if they think/fear that, maybe they’re right–if nothing else, maybe their subconscious picked up on something–and so they should get checked out until they’re *sure*.

            (BTW, I notice Sarno and Schubiner have a whole complicated rationale to convince readers they’re *not* actually injuring themselves, the pain is a signal about their *emotional* state instead…)

            Here’s *my* quack theory of chronic pain that I just made up just now: Maybe a subset of people who have chronic pain have noticed they have some kind of medical problem soon enough to develop coping mechanisms (such as doing less and less of a certain type of motion because of the pain) which slow the progression of whatever-it-is. However, they’ve detected the whatever-it-is at a stage where it’s not severe enough yet for doctors to detect it. And now, their coping mechanisms have also altered the course of whatever-it-is so that it’s progressing much more slowly than expected and it will be a very long time before it does get bad enough for fallible human doctors to detect it. Meanwhile the patients’ lives are severely impacted because their coping mechanisms take up so much time/effort/money. Potential quack solution for these folks: They might behave more normally even though it *is* causing further damage, so that normal life continues and so does the progression…and so they get diagnosed a year from now instead of ten years. Cynical enough for ya?

            …I don’t know your situation, but I wish you the best of luck.

        2. Cord Shirt

          The first question is strange to me. I thought it was pretty unobjectionable that there exist experiences where people very very much want painkillers. While I’ve never personally “screamed for pain killers”, I’ve had experiences where I very much would have wanted them. Heck, I don’t think I’m past that point even now. I didn’t anticipate anyone could take offense to that part because hey, if you can’t imagine ever wanting pain to be gone, you’re pretty clearly not the target audience – good for you, and I hope I get there someday!

          Oh, it’s my “opposite of what Sarno/Schubiner expect” subculture. It’s not a matter of not having experienced severe pain or of having thoroughly detached from it, it’s a matter of the subculture valuing stoicism.

          So saying things like, “Even when painkillers are a wonderful solution and you’re right to want them,” is likely to impede communication with someone from my subculture because my subculture takes for granted that you’re *never* right to want them. 😉

          That message is actually very different in content. That may be how you go about it, but it’s different from how I go about it in important ways.

          Interesting! Where is it different?

          In addition, I specifically don’t want to say anything that tells people what to do or even looks like directly actionable advice.

          OK, I see where you’re coming from. For me, expressing this idea as if it’s a “shocking revelation” feels extremely off-putting, and to avoid that, I was willing to put it into the “giving advice” frame instead.

          I anticipate that if I tried to do that, it would just result in hard-to-see miscommunication that does more harm than good (including, for example, people “not minding” important pain even after the warning. I’ve had that outcome in the past and regret it).

          I suspect that outcome can’t ever be eliminated entirely. After all, pain evolved to prevent it. Relying on your conscious mind for this task instead of on pain is going to cause the occasional mistake.

          So I’m inclined to think the best we can do is just warn people against it. A lot.

          However, I do think that I can express the simple idea that pain isn’t the problem and that there *is* something to see for yourself. And I think that point is worth expressing very strongly – because it’s not a “pain isn’t the problem maybe/sometimes/for some people unless it *really* hurts”. It’s a “pain isn’t the problem *period*”.

          I completely agree.

          Even when painkillers are a wonderful solution and you’re right to want them.

          For my subculture you’d have to reword this to something like, “Even when ignoring the pain won’t further injure you, so the recommended treatment would normally be painkillers.”

          Overall, glad to meet someone else who’s done basically the same thing. 🙂

          1. jimmy

            >t’s not a matter of not having experienced severe pain or of having thoroughly detached from it, it’s a matter of the subculture valuing stoicism.

            Ah, I thought it was the “hey, don’t act like I’m a little bitch that feels an impulse to want the pain gone!” sort of response, not the “I know how horrifying pain can be and I *still* want to not use pain killers despite that impulse” sort of response.

            I’m surprised that you thought that takes away from the message then. As it happens, I kinda naturally fall into that category myself. When I say “I’ve been there”, I mean that I’ve felt that temptation not that I would let myself give into it. When I had to get back surgery I was in enough pain that it freaked the doctors out and they didn’t want to take “no” for an answer so I finally gave in and let them give me a bottle of vicodin – and then never took any of it.

            >For me, expressing this idea as if it’s a “shocking revelation” feels extremely off-putting

            Huh. For me it *was* a shocking revelation. I mean, my theories predicted it should work and it felt completely normal, but it was still quite a “woah…”. How completely normal it felt was part of what was shocking for me. Like, “this really *is* normal!”

            >Interesting! Where is it different?

            You said “Let yourself *notice* the pain–don’t try to shove it away–but choose not to *mind* it.”

            This, and what you said above, reads to me like conscious level instruction. Like you’re using your conscious mind to override what would be your automatic response to try to implement the advice you give. The problem with advice in things like this is that what motivates them to go through with it is fairly disconnected. It’s an override powered by trust in Cord Shirt, trust in the arguments, “will power”, etc. It’s susceptible to the the same failure mode as the advice “if you want to lose weight, eat less and exercise more”. It’s *true*, but when people leverage their motivation to override their automatic response against their automatic compulsions to eat, they’re frequently going to come up short and then conclude they “can’t” do it.

            In reality it’s not that they “can’t”, it’s that they’re mismanaging their motivations so of course it doesn’t “work”. By telling them to do it I’m implicitly suggesting that I believe they should be able to “just do it” and if they can’t I’ve been proven wrong – at least how it applies to them. I don’t believe this, so I try not to accidentally mislead in ways that is bad for people and ruins my credibility.

            It’s not a trivial distinction to me when instead of framing it as an instruction, I prefer to say “it’s *possible* to just notice the pain and ultimately realize that it’s not a problem”. It *is* possible, and if you find yourself thinking “what!? I don’t see how!”, then YES, that is true and important. You don’t see it yet. Would you like to? That kind of thing begins to open the doors to changing what the automatic responses are so that there’s no conscious level intervention necessary.

            When I’m trying to help someone that is in pain, I don’t give them any conscious level instruction because I know they’re just gonna screw it up. I just walk them through it instead. For example, my kid cousin burned himself kinda bad on a fire poker one time when we were out camping. Everyone was trying to help in the various ways people do and he looked like he was trying not to cry. When I showed up, I just squatted down to his level, looked him the eye, paused for a few seconds while establishing rapport, and asked “hurts?”. That’s all it took. He lit up, started smiling, and then started telling me how “*actually*, it just kinda tickles. When I get hurt I feel tickling”.

            If I had told him “try to notice and then not mind it because there’s nothing else we can do about it” (to phrase it purposely ineffectively), the weight of that instruction would have been outweighed by the other things going on in his mind and he would not have succeeded. By just going with the emotional flow I didn’t have to fight that and I didn’t have to have him consciously override the pain. We just asked the pain itself “yo, is there a problem?” and the answer – not the conscious level answer but the subconscious one – was “no, we’re good”. So the “bothersome pain” shifted in automatic interpretation to “fun and games pain”, which is just ticklish. The problem was that before me, he hadn’t stopped to ask because the way everyone else was responding heavily presupposed that there *was* a problem – and no solution that left him not-miserable.

            The other upside of going about it this way – besides preventing people from misleading themselves into a dead end and failure to relieve pain – is that you don’t get the mistake of consciously missing the full message of the pain and ignoring it when part of you knows you shouldn’t. In order to get the results the pain “itself” has to agree that you’re not missing anything.

          2. Cord Shirt

            Ah, I thought it was the “hey, don’t act like I’m a little bitch that feels an impulse to want the pain gone!” sort of response, not the “I know how horrifying pain can be and I *still* want to not use pain killers despite that impulse” sort of response.

            No. Again, it’s neither. Or both, I guess. Hmm, how can I make it clearer…

            My subculture’s axiom is, “Pain is good. It gives us useful info.” So in my subculture, one doesn’t “want the pain gone,” ever. What one wants, always, is for the “actual problem” to be addressed. I was taught that from infancy, so even though I’ve experienced a lot of very painful things, I never really had a chance to “just want the pain gone.” Interpreting “pain” as “there’s an injury/illness, fix the injury/illness” is just too automatic.

            So you can see how my subculture really paved the way for the relationship with pain that I now have. Already the “problem” is defined as the injury/illness and not the pain. That’s probably also why I did not feel like extending this was “weird” enough to be “a revelation.”

            It’s just that my subculture still didn’t offer any way of dealing with pain whose cause cannot be addressed, such as neuropathic. Pain where the problem *can’t* be solved, or there *is* no “real problem” to solve. (Or…where you *mistakenly conclude* there’s no problem.) So all I did was to extend that “the problem is the injury/illness” attitude to “…so if there *is* no injury/illness (or no more needing doing to heal it) then there’s no problem.”

            Sorry to repeat myself, but the problem *there* is that some injuries or disease processes aren’t immediately obvious, or aren’t even clear to your *sub*conscious mind. You (including your subconscious) can also have other priorities higher than avoiding all damage to yourself. And you can misjudge the risk/benefit ratio in this area and end up taking more damage than was wise or than you considered acceptable.

            It’s susceptible to the the same failure mode as the advice “if you want to lose weight, eat less and exercise more”. It’s *true*, but when people leverage their motivation to override their automatic response against their automatic compulsions to eat, they’re frequently going to come up short and then conclude they “can’t” do it.

            Yes, I know what you mean. I had the same issue as you–predicting the problem but not sure how to avoid both it and the other failure mode. I made the choice I did because to me, the other failure mode is even more cognitively available / “feels more likely.”

            I didn’t have to have him consciously override the pain.

            Yeah, that’s what I was trying to preempt with “don’t try to shove it away.” “Don’t try to consciously override it” would work too. Or just plain “don’t try to fight it.”

            you don’t get the mistake of consciously missing the full message of the pain and ignoring it when part of you knows you shouldn’t. In order to get the results the pain “itself” has to agree that you’re not missing anything.

            Well…on the one hand I agree that the subconscious is often more right about the pain’s message than your own conscious mind–or the doctor’s (as I said to moridinamael). OTOH…I don’t think it’s a good idea to treat it as “magic” or “a message from God.” It’s *your* subconscious; it’s fallible, just as you are. It too is sometimes wrong. And your conscious mind (and/or the doctor) can mistakenly convince your subconscious mind that there’s nothing wrong when there is. And…what I said above.

            (BTW, I used to have a little bitch. She was a great helper, but she eventually died of old age, and her replacement happens to be a dog instead of a bitch. If you get my point. 😉 )

            I can see we’re having a culture clash here. This conversation is an interesting exercise in describing what seems to be the same idea, but with rather incompatible communication styles. So, what subculture are you from? Is yours an example of “California style”?

          3. jimmy

            I’m in complete agreement that the pain signal isn’t the problem – the damage is. I even think that *most* of the time you see someone in pain they aren’t even acting like pain is the problem – they’re acting like the damage is and that they don’t know what to do about it (even if they aren’t aware of this).

            However I wonder if I’m just using the word “want” differently than you. I’m with you in *ideals* about how we relate to pain, but are you saying that in *practice* you’ve literally never experienced “some part” of you wanting the pain gone, even if this contradicts what you want to want? Can you not imagine pain so intense that it would at least *tempt* you to cheat with painkillers – even if you ultimately choose to bear it? Could you never get to the level where thoughts of not wanting to be in pain complicate the process of finding and dealing with the damage appropriately? To make you at least ask the question?

            If you’re really confident that you’re completely immune to that extra layer of complication, that’s pretty cool. I may be by now, but I’m not confident in that at all.

            Your other comment about choosing between the pain of boiling water and the damage is interesting, and I’m completely with you there. In interest in challenging the frame, if you’re for reals about “pain isn’t the problem, damage is”, then whenever you can find “cheap” sources of pain, it shouldn’t take much to convince you to do it – since hey, it’s not actually damaging you and “it’s just a [misleading] signal”, right? ;). Not just “I’d choose ‘pain of boiling water’ over ‘damage of boiling water'” but “I’d go through ‘pain of boiling water’ if you give me a dollar”.

            How far would you actually take that? Would you eat a ghost pepper just to “put your money where your mouth is”? Would you be confident that you could do it without “breaking” and drinking water? First time I tried it I did break. Second time I felt pretty silly for it.

            There are other “cheap” sources of pain too. I recently learned that we have tarantula hawk wasps around here and that their sting is (supposedly?) harmless but apparently incredibly painful for a few minutes. I’m kinda feeling nervous because if I can confirm the “harmless” aspect to my satisfaction I kinda feel like I have to get one to sting me and it doesn’t exactly sound fun.

            As to which subculture I’m from, I’m from southern California, but I don’t really feel like I get much of how I relate to pain from the general culture around me – I feel like an outlier here. This *living* the “pain is just a signal and it doesn’t have to bother me” thing came after I started researching hypnosis and the “pain is just a signal and I’m not gonna let it boss me around (but if we’re being honest, I don’t like it)” thing feels like it’s just in my blood. My dad is the kind of guy that learns he’s bleeding from other people telling him and I always thought that was cool and looked up to him as a kid, but he isn’t exactly typical for the area and it really just feels like how I grew up dealing with pain was more a manifestation of an innate stubbornness more than anything.

            Today I found myself in the middle of a conversation about pain of tattoos in a mma/bjj group and they’re definitely tough guys whose subculture has a thing about shrugging off the pain from being kneed in the face and fighting through – but when it comes to talking about pain in the context of getting a tattoo it seemed pretty typical from what I’ve seen from other people. Stuff like “yeah, it hurts!”/”it just gets worse with each tattoo too. I know one guy who has his whole body tattooed and now he takes Norcos before getting them”/etc. They’ll still *do* it, of course, but they’re pretty open about not liking the pain and joke about being tempted to break a tattoo into two sessions when they really don’t have to.

            Does that answer your question?

  13. wintermute92

    Your theory on the placebo value of Unlearn Your Pain is fascinating to me as an answer to a deep-seated issue in medicine.

    The placebo effect obviously exists, and works strongly in at least a few cases. This is the basis for a lot of complexity, because it means that totally ‘useless’ treatments can produce large and consistent benefits for patients. Cue endless wrangling over “we should find and eliminate placebos!” versus “we should give everyone placebo treatments!” versus “you can’t do that without ruining faith in treatment, you have to lie about it!”

    This came to a head (most recently) in the fight over meniscectomies, where I saw a bunch of people offer some variant of “maybe it’s placebo, but we shouldn’t investigate too vocally or it will stop working”. Which is obviously the core complexity of most placebo treatments: they’re actively counter-rational, and if everyone understands them perfectly they weaken or disappear.

    I’ve never seen a good way out of this before; it actually appeared to be one of the stronger anti-rationality examples, a clear caveat in the Litany of Tarski where perfect knowledge is counterproductive.

    Your take on placebomancy is a (partial, theoretical) resolution to this. Given a decent “theory of placebo” like “it helps resolve misaligned pain sensors in your brain” it might be possible to hand people health-improving techniques despite clear admission that you’re not dealing in physical cures. There’s some mechanism by which placebos work, and it ought to be possible to hand that mechanism out directly as the nature of your cure.

    1. gbdub

      It seems to me that “helped by placebo” basically means, “this symptom is susceptible to psychological mitigation”. There’s nothing inherently irrational about that, and honestly it seems like saying “we’ve found this activity (taking a sugar pill, doing an exercise, whatever) to be the most effective way to activate psychological symptom relief” would be both true and effective, without nuking the placebo effect. Has anyone tried something like that? Run a test where one side gets something they are told is a new wonder drug, and the other is told they are getting a sugar pill, but rather than say, “this is a sugar pill, so it shouldn’t work” they are told “this is a sugar pill, but previous studies say you should feel 30% better just by taking it!”

  14. SUT

    Given how complicated it has been to get robots to do run-of-the-mill bio-mechanics – upright walking, hand manipulation tasks – it goes underestimated in my opinion the cognitive task associated with processing “sensor data” and figuring out “actuation strategies” to achieve movements or even just maintain a comfortable sitting posture in the human body.

    And if there’s one result from the study of bio-mechanics that is well known it’s that weakness/tightness in one module (e.g. the foot) will cause a cascade of compensations across other modules (e.g. the spine). In this way, people seem to get stuck in a local minimum by the force of habit and convenience, which is sub-optimal from what they could achieve by dramatically shifting their strategy.

    I’d speculate that you’d see more variation in how much a person uses their abdominal muscles when sitting based on accrued habit, then any amount of relevant variation that arises due to genotype.

    So, if the human body is a complex cognitive task that is carried out largely by subconscious process, and often one that periodically becomes open to learning and cementing inplace a pain causing strategy, the best way to disrupt that *is* forms of “coaching” – which is the art and science of getting people to make movements often too subtle to demonstrate and decision too quick to intervene with. In other words, what science tells us about the chronic non-structural pain in the human body seems to be: “Any cure targeted at the root of the problem is indistinguishable from magic [or yoga, or alternative medicine, or new age visualization techniques, etc]”

    1. Forge the Sky

      I work with a lot of chronic pain professionally. The sort of compensations I see are often very intricate. I’d be surprised if it didn’t play a role.

      That said, I also see a lot of people with gross morphological issues (amputations, malformations) that nonetheless have little or no pain. So I’m not sure how much of a role this actually plays.

      However, let’s look at this from a bit of a different angle. I agree that there is a TON of stuff going on in our muscoskeletal system that we’re unaware of and that isn’t really under conscious control. Subtle alterations in the firing times of different adjacent muscles, for example, could overload surrounding structures or misplace joint movements. And a lot of this can just be something that got mis-learned through habituation.

      In addition, there’s a theory out there of chronic pain (see Dr. Robert Scaer or Dr. Paul Levine, for example) that says our reflexes – say, the reflexes governing the baseline tension of spinal postural muscles – become susceptible to re-wiring during traumatic incidents (such as a car crash). I’ve seen clinically that sometimes chronic pain can actually leave when an afflicted area gets injured in some accident as well – hypothetically, the new trauma offers the body another opportunity to re-wire its reflexes once again.

      In fact, it’s possible the therapy I perform (extracorporeal shock wave), which I’ve observed clinically to be strangely effective in the resolution of very chronic and treatment-resistant pain, operates in a similar fashion – in this case by creating a ‘fake’ trauma in the treatment area which can allow the area to re-set itself. It’s one of two theories I have running.

      Perhaps chronic pain is the memory or anticipation of injury that the body erroneously doesn’t hit the ‘off’ switch too once the threat or damage has passed. In a similar way to how transient stress isn’t so bad for you but chronic stress is, chronic hyper-vigilance towards injury in an area – with accompanying tension and inflammation – causes a trouble that has no obvious cause, and therefore no obvious solution.

  15. Conor

    Extremely surprise by your take on benzos here in the comments. Seems to be the exact opposite of what I’ve gathered psychiatric consensus is. Curious to hear why you’re so different form the mainstream.

  16. Eric Rall

    The bit on pain gating reminds me of a claim I heard a while back that strength training often mitigates the symptoms of fibromyalgia. The suggested mechanisms were 1) the training itself helped improve pain gating (lifting heavy-for-you weights is very uncomfortable, which helps put everyday pain and discomfort in better perspective) and 2) the improvement in strength increased the body’s tolerance to general wear-and-tear, so there was less pain and discomfort to gate.

    Caveats: I came across the claim on Mark Rippetoe’s discussion forum, and the main people making the claim or chiming in supporting it were strength coaches who probably had very strong priors in favor of strength training being broadly beneficial. Most of the arguments in favor were anecdotal or speculative in nature.

    1. gbdub

      An argument in favor – physical therapy seems to work for a lot of conditions, and a lot of physical therapy is basically strength training. Maybe lighter weights than Olympic lifts, but a lot of the movements are the same. I’ve done both physical therapy for injury recovery and personal training for strength – both tended to increase the ability of the exercised system to operate pain free with greater endurance.

  17. conan_the_liberian

    Long-time listener, first-time caller here.

    I have practiced John Sarno’s and Howard Schubiner’s general methods, as treatment for chronic arthralgia, esp back pain. 12mos ago I was on the border of going on work disability due to an inability to function, or sit down for any length of time. Their books and methods have produced a near-100% recovery for me, when coupled with periodic talk therapy from a local psychologist. AMA

    More background – I am a chemical engineer in the med device field, design Bayesian filters for a living, and know just enough about medical practice and clinical studies to be alternately very informed and very ignorant about the dynamics of the sorts of studies Scott cites above. My current professional opinion on all this is that the human mind is not a suitable subject for randomized clinical trials, and that no statistical treatment or study design can overcome this limitation. Thus skepticism about studies of a given psychologically-induced phenomenon are warranted on both the pro and con side, and we are likely always going to be dependent on anecdata. Not ideal, but it’s the way the universe seems to work.

  18. David Friedman

    Your post reminds me of Mark Twain’s comment on Christian Science. I don’t have the exact quote, but it was to the effect that Christian Science teaches people how to cure imaginary diseases and since half the diseases humans suffer from are imaginary, that gives it a better cure rate than anything else.

    1. Max Goedl

      “Well, it is the anxiety and fretting about colds, and fevers, and draughts, and getting our feet wet, and about forbidden food eaten in terror of indigestion, that brings on the cold and the fever and the indigestion and the most of our other ailments; and so, if the [Christian] Science can banish that anxiety from the world I think it can reduce the world’s disease and pain about four-fifths.”

      1. Jiro

        Remember the state of actual medicine at that time. No antibiotics, vaccination didn’t exist for anything except smallpox, X-rays had been barely discovered. Imaginary cures probably weren’t a whole lot worse than medicine at that point.

          1. Adam

            This is funny. Based on Bram’s comment above about wearing polarized sunglasses while driving, I spent about half an hour trying to find a decent pair and was extremely reluctant to make the purchase because everything I found was under $30, even with thousands of five-star reviews. I’m clearly traumatized by years of shopping at REI and refuse to believe I was being so badly ripped off all that time.

          2. Nornagest

            You do get what you pay for in sunglasses. It’s just that you’re often paying for the brand.

            (That said, REI sells, or at least sold, polarized Oakleys and probably other brands. Usually at a $20ish premium over the base model.)

          3. Adam

            I used to actually have a military account with Oakley and they’d send me discount catalogs that they only offered active military and LEO, but I really never used it.

  19. Finntroll

    Surveys suggest that between 40 million and 100 million Americans have chronic pain;

    Anyone else find this number totally unreasonable? ~1/3 Americans have chronic pain?

    If i walk down the street in a random American city and ask people: “Are you experiencing chronic pain?”
    1/3 would answer yes?

    Hard to believe that number even if i only asked inside hospitals.

    Can anyone enlighten me on how one would get such a high number?

      1. Protagoras

        Yeah, as Nancy implied, it seems likely that the proportion would increase dramatically with age, and there are ever increasing numbers of older people.

        1. Charlie Davies

          Minor injuries and nagging pains accumulate with age. As do the effects of bad lifestyle choices.

          People with chronic pain will be less visible on average. The people you see on scooters at Walmart probably don’t leave home except for absolutely necessary trips to very accessible places.

    1. Nancy Lebovitz

      “Can anyone enlighten me on how one would get such a high number?”

      We’d need to know what the question was.

      The survey included asking whether the person felt physical pain in the past day, and I’d be surprised if the answer was under 3/4. On the other hand, to take a low end interpretaion, feeling moderate pain once or twice a day isn’t what I’d call chronic pain in any significant sense.

      On the other hand, I’ve done a little looking for the source for the claim that 100 million Americans suffer chronic pain, and I haven’t found it. I have realized that if I wanted to write a survey about chronic pain, I’m not sure what I’d ask.

      Difficulties with pain scales. If you don’t know what this link is to without clicking on it, you should click. This is a classic.

      1. The Nybbler

        I never liked that 1-10 pain scale. I mean, who knows? But now that I’ve felt what has to be a 10 (pain to almost the point of passing out; it must be a 10 because any higher and I wouldn’t be able to describe it), I can use it. This tends to result in rather low numbers, however.

        1. Adam

          Same here. After experiencing pain that did, in fact, cause me to pass out multiple times (from back spasms), I almost never rate anything higher than a 4.

  20. sohois

    There’s something to be said for glorifying in the placebo effect, laying it on as hard as possible, putting on the fanciest robe and wizard hat you can find and saying “I CAST YOU OUT BY THE POWER OF PLACEBO, GO FORTH AND SIN NO MORE!” I think in some ways there can be better and worse placebo therapies just as there can be better and worse real therapies, placebo therapies that activate the placebo effect only a little and don’t help much, and placebo therapies that activate the placebo effect really strongly and use it to work miracles. Maybe we should give more status to the best placebo therapies, to view them as highly perfected works of the placebomantic arts in the same way that powerful medications are triumphs of psychopharmacology

    I’m surprised that you mentioned this and didn’t then have a study linked on this very topic. Surely someone has looked into the level of effect of placebos based on how impressive they seem from a visual, magic or ‘sciency’ standpoint?

    If not it would seem like a quite important area to look into; someone above mentioned how alternative medicine is a worthwhile target of funding due to placebo, but this is only true so far as it’s a cost effective method of providing a placebo effect. If all the extra pomp and circumstance of homeopathy produces no additional placebo effects compared to, say, just giving someone a pill and telling them it will cure everything then homeopathy is a waste of funding and entirely unnecessary.

    1. Corey

      Not a study, but the PBS “It’s OK to be Smart” video on the placebo effect says so: placebo machines > placebo injections > placebo pills. Fancy packaging, brand-naming, and/or increased price also make placebos more effective.
      Also the placebo effect has been getting generally stronger over time (one factor making it harder for new medicines to clear the better-than-placebo bar).

      1. onyomi

        “the placebo effect has been getting generally stronger over time”

        Could this be the corollary to an uptick in psychosomatic illness?

          1. Forge the Sky

            Interesting idea. It kinda competes with the popular idea that being emotionally stoic will tend to redirect your feelings into psychosomatic issues.

            So is greater permissiveness towards emotional expression making people actually more emotionally driven? Or does it just allow our static emotional level to be more or less displayed?

      2. sohois

        Thanks to you and Mark Z. for the replies, though I am surprised that there haven’t been any published studies on the subject. I suppose there might be an ethical restriction somehow

  21. Karthik Srinivasan

    Fascinating read 🙂 I do not want to believe this but am not able to consider believing – I have been having ‘Irritable Bowel’ and ‘Mouth Ulcers’ for over 30 years (since I was about 5-6 years old) and have a strong feeling that they psychosomatic (MBS!). Definitely add ‘Mouth Ulcers’ to this list.

    The ‘childhood trauma’ part makes it very skeptical – I had no trauma as as child. Well some people say it is ‘repression’ blah blah but then, one can always cook up something and say ‘that was the trauma’ part but then everyone would have had one unhappiness or another in their childhood, ain’t it?

    I am going to take it as a homework to just tell my brain to forget those pain paths 🙂 Let us see.

    1. Anonymous

      How can mouth ulcers be psychosomatic? Can’t you physically see the ulcers on your gums?

      1. caryatis

        Because psychosomatic illness has to do with the cause of the symptom, not the reality of the symptom. Common misconception.

    2. Jon

      Re mouth ulcers:
      I have found that eating spicy food is a major cause of mouth ulcers for me. If I clean my mouth thoroughly after eating something spicy, I am much, much less likely to get any ulcers. (The downside is that rooting around in my mouth with a finger makes me look like an old geezer who has ill-fitting dentures or something, but I can live with that, especially since geezer-hood is sort of an oncoming train at this point anyway.)

      Anyway, if you are fond of capsicum, try rinsing your mouth completely after eating, and physically clean it if you can. It makes a huge difference for me.

      1. anonyrat

        Also re mouth ulcers, I find that chlorhexidine mouthwash is very effective for speeding healing and especially reducing pain.

    3. Anonymous

      I used to have chronic mouth ulcers, but rarely get them anymore. The change that seemed to have helped the most was switching to a toothpaste sans SLS. A sharp reduction in stress may also have had something to do with it. (I also had a dentist file down the tips of my canines so that I wouldn’t bite myself as often, which also helped.)

  22. HeelBearCub

    @Scott Alexander:

    I only say this because you removed the reference to real pain.

    I wonder if you just tossed this part off, and didn’t consider whether everyone who reads it will understand what you are signaling, and to whom.

    On the other hand, patients’ rights groups get very upset at claims that their conditions are “all in their head”, accuse doctors of thinking that they’re lazy or making up their symptoms, and pass around stories with titles like RE: RE: RE: FWD: RE: THE MEDICAL PROFESSION about some guy whose doctor dismissed him as making up his symptoms but who was later diagnosed with zebra-itis and cured with an experimental gene therapy treatment.

    When I read that, I feel like I am meant to be laughing at someone…

    1. Forge the Sky

      Alternatively, you could just laugh at the universal human foibles of over pattern-matching, arguing from the specific to the general, constructing us-vs-them models, and fixating upon dramatic rather than ordinary scenarios, and the weird sorts of behavior that sometimes results.

  23. Max

    This makes me wonder, are there people at the opposite extreme – people who consistently report zero benefit from placebos?

    1. Leo

      This is extraordinarily unlikely. Everything changes over time; by regression to the mean, for patients, it will usually be an improvement. This is part of the placebo effect.

  24. StereoFriedHawk

    One of my medical school professors had a pretty good diagnostic test for this – feign a punch at the patient’s face, really quickly, without warning her. If she instinctively uses her “paralyzed” limb to block it, it’s conversion disorder.

    Why is this patient a she? Do you randomly assign sex to every human being in your texts?

    1. caryatis

      >Do you randomly assign sex to every human being in your texts?

      I’m not Scott, but yes, it is standard practice to either use “she” or randomly pick a gender when writing about a person whose gender is unknown. May be controversial because so many on this blog seem to suffer from gender dysphoria, but writing without gender requires grammatical contortions or the ugly use of “she/he.”

    2. Montfort

      I seem to remember Scott once saying he does actually assign gender at random to people in his essays (unless the gender is relevant or the person exists in real life and is named). I don’t know if he still does it, but it seems like a safe bet.

    3. CatCube

      Switching between sexes in hypothetical situations has been on the rise for a while in a lot of places. It’s easier than dealing with the whining if you use the old “he refers to both sexes” or just using “she” throughout.

      1. Exa

        In my opinion, singular they is significantly superior, because rather than trying to contort gendered language into a gender neutral form (he/she, which still leaves out nonbinaries), selecting a default gender (always he, always she), or just picking at random, you eliminate the problem at the source by removing the gendered language. Also, given the choice between a part of grammar where you literally have to pick randomly or using a conventionally-plural pronoun as singular (or, worse, using any of the high-double-digit number of varieties of neopronouns), I far prefer the latter.

        1. Mark

          I wish some committee of language could coordinate on a single gender-neutral singular pronoun.

          “They” works, but we lose some potential information-density by not letting it continue to be solely plural.

  25. Steve B

    10 years ago I had a hellish year-long battle with RSI (repetitive strain injury), along with other migrating problems. Then I recovered completely within a few days after reading a John Sarno book (on a friend’s recommendation), and have been great ever since. I had no childhood trauma and am very skeptical of psychoanalysis in general, so there were large sections of the John Sarno book that I kinda shrugged off and skipped. My experience was instead summed up by your comment: “the active ingredient is…the belief that the pain is caused by Mind-Body Syndrome” – that was really the only thing in the whole Sarno book that I believed, and that was sufficient. (Well, he also had helpful concrete suggestions like “talking to your body” etc.)

    These days I really like the following vicious-cycle theory of chronic pain: (1) Worry/stress about elbow pain (or whatever) will (2) constrict your blood vessels and reduce oxygen to your elbow muscles, and then (3) naturally it hurts to use your elbow…which causes even more (1) worry/stress about elbow pain. A vicious cycle! There’s a physiological component there – it’s just one component of the cycle, and it’s not the ultimate cause, and it’s not worrisome in itself, but still, it’s something that “objectively” hurts a lot (whatever that means).

    This theory meshes well with my own feelings and experience. Also, it neatly explains why there is small but nonzero correlation with observable anatomy, behaviors, and old injuries: Anatomical pain or discomfort (or memory thereof) can initiate the vicious cycle (as can other things). But in this case, the anatomical pain or discomfort is not the real problem: The vicious cycle is the real problem. And lots of things can break the vicious cycle, including I guess placebos, psychotherapy, reading Sarno or Schubiner books, etc.

    (I didn’t make up this “vicious cycle” theory: I learned it in a very different context years later … a “hypnobirthing” class! I haven’t looked into it in any detail, and am not a doctor or biologist. I am eager to hear other people’s opinions! I guess I should say, I’m pretty confident that there is some sort of vicious cycle in which worrying about a particular part of the body will cause pain in that part of the body. I’m less confident in saying what mechanism(s) mediate this cycle.)

    1. Cord Shirt

      …some…people aren’t raised with that theory?

      …yeah, “All Debates Are Bravery Debates” *definitely* applies. Wow.

      Thank you for posting this comment! I learned something today.

      1. Mark

        >…some…people aren’t raised with that theory?

        As a data point, I’d never hard it before, and even after seeing it on my most-trusted website it seems kind of stupid.

        Upper-middle class Catholic American upbringing with a high density of medical professionals in the family and generally pretty sceptical/ concrete people.

        Maybe the mind-body connection is more of a California thing?

    2. Forge the Sky

      There’s a book by a neurologist on this chronic-pain-as-artifact topic called ‘The Body Bears the Burden.’ He proposes a mechanism he calls ‘neurological kindling’ if I recall correctly, and goes into some basic detail about what such a cycle would entail at a neurological level.

      Also, I’ve read a bunch of these sorts of books and that’s the best one I’ve found for the more scientifically/medically inclined rather than the afflicted layperson, so this is also a general recommendation for that book.

  26. Cord Shirt

    I have enough experience mistaking physical pain for psychological–for example, I once spent weeks thinking a stomach ulcer was “anxiety.” I felt the pain, just thought it was from my emotions when really it was from H. pylori–that it occurs to me that “No chronic whiplash in Lithuania” could just as easily be, “People misinterpreting a physical problem as psychological in Lithuania for cultural reasons,” instead of, “A culture-bound syndrome in places other than Lithuania.”

    IMO this is as subject to the “All Debates Are Bravery Debates” problem as anything else. I know people whose family cultures give a lot of sympathy to physical illness and little to emotional pain, some of whom seem to have learned to turn psychological issues into physical ones. And then there’s my family culture, which gives a lot of sympathy to psychological issues and little to physical ones…and I sincerely believed pain from an ulcer was coming from whatever random anxiety I happened to be feeling that day.

    Doesn’t psychology/psychiatry already have the idea that some people would rather blame themselves for something that isn’t their fault than accept the idea that sometimes “bad things happen to good people”? For me, at least, something similar applies to physical illness–I much prefer to think I’m just upset, or even something pejorative like “being silly” and “needing to use more willpower,” than that I’m physically hurt/ill.

    I can believe other people have the opposite reaction–prefer to believe they’re physically sick rather than emotionally upset. I’m just saying…people like me exist too. Again, “All Debates Are Bravery Debates” applies.

    1. Forge the Sky


      From what I can tell, my family didn’t particularly stigmatize emotional or physical issues overall. But my mother’s family of origin certainly didn’t understand/sympathize with psychological/emotional pain very well, and she’s still very much of a ‘suck it up’ sort of mentality when it comes to depression, sadness, and so on. She also has moderate chronic pain issues, which she predictably never complains about.

      Anyways, once I had a relationship falling apart in a fairly painful fashion, and for weird reasons I couldn’t really talk to my family about it, and I developed pain in my hip that was intermittent but sometimes debilitating, had no obvious physical cause, and didn’t respond to treatment. It went away as the relationship did.

      Other upsetting circumstances I’ve had outlets for, and I haven’t had other clearly psychosomatic issues.

      Just a random anecdote. But I wonder in general how many of our ills are due to inadequate sources of sympathetic attention.

  27. Devilbunny

    Only tangentially related: I have an unusual psychosomatic condition that arose somewhere around age twenty. If I eat a dairy-heavy dessert (e.g., ice cream) within, say, an hour after a meal, I will become intensely nauseated and very likely will vomit. If I were to eat the same thing in the middle of the afternoon, no such problem.

    My wife and I are both physicians, so the matter has been of some interest to us. She didn’t believe me at first, but she came to understand it the way I do now: just because a problem/disease is psychosomatic does not mean it is under conscious control. A major factor was that she started seeing pseudoseizures in her neurology resident clinic and was able to recognize the correlation.

    To me, it’s just bizarre. I don’t have bad memories of ice cream, cheesecake, or anything else. I’ve never had food poisoning. So far as I can tell, I have no reason to have this reaction. If you ask me to dinner, though, please don’t be offended if I pass on dessert.

    1. Scott Alexander Post author

      You probably know more than I do about this, but are you sure it’s psychosomatic? A lot of things are different in the morning vs. the evening. I feel really sick if I nap after about 6 PM, but if I nap before then I feel great.

      1. Devilbunny

        I’m not sure, but given that the experience is unpleasant, I’ve not been tempted to experiment. And as for morning vs evening, why would your body care? Sleep cycles matter, of course, but naps are naps.

        And it is (so far as I can tell; as I said, I am not motivated to experiment) very much related to how recently I ate a meal, not to time of day.

      2. CatCube

        Huh. I didn’t know that was a thing. If I get up in darkness I tend to feel nauseated (especially when it’s cold), where I don’t seem to have the same reaction to getting up later.

        I always figured it was something psychological, because the reason I usually get up early in the cold is for unit physical training, an activity I intensely dislike–and I don’t usually feel nearly as bad when I’m getting up for other reasons.

        A Google search for “morning sickness” doesn’t turn up anything useful for males, so I’ve always wondered.

    2. moridinamael

      This reminds me of when a close friend was having severe digestion problems similar to what you described, and he was diagnosed by various doctors with
      – severe anxiety
      – gluten intolerance/Celiac
      – genetic glandular something something

      and it turned out he had Lactose Intolerance, one of the most common conditions that humans can have. He can now eat whatever he wants as long as he eats it with lactase. No less than four doctors failed to diagnose this.

  28. Tanya Gulliver-Garcia

    It’s interesting and I need to reflect on this more. While I feel that my fibro and other pain symptoms aren’t purely MBS, I do recognize that in times of happiness I often feel less pain (and not necessarily less stressful because I’ve been on high intensity disaster deployments with the same results). But I’ve also had low stress happy times marred only by pain.

    I recently started the Healthy Back program at Ochsner hospital in New Orleans. For the first time I’m not being told “go exercise” with no support or direction but have personalized weight machine training aimed at strengthening my muscles. The weights are increased gradually depending on ability and strength and the is a ton of positive encouragement from staff. The results are kind of remarkable. When I entered the program after months of acute sciatica walking from the parking lot to the office hurt; now I’m biking from my home (1.2 miles each way).

    1. Jill

      Wow, now that’s impressive. Sounds like a great program you are in.

      Adrenalin dulls pain, so that may be why a happy but stressful time may have resulted in less pain.

      1. Charlie Davies

        This is nearly the universal experience of people who do a program of progressive strength training that works the low back and hips.

        It’s not just adrenaline, the extra muscle helps you hold good posture, the better blood flow helps things heal, and you tend to interpret the remaining pain as “good pain” and feel empowered rather than fragile.

        The problem with telling people to go lift weights is that you can do it wrong and hurt yourself. You want to stress the spine in compression and not let it flex under load, which tends to damage your discs. There’s a textbook, “Starting Strength”, that I recommend, but I for one needed some in-person coaching as well.

  29. onyomi

    One thing I wonder about is whether people have always been subconsciously looking for a disorder to have, or if this is a more modern phenomenon. If it’s a longstanding feature then one imagines it must somehow be adaptive. If it’s a side effect of modern society, I wonder what causes it? Theoretically our lives should be much lower stress lives as compared to most of our ancestors, but then there’s the whole “you’re adapted to intense bursts of strong stress like being chased by a bear, but not constant low-level stress like having a mean boss” theory. It could be that tensing muscles when encountering stress is adaptive for obvious reasons, but constant low-level tensing of the sort maybe our ancestors would have less prone to may not be?

    A Freudian repression kind of idea also comes to mind: you can’t scream and wail and punch when you’re angry, irritated, and sad as an adult in the modern world, so you subtly clench your jaw, your stomach, your leg…

    I do think some of it is undoubtedly physical/postural; it would actually be weird if we could go from hunter-gatherer lifestyle to crouching in front of a computer half the day and have no side effects; that said, it does also seem like constant chasing of the problem in a physical explanation with the idea that if only you get your posture perfect, your psoas muscle relaxed, etc. etc. the pain will end, does seem to be barking up the wrong tree in many cases.

    1. nope

      This is a really good question. I can certainly see possibilities for adaptation: mental illness is functionally debilitating, but is also stigmatized in most societies. So people whose capacity for taking care of themselves is diminished in a way unacceptable to would-be caretakers are better off having a more sympathetic reason, a “real” illness. And since the best lie is the one you believe, selection makes sure you do believe it. It might also explain the fury patients have at the suggestion of psychological causes – it calls them out on a self-preserving lie they’re not even supposed to know about.

      1. onyomi

        I wonder if, in prehistoric times, if your pain and misery were going ignored and not taken seriously, it might not have been advantageous to say, become “possessed” by demons in a way which even you yourself would not realize you were, in some sense, “faking.” We’ve since come up with new names and symptoms for the demons.

        1. Rob K

          Or maybe join up with one of the medieval dancing manias? It certainly seems like there are medical phenomena that are historically bounded in a way that means there was a cultural component to them.

          1. keranih

            Alternatively – folk medicine cures and casting out demons were invented and maintained because they worked – at least as well as anything else at hand.

            A “cure” often seemed to involve a complex ceremony, in which all the ill person’s family would attend, and an important person (elder/shaman/witch doctor) would pay close, specific attention to the ill person. Wrapt up in all this attention and support, the patient might surely feel a relief of the stress/distress that had been feeding into the “demon-affected” illness.

            (For those who like their antecdata to come from fiction – Barry Hughart’s Eight Skilled Gentleman has such a ceremony.)

            (And oh, huzzah! The Hughart triolgy is available on kindle! Oh happy day!)

  30. AnthonyC

    The maximalist position has the whiff of politics to it, “I have to push the strongest version of the hypothesis to make any headway” (even if the proponent truly believes it). I, for one, have known a *dog* with chronic Lyme symptoms, and I doubt they were psychosomatic (and the humans hadn’t known about chronic Lyme, or its controversial status, up until then).

    Conversely, I definitely think some (far less severe) issues I have are at least partly psychosomatic, but this gives no relief whatsoever.

    Lastly, Scott, I look forward with hopeful trepidation to your further development as a pioneer in the field of kabbalistic psychiatry.

  31. Jill

    As a psychotherapist, I see a lot of issues with social science research, because it is so different from e.g. chemistry research. It’s impossible, to control or hold steady all the variables you are not studying.

    For example, consider the case of identical triplets raised by the same parents. Both their environments and their genetics are considered identical, in the research study they participate in. Their parents send them to a large school where each child, though in the same grade, can be in a different classroom and thus develop some independence. Thus their peers are different, though the researchers did not measure that or consider it.

    As often happens with twins or triplets, the 3 kids want to distinguish themselves from one another in some ways and enjoy their bond and similarities in other areas. One child joins the school acting club, one the science club, and one the swimming club.

    The one that joins the swimming club has an unfortunate accident in the pool that involves pain and having to stay home from school for an extended period. The parents are busy and have other kids besides the triplets too, so there isn’t enough attention to go around. But the twin in bed with the painful injury gets the lion’s share of the attention, at least for a while. So at some level, perhaps an unconscious level, he learns that being in pain brings you love and warmth and specialness, such that you get treated better than others.

    As adults all 3 kids suffer injuries from a car crash they are all in together. Only the former swimmer has chronic pain. The 2 others recover quickly. Their X-rays and MRIs show nothing that would have predicted this. This is a mystery to the researcher.

    Maybe the researcher interviews all subjects in depth and guesses the reason for the difference– that it was the painful injury and extended stay at home, combined with extra attention from the parents that made the difference. So in the next research study, the researcher asks questions about injuries in childhood and whether the child got extra attention for a certain period of time when sick and in pain.

    But the problem is, there are tons of different circumstances that can lead to similar results– not just that one. You can’t test them all in research. So you choose a few.

    Humans are trial and error creatures– constantly trying what occurs to them to try. And humans are meaning making creatures. Several kids can have what looks like the same experience to a researcher, but the meaning they make out of it is entirely different. There could be as many things people try to do, and as many meanings that can be made out of the results, as there are possible experiences that people could have.

    And if that is not complex enough, consider psychotherapy. Consider the possibility that it might be more an art than a science. Consider that it might be about teaching a person to understand what conscious and subconscious meaning that person has made out of their life experiences– and then teaching the person to heal themselves by applying some method that counteracts a conscious or subconscious misunderstanding.

    And consider that when 3 clinicians do “psychotherapy”, they could not possibly be doing the same thing. Just to start out with, each patient says different things, so the therapist says different things in response.

    One therapist is the Michael Jordan of psychotherapy– really exceptionally good at this. Another is rather dense in social intuition and communication skills– maybe is even somewhere on the high functioning end of the autistic spectrum. Another is great for most patients but the particular one assigned to that therapist, is someone with a huge personality conflict with them. Maybe the therapist looks very much like that person’s ex-spouse, but the patient is too embarrassed to mention it.

    Anyway, if something works to help a good percentage of people, maybe that should be good enough, even if it’s placebo, until we come up with something that works better, for more people. I think determining cures is more important than determining causes, or knowing why the cures work– unless there are other important factors, like bad side effects.

    And I totally agree that wonderful placebos that cure a lot of patients thoroughly and last a long time, are better than ones that work only partially or temporarily or for very short times.

    The thing about placebos is how do you know it’s a placebo? Maybe you just don’t understand how it works. And the thing about psychosomatic illness is how do you know it’s psychosomatic? It’s entirely possible that the medical test to determine what is physically wrong has just not been invented yet.

  32. Nathan Wilson

    “discovered things were much more ambiguous picture than it let on.”

    ‘discovered things were much more ambiguous than’
    ‘discovered a much more ambiguous picture than’
    would make sense.

  33. sabril

    Tinnitus is an interesting case, since pretty much everyone has it to some degree.

    Actually, it seems pretty much impossible to hear total silence; impossible to see total darkness; and impossible to feel nothing at all. e.g. if you walk into a completely dark room during the middle of a moonless night and shut your eyes tight, if you pay careful attention you will still see little flashes, colors, what have you.

    Evidently the subconscious brain does a pretty good job of filtering out most of the nonsense. But with tinnitus, it seems that what happens is “the loop.” i.e. you focus on the noise, find it annoying, and start hearing it more and more. So there does seem to be a psychological component.

    My personal hypothesis is that some people have a similar problem with their internal tactile sense. A small feeling of pressure or pain which most people would not even notice starts looping and becoming very uncomfortable.

    Another interesting fact: Chronic pain is highly correlated with obesity. This might help to explain why chronic pain is increasing as a problem, but one can still ask what the connection is. Possibly the extra adipose tissue puts extra pressure on nerves. But I strongly suspect that much of the problem is psychological, i.e. constant overeating of junk food alters your brain chemistry and makes you more susceptible to uncomfortable sensations looping into chronic pain.

  34. Charlie Davies

    Here’s my vote for the “body/brain pain management is difficult” theory.

    When I was sedentary, and I had a back-pain episode, I’d avoid stressing it. It would hurt cripplingly for a week, and take a good month to fade to merely annoying.

    Now when my back “goes out”, I treat it with light deadlifts. This stops the cramping and agonizing pain immediately. It stops the fear and anxiety and makes me feel like I’m healing and in control.

    I think the intense effort and brief discomfort of deadlifting resets some low-level brain system, changing how the pain signal gets categorized from “bad pain” to “good pain”. This happened the first time I experimented with deadlifts for back pain, against my expectations. It’s not entirely placebo.

    Disclaimer: please don’t try this at home if you don’t have a good coach or have a severe bony problem in your spine. Incorrectly-performed deadlifts can injure you, and loading a bad spondylolisthesis can rip your spinal cord.

    1. Scott Alexander Post author

      Both medical consensus and Unlearn Your Pain recommend using affected areas rather than letting them rest, when possible.

      1. Charlie Davies

        Some people need a “Dumbo’s Feather” to convince them that exercising their hurty bits will make them stronger, rather than breaking them further. I’m sure avoiding all exercise of an injured area greatly slows healing and can lead to persistent pain.

        Maybe giving them a bullshit psychotherapy crisis where they yell at an imaginary parent can be their feather.

        Much of physical therapy is made of Dumbo Feathers. Kinesio tape, for example is pure voodoo, and it’s *really* hard to prove any benefits to static stretching. But if a PT can just convince a client to move again, it works.

  35. Vanvidum

    For reasons that I’m sure are not entirely rational, I find placebo effects to be profoundly irritating–almost as irritating as I find evangelists of the latest incarnation of the divine savior Placebo, whose first sacred rule states; “Blessed are the credulous, for they can be told to be happy”. For that and related reasons, Freudian psychoanalysis and talk therapy more generally has always felt terribly tedious and unhelpful. If all I need to do is unburden myself, a Catholic confessional is theoretically available even if I don’t practice, and they won’t ask about my insurance. Even that though would simply be a rehash of what I already know, and it’d probably be equally effective to find a stuffed animal and carefully talk my way through something if necessary

    The same goes for evangelists of mediation. It’s great that they find benefits to it, but I’m not sure it’d be much different than a habit of regularly walking through the park, or zealously guarding the sanctity of regular nap time.

    1. Scott Alexander Post author

      I hadn’t! Thank you! That really raises my opinion of the technique – I trust Guyenet a lot, and if he finds it plausible there’s got to be something to it.

  36. Bram Cohen

    In my experience as an untrained amateur massaging people in pain, when people are in pain they pretty much always have spasmed muscles in the area in pain, and massaging those directly burns while doing it but causes noticeable short-term pain relief immediately afterwards. Whether the dynamic is primarily stress -> muscle spasms -> pain or pain -> muscle spasms -> stress I don’t know, but muscle spasms can definitely cause pain directly. Unfortunately massage seems to only offer temporary relief most of the time, although I have managed to dramatically improve my wife’s foot pain by doing it a lot over a period of years, so there’s at least one apparent success story.

    There’s also a dynamic back and forth between pain and poor posture. That one is much, much easier to fix at the posture level. The simplest intervention is to always wear polarized sunglasses while driving. Looking at glare overworks the muscles which focus the eyes causing chronic headaches. Note that non-polarized sunglasses don’t work, the eyes just adjust to the overall light levels and still have the glare problem. Polarization makes glare considerably less blinding so it isn’t so bad for your eyes. Eye exercises don’t really help. My experience was that eye exercises made me able to pinpoint what muscles were injured instead of experiencing problems as vague generalized head pain, which was useful for realizing that I really should keep wearing polarized glasses while driving, but didn’t directly help with the injuries at all. This is a very driving specific phenomenon. Human eyes are designed to be able to handle sunlight just fine, but not staring at sunlight bouncing off shiny objects like cars.

    By far the biggest source of postural problems is sitting at a computer. The first thing everybody should do is learn how to touch type. Having to look at the keyboard while typing causes all kinds of problems for one’s neck and eyes, and is just plain slower and less productive. A few days or weeks of practicing only looking at the keyboard when truly stumped as to where a key is and anybody will have it down. The next most common cause of problems is keyboard positioning. The most expedient solution for that is to get a wireless keyboard and trackpad or trackball and a keyboard tray which fits them and keep it in your lap. It also helps to get a laptop stand.

    The most maddening aspect to desk ergonomics is the chair. This is where most of the things you read are outright wrong. The best thing for sitting on is a stool. If you want to get fancy it can have a cushioned seat and height adjustment. It should have no wheels, no swivel and absolutely, positively no back. After a few days of sitting on a stool your body will come to the realization that there’s no back there and stop trying to slouch, resulting in a huge improvement in seating posture.

    There are some direct interventions for people habitually carrying around tension as well, but they’re much more difficult to pull off. Alexander technique teaches a bunch of them. A fairly typical one involves lifting and lowering the subject’s arm. This looks goofy and pointless, but the crucial details are that the subject be told to relax, and the instructor give feedback as to when they’re providing resistance instead of relaxing, and then tell them they’re doing it wrong when the subject inevitably tries to correct by lifting their arm in tandem with what the instructor is doing instead of relaxing. This sort of thing requires quite a bit of expertise on the part of the instructor and motivation and cooperation on the part of the subject, but can sometimes result in dramatic reductions in chronic pain.

    1. John Maxwell

      This site is good for (relatively) evidence-based massage therapy advice:

      “massage seems to only offer temporary relief most of the time” – Most trigger point books include a section on perpetuating factors, which is plausibly the most important part of the book. For me, learning about Morton’s Foot seems to have been useful. I think in a lot of cases, people don’t just have trigger points/spasms in one muscle, they have trigger points in many muscles, with only a few of the trigger points causing serious symptoms. But it often makes sense to treat the trigger points that aren’t causing serious symptoms too, because they are working to perpetuate the troublemakers. Trigger point books often have good information on where the “root cause” of your symptoms may be. (Example: some time ago, I had a very nasty case of chronic eyestrain, which I tried treating using all kinds of eye-directed methods for months to no avail. I found info in trigger point books saying the pec major can pull the clavicle out of alignment, which puts the sternocleidomastoid under a state of constant tension, and the books also say that the sternocleidomastoid can refer pain to the eye. When I focused my massage efforts on the pec major for a while, the sternocleidomastoid became dramatically easier to treat, and my eye pain cleared up–career saved!)

    2. Berna

      “The best thing for sitting on is a stool. If you want to get fancy it can have a cushioned seat and height adjustment. It should have no wheels, no swivel and absolutely, positively no back.”

      Why no wheels and swivel? After taking Alexander classes (which I can’t recommend enough!) I took the armrests and back off my chair, and recently I bought a new chair (which I also took the back off) that doesn’t have wheels, but it does swivel.

      1. Bram Cohen

        Wheels make it move around when it shouldn’t and swivel makes it provide less support than it should. Neither of them are all that bad though, and there’s a fairly good engineering reason for not having swivel: The simplest, most robust, and highest legroom design has a single post in the middle, and if you have that then there will be tremendous torque on the central point and it will tend to break unless it swivels. It is better to bend than to break. I have two stools now, and as it happens both of them swivel, but the one I didn’t just buy has lasted me for the better part of a decade. I’ll take swivel for that kind of robustness. My new one also has pneumatic height adjustment, which is a nice feature which does no harm. There’s a great selection of them on Amazon.

        I too got turned on to removing the backs from chairs by Alexander Technique classes. Once you’re doing that you might as well go for the much cheaper and more versatile seating which was meant to be used that way.

        1. Berna

          Yeah, my stool does have height adjustment too, and I like that about it. And because it was made to be a chair, it has a full-size seat, unlike most stools with a round seat. 🙂

  37. Nancy Lebovitz

    I’ve heard that doctors generally think there is nothing to be done for tinnitus. (Is this actually a true thing about doctors?)

    I get tinnitus sometimes in my right ear. I had a inspiration to try running my attention down the big muscle on the right side of my neck. After doing this a number of times, the tinnitus goes away, usually for weeks or months. A couple of times, I’ve felt that muscle pulling on my eardrum when I turn my head, so I think there’s a physical connection.

    I’ve tried paying attention to see if I can observe the moment when the tinnitus goes away, but this makes the technique not work.

    There seems to be some connection for me between getting tinnitus and worrying about money.

    I have no idea whether this technique would help with tinnitus that was caused by loud noises.

    I tried out this trigger point video for tinnitus, but I didn’t have tinnitus at the time, so that wasn’t tested. It’s a pretty good head massage in any case, and interesting for it’s approach of checking on which muscles are involved. It also had anatomy charts overlaid on the demonstrator’s head, which is a nice touch.

    As for leg cramps, I’ve found that adding postassium to my diet (usually bananas) helps tremendously.

    1. Anonymous

      A couple of times, I’ve felt that muscle pulling on my eardrum when I turn my head, so I think there’s a physical connection

      The tensor tympani muscle? (I’ve had tensor tympani myoclonus, which what you’re describing reminds me of.)

      1. Nancy Lebovitz

        I think it’s the sternocleidomastoid muscle that I work on for tinnitus.

        Maybe the next question is “How closely involved are the sternocleidomastoid and the tensor typanus with each other?”.

    2. moridinamael

      Tinnitus is absolutely a symptom of tight or spasmed neck muscles. Neck tension is definitely caused by stress. This is a loop that I get to witness in myself on a regular basis.

    3. wintermute92

      As far as I know, the “nothing to be done for tinnitus” thing is a pretty narrow claim. If you present with chronic, acquired tinnitus, doctors will tell you “there’s no cure for this, you’re going to have to mitigate and live with it”. This appears to be true.

      Most people with tinnitus have a lot of variance in their symptoms, and I’ve definitely known people with tricks they use to mitigate it (that attention thing works on pain, too, although the duration is usually low). I think doctors are generally warning you that they have no permanent fix or ability to reverse the physical causes of the issue.

  38. Matt H

    Because we grow up with antibiotics and vaccines it’s easy to believe doctors have all the answers. Unfortunately, medicine barely brakes even in terms of helping more than hurting, and so it’s often that doctors just don’t know what the’re talking about.

    These chronic pain conditions seem a good example. The same symptoms can have multiple different causes. When someone says they know the one definitive answer, its almost a dead give-away they are a crackpot. I’m sure psychological causes play a part for some, even many patients, but not all, sometimes the answers is physical, sometimes genetic, viral, bacterial, or something we don’t even know about. This makes any study looking at chronic back pain hard to take seriously, its not a uniform group, If you try to treat based on proposed cause that only actually affects 20% of patients in the group, well then its really hard to untangle placebo effects, from real effects. So treating symptoms is going to work better.

    As someone who had vague health problems that got worse over time, many doctors told me it was in my head. It turned out I had pernicious anemia, I figured it out, from doing extensive research, and made my doctor test me for it. My b12 was 42, normal is over 200. Worse after having a deficit for so long my nerves were damaged and its take a decade for it to mostly heal. But the nerve damage caused me to have some wired sensitivities to things which previously didn’t bother me. It was mostly skincare products that bothered me, doctors again told me i was crazy. I made spreadsheets of ingredients and figured out what bothered me. It was mostly PEG, and related compounds like PEG-1, etc.., they inexplicably made me tired. So I avoided them.

    But that wasn’t enough, I had to know if this was in my head. I had my wife decant 3 types of shampoo into identical unlabeled bottles. One that had no PEG, and two that did, and I found the bottle that didn’t make me tired on the third day. It was the one without PEG. A decade later they don’t bother me nearly as much. So have sympathy for folks with odd symptoms, vague pains, that don’t fit neatly in a box. We may just have not discovered the box yet.

    1. gwern

      But that wasn’t enough, I had to know if this was in my head. I had my wife decant 3 types of shampoo into identical unlabeled bottles. One that had no PEG, and two that did, and I found the bottle that didn’t make me tired on the third day. It was the one without PEG. A decade later they don’t bother me nearly as much.

      You mean that you can now use PEG-containing shampoo without a problem, or that you avoid anything containing PEG and now you don’t feel as tired anymore?

      1. Matt H

        My tolerance for them slowly increased , and now I can use anything I want without much issue. But for the most part when I’m not traveling I still avoid them, at this point I’m kinda used the the soap, shampoo and conditioner I’ve been using.

  39. Mary

    “There is form of psychiatry based around corny puns,”

    Alternatively, the symptoms linking the pain to the problems is the source of the metaphor. If some people really do have stress that keeps them from standing, it is very easily to press the keeping from standing as the vehicle for the tenor of stress to create a metaphor, as well.

    After all, many people say ROFL even though very few of us actually do — but sometimes. . . .

  40. Dan T.

    When you said “Right now, your head is itching”, immediately my butt started itching… shows how contrary I am.

  41. grort

    Could you remind me how twin studies work? Like, in: “On further analysis of monozygotic twins — who are genetically identical — the association between symptoms of depression and low back pain disappeared“, what does that mean?

    Like, if you look at an individual who is depressed, that individual is 1.6 times more likely to have chronic back pain. But, if you look at a pair of twins, then what exactly do you see or not see?

    Is it: “if you look at a pair of twins, in which one twin is depressed and the other is not depressed, neither twin is more likely than the other one to have chronic back pain”?

  42. Reel Mower Man

    In Zen and the Art of Motorcycle Maintenance, the main character (i.e. Pirsig) has a kid who suffers from stomach pain and diarrhea. He explains to his friends that the cause is a mental disorder. There’s no further discussion in the book of this particular instance of the mind-body connection.

  43. K

    Hey does anyone know whether the anxiety or the exaggeratedly interpreted muscle twitch comes first?

    I had this problem for like 2 months where I would get panic attacks because I would get these muscle twitches in my chest and arm area that felt like heart palpitations/fluttering. Online it says this is a common anxiety symptom, but I’m not an anxious person really. So is it the misinterpreted muscle twitch which leads you to this constant anxiety, or is the anxiety which makes you interpret these benign muscle twitches as heart attacks which starts the spiral downwards?

  44. Usually a lurker

    On the other hand, patients’ rights groups get very upset at claims that their conditions are “all in their head”, accuse doctors of thinking that they’re lazy or making up their symptoms, and pass around stories with titles like RE: RE: RE: FWD: RE: THE MEDICAL PROFESSION about some guy whose doctor dismissed him as making up his symptoms but who was later diagnosed with zebra-itis and cured with an experimental gene therapy treatment.

    I’m one of those people who spent years diagnosed as “maybe it’s fibromyalgia…or some nonspecific rheumatoid thing…or depression/anxiety…or…” and it turned out to be indisputably physical.

    Maybe the fact that, among a group of people as small as your readership, at least one them actually fits that description, might mean it’s not as rare as some people think.

    But your readership isn’t an unselected group. Maybe it’s selected for “people who can’t physically do a lot, or else they would be outside doing it, not sitting inside reading a blog” in addition to everything else it’s selected for. Is that enough to explain it, I wonder?

    1. Leo

      If your blood calcium is too high, you get diagnosed as “maybe it’s thyroid problems”, and it turns out to be cancer, I don’t think you’ll be upset at the medical profession. You may be very unhappy because the mistake made you sicker and possibly dying, but you’ll probably agree it was a reasonable mistake.

      If you have chronic pain, get diagnosed as “maybe it’s a psychosomatic disorder”, and it turns out to be purely anatomical, you’ll be angry. Why is that? I can think of three hypotheses.

      0: My premise is actually wrong. Either you’re not all that angry at the chronic pain misdiagnosis, or you’d be angry at the cancer misdiagnosis.

      1: You interpret “it’s probably psychosomatic, we’ll try therapy and psychiatric medication” as dismissive, when you wouldn’t interpret “it’s probably the thyroid, we’ll try surgery” as dismissive, even when equally misguided. This is a problem with you thinking psychiatric disorders are somehow lesser.

      2: The doctors aren’t telling you “we’ll try therapy and psychiatric medication”, they’re telling you “this isn’t that bad, go home and maybe see a therapist but we’re not going to help you find one”. This is a problem with doctors being dicks.

      1. Jiro

        “Maybe it’s a psychosomatic disorder” is a diagnosis that can happen as a result of motivated reasoning when the doctor just doesn’t like the patient or members of the class that includes the patient. It can be a result of motivated reasoning on the doctor’s part, since he wants to tell the patient to go away and he can’t treat psychosomatic disorders to they are an excuse to tell the patient to go away. It can also be a result of doing inadequate testing, since it’s a catchall diagnosis that is given when there is no evidence for something else, and the doctor could be lax in gathering evidence. Either of these situations are plausible because they are safe mistakes for the doctor (unless the patient gets a second opinion.)

        Many physical disorders aren’t like this. If the doctor says it’s thyroid because of motivated reasoning or lack of tests, it isn’t safe for him–he takes the risk that reality will prove him wrong when thyroid treatments fail to work or the cancer kills the patient. So it’s much more likely that any mistakes he does make are unavoidable mistakes, not mistakes caused by motivated reasoning or carelessness.

        And to the extent that physical disorders are default explanations and not disprovable by reality, such physical diagnoses also lead patients to become upset. Note the OP’s references to fibromyalgia and rheumatoid conditions.

          1. Jiro

            But is the causality in that direction?

            If a doctor doesn’t want to deal with a particular patient, then the doctor is more likely to act in ways that will lead the doctor to be unable to treat the patient.

          2. moridinamael

            In my experience, doctors can start out optimistic and interested in helping, and gradually become visibly frustrated (over the course of weeks) as all their attempts to fix the problem fail.

            My uncharitable assumption is often that they suspect that I am faking it because I “should” be getting better.

      2. Earthly Knight

        I think there’s also a presumption that each individual is an expert when it comes to the nature and causes of her mental states, a presumption which can be insulting to challenge. I know damn well that the pain I’m experiencing is physical and not psychological– I can feel it right there in my arm! How could you know better than me, it’s my pain! Etc. Diagnosing pain as psychosomatic unavoidably insinuates that the patient has poor insight into her own mental life.

      3. Tracy W

        I think I’d be equally upset with the medical profession under either scenario. I was misdiagnosed at age 11 in a way that cost me a lot of pain and I refused to ever see that doctor again.

      4. Garrett

        3: The doctors are saying “we’ll try therapy and psychiatric medication” because they believe those have lower costs and fewer side-effects than invasive testing or surgery, and are more likely to help. If therapy and psychiatric medication don’t help they can re-assess.

        My arthritis had the same problem – when it moved into a new joint the dr./insurance company wanted me to try physical therapy for a while before they would authorize an MRI. It turns out it wasn’t a muscle strength problem but actual arthritis creeping in. Retrospectively a waste of time and money, but there wasn’t a good way to tell that in-advance.

        1. Leo

          That does not answer “Why are people angry at misdiagnosis if and only if they’re misdiagnosed with something psychological?”.

          Accepting your change of subject, I’m not sure psychiatric treatments should be tried earlier. They’re cheap, and therapy has few side effects, but medication has plenty of bad side effects, and, more importantly, it’s really hard to notice you should stop.

          Psychiatric treatments very often fail, and the response is to try a different treatment until something sticks. So a string of failures will not make you re-assess.

        2. Jiro

          Psychological misdiagnoses (and generally, catch-all misdiagnoses) are Bayseian evidence for incompetence and motivated reasoning on the part of the doctor.

          Also, psychological misdiagnoses imply that the doctor will not properly consider your further complaints, since he will see them through the lens of “the patient is probably just saying this for psychological reasons”.

      1. Usually a lurker

        A genetic disorder. The kind where there’s a problem with one of your body’s basic building blocks and so many different systems are affected. I don’t want to be more specific than that.

        So a zebra.

        Are there any zebras here whose diagnosis went quickly and easily?

        1. wintermute92

          Yep. Chronic back issues, never linked to a physical source by a General Practitioner.

          Went to an orthopedist, but before they could even look over my scans the x-ray tech went “Wow, I’m not supposed to say anything but this is definitely your problem.” Blatant-but-unconventional spinal issues with a clear skeletal cause.

      2. Anonymous

        I had chronic, diffuse low-level muscle pain for years before stumbling across the idea (on the internet) that it could be a rare side effect of SSRIs. When I stopped taking the SSRI I had been on for nearly a decade, the pain went away.

        (The depression came back, but that too went away after a while, along with 25 pounds.)

      1. Usually a lurker

        See my reply to Scott. BTW HeelBearCub reminded me not everyone will recognize the “When you hear hoofbeats, think of horses not zebras” reference that Scott made and I repeated, so, that’s what the “zebra” stuff was.

        Signs and symptoms…pain in many different places, some body systems behaved in unexpected ways and it was easy for people to believe I was lying or delusional.

        One in particular is actually one of the major diagnostic signs of the disorder, but if you don’t make the connection between how a layperson who’s never heard of the disorder describes the sign and the phrase you memorized in med school, and most doctors didn’t, then there’s no mental box to put it in and it just gets ignored or interpreted as “patient is ‘crazy'”. (It is a sign not a symptom. They didn’t think to check it for themselves.)

        I understand what happened, but making that connection is a doctor’s main job.

        Also lack of treatment eventually led to damage that should have been preventable. It’s frustrating to know this could have been avoided if my doctors had put two and two together. When this happens because you didn’t go to the doctor soon enough, you join a campaign to raise awareness about your disease. When you went in time but multiple doctors made misdiagnoses, then became frustrated and dismissive…what’s the constructive response to that? Mostly I’m just happy to be finally getting treatment but, I think it’s normal to be frustrated at the situation.

  45. Davide

    The sentence ‘Unlearning your pain’ reminded me of something I have wondered about in the past..

    Is it possible that the idea that pain is in some way ‘good’ (or at least not bad overall) makes people more vulnerable to it, rather than making them more motivated in withstanding it?

    Think about western religion justifying God not simply making life painless, idioms such as ‘no pain no gain’, the idea that pain is a necessary part of life without which there would also be no pleasure or personal growth, pain-punishment as part of redemption, the opposition to pain abolitionism (and transhumanism in general, which *might* eliminate many painful things)…

    I’m saying that sometimes parts of society seem to be arguing that there is a moral duty to feel pain and suffer.
    Perhaps not in specific situations – it’s not like they say ‘painkillers are morally wrong’ – but at the existential level I often see pain as something people romanticize.

    There are also beliefs system sometimes associated with pain tolerance – for example buddhism – which, at least in my limited understanding, seem to clearly say that pain and suffering *are* bad.

    This isn’t just about physical pain, by the way. I also see it applied to emotional suffering. The idea of pills to cure lovesickness is quite controversial, for example.

    Is this worth thinking about?
    Are there studies/surveys on pain perception based on society & belief system?

    1. sconn

      When I stopped being Catholic, I started taking ibuprofen for my migraines. I just realized that all this time I’d held off unless I really couldn’t function, without any really good reason to do it. It just seemed like sweating it out would somehow be good for me or make me stronger. When I really thought about it, I realized I was wasting energy I could be spending on actual good deeds by putting up with pointless suffering.

      Now, of course that’s not really changing my pain level or pain perception in a psychological way. I’m simply medicating the pain away. But I wasn’t motivated to do this when I was religious. The Catholic belief is that all suffering can be beneficial, if not for you, for someone else. That can be really helpful when you can’t help suffering and would like to have some purpose to it. But it can be a colossal guilt-trip when you have a choice about whether to suffer or not, and feel like you ought to pick the more painful option.

      1. Davide

        Though it’s about taking drugs rather than (directly) changing your psychology, your example still fits.

        I don’t think I’ve ever seen a Catholic openly speak against painkillers, but it certainly fits with the ‘Suffering brings you closer to God’ point of view some advocate.

        Mother Theresa as described by Hitchens and various critics could be a fitting example, I suppose.

        Having said that, it’s obviously not a mindset that only religious people have – which is why I brought up ‘personal growth’ and ‘no pain no gain’.

  46. Leo

    I used to have psychosomatic pain and intermittent leg paralysis. (And I get stress-induced leg cramps, which I always assumed was common.)

    The pain was not located anywhere in my body. (It simply didn’t have or seem to need any location at all.) It didn’t respond to painkillers but did respond to alcohol. It went away with bupropion.

    The paralysis affected both legs, without warning, for a few minutes to a few hours. I saw a doctor for it but it didn’t happen while in front of a doctor. While not paralysed, I had normal reflexes, balance, etc. An MRI found nothing. It went away with a combination of bupropion and lots and lots of water.

    Is testing the knee-jerk reflex on oneself reliable? It was absent when I tried it while paralysed, which is odd for conversion disorder. (But then conversion disorder isn’t intermittent either.) While not paralysed, I can consciously suppress the reflex if I have something to brace my leg against and tense it up, but can’t otherwise.

    I worry that patients with psychosomatic problems will be simply ignored, rather than given fancy masculine-pose therapy and psychiatric medication. (A worry that is not helped at all by you using “real pain” to mean anatomical pain.)

    I’m also pretty fucking livid at “la belle indifference”. I take pride in overcoming my problems, I accept they’re the current situation instead of self-pitying, I’ll damn well crawl to class because my legs aren’t working, I refuse to be ashamed of it… and that’s supposed to be a symptom? Fuck you.

    1. sconn

      Your experience reminds me of a time when I had trouble breathing. It went on, off and on, for several days, when I would gasp for breath, feel dizzy, my heart would pound — seemingly at random. I went to the doctor and, of course, the symptoms weren’t present in the time I was there. They said “probably stress” and sent me home. The symptoms eventually went away, though they have recurred a couple of times since. I just go lie down and wait till I can breathe right again.

      But, whether it’s in my head or not, I still kinda need to breathe, you know? The average doctor’s response is “if it’s in your head, it’s on you to fix yourself.” That’s not a solution!

      1. caryatis

        > The average doctor’s response is “if it’s in your head, it’s on you to fix yourself.” That’s not a solution!

        I think this is part of why patients are so resistant to being given a diagnosis of psychosomatic illness. It doesn’t really give you a game plan or hope for a symptom-free future. Knowing the symptom is psychosomatic doesn’t make it go away.

        1. Leo

          It does too give you a game plan! Try therapy. If you got anything diagnosable try to treat that, with specialised therapy or with medication. Try the usual combinations of sleep, exercise, diet, sunlight, friends, hobbies, relaxation techniques, meditation/prayer. Try the usual semiplaceboish supplements like vitamins C and D, fish oil.

          1. caryatis

            I meant that doctors too often don’t give the patient a game plan. Anyway, thank you, I will keep your advice in mind if I have a recurrence of psychosomatic symptoms.

    2. Scott Alexander Post author

      I’m no expert, but I think you can knee-jerk yourself. Probably the best test would be to see if you can do it when you’re not having a conversion episode. If it works then, but doesn’t work when you are having an episode, that’s odd and I don’t know what to tell you.

      I’ve removed the one reference to “real pain”.

      I think I understand la belle indifference to mean something more striking than you do. For example, read this description by a psychiatrist (with bonus complaint about the mainstream media at the end). I think that’s a level above just being able to stoically deal with pain.

      1. Ninmesara

        I wonder if anxiety during a crisis might suppress the reflexes, or at least make ot harder for a potentially untrained person to hit the tendon? I’ve had patients with hard to detect reflexes unless I actively distracted them or used the Jendrassik maneuver, which you can’t use if you’re testing reflexes on yourself.

      2. Leo

        Yeah, I tested between episodes at the time and it was present, so I guess I’m just odd.

        That lady sounds a lot like me that the time. I was worried and a little upset at the beginning, but soon I started shrugging it off, and either crawling places or sitting and reading until it went away, airily dismissing anyone who asked me if I was fine.

        It was in part aggressive disability pride (I read a lot of Tumblr back then) and it part finding genuinely hard to get worked up over a problem far less bad than the depression that caused it. This might actually be an explanation: wanting people to think “Wow, this guy is upset over depression even though he’s not upset over his legs randomly giving out, his depression must be really bad”.

  47. Garrett

    I have psoriatic arthritis. Untreated, it has significant physical signs. It’s also painful. Fortunately, NSAIDs deal with most of the pain. (ESR is basically 0, pain persists. Could be evidence for psychosomatic pain, could be evidence for ESR being insufficiently sensitive).

    I’ve noticed that many of the body systems tend to act in a differential-signally fashion. Eg. sympathetic/parasympathetic nervous systems. I suspect that pain and not-pain act in a similar fashion, and if the pain level increases above not-pain, we become aware of this and sense it as pain. Not-pain can be chemically activated with opioids, for example. The human consciousness has imperfect control over some of these. For example, imagining yourself surrounded by puppies can increase your not-pain levels to the point that pain is no longer bothering you, at least temporarily. But that requires you to be able to put yourself into that mental space continually or on-demand. Likewise, having a boss making impossible demands of you makes it much harder to create that wonderful not-pain headspace, so pain can come to the forefront.

    This would explain why some people can be “cured” of chronic pain through therapy. If some aspect of your past is continually at the forefront of your mind “harshing your mellow”, non-pain isn’t as high as it might otherwise be. Addressing those issues can help. (Also, this may explain why marijuana is claimed to be helpful for chronic pain).

    Yes, I’m modelling the pain experience as a 741 Op-amp.

    1. J

      Dr. Garrett changed my life! I used to be a humble bus driver, laying awake at night worrying that Eli the ice man was coming for me, and I’d go rail to rail at the slightest provocation. But he taught me to give myself enough phase margin to be stable, and helped me gain the capacity to bypass the noise that was causing harmful feedback loops. He’s great with power supplies too.

  48. Becky H.

    It’s good to see the entire suite of mid-century modern psychiatry is taking a stab at chronic pain. Previously Elavil was holding the fort on its own, so it’s nice to see some of the non-drug therapies of the era helping out.

  49. Arnold Layne

    Thanks for the nice review. This is a tough topic. I’m a radiologist, and wanted to comment on the issue of back pain and TMJ/facial nerve neuralgia.

    Back pain: Some radiologists are adamant that we rename “degenerative changes” to “age-related changes” to stress the fact that these often are age-approproate and aren’t necessarily causing pain. The following anecdote is an extreme example of the importance of reporting:

    I had a patient during residency run into me in the hallway and ask me to look at her radiology report because “every time I come in I get a new osteophyte but the reports keep saying everything is stable.” She was homeless, and would be brought in after being found passed out on the sidewalk. On each admission, she’d be treated as a potential trauma and get a head and neck CT. On each study, the diligent overnight resident, finding nothing acute to comment on, would describe one new osteophyte that had not been commented on previously. The effect was that the medical record showed that each pass-out session resulted in more “degenerative changes.”

    Regarding TMJ/facial nerve neuralgia: During residency again (I didn’t subsequently specialize in neuroradiology) we’d do all these really high-res MRI scans of the cranial nerves trying to figure out if a vessel was touching the nerve somewhere along its course. These were extremely unsatisfying studies, because even though we’d get very nice images, if we didn’t have the clinical info on which side was the painful side, it would always end up being a 50-50 decision on which side was abnromal (to my eyes at least).

    The same with TMJ, we see a lot of horrible TMJs incidentally on PET/CTs and C-spine CTs and MRIs in patients who are asymptomatic. Then we’d look at MRIs done speficially for patients with TMJ pain, looking for abnormalities that would often be very subtle.

    Anecdotally, I don’t know any patient with TMJ pain/facial nerve neuralgia who is not a little bit off. I don’t want to be disparaging here, but I don’t know how else to describe it (kind of like when you say FLK in the neonatal unit when you don’t know why a newborn is a little bit off-looking, until the geneticists come and do their magic). Now, whether being “off” is causing them to focus on and magnify the pain, or the fact that they have been living years with intractable TMJ/facial nerve pain has caused them to become “off” is not known to me.

        1. Leo

          Funny-lookin’ kid. It’s one of those acronyms you use to say unflattering things in front of patients.

  50. Luis Pedro Coelho

    “When you control for genetics, WHICH YOU SHOULD ALWAYS DO AND I AM SO SERIOUS ABOUT THIS, there is no link between psychological problems and back pain.”

    Mmmm… If genes cause depression and depression causes back pain in a gene mediated way, then controlling for genes will make the depression/back pain link disappear, but it’s still the case that there is a link between depression and back pain.

      1. Trey

        Is there any chance you can post any sources about mainstream psychiatry moving away from childhood trauma theories? Has this become the majority opinion among psychiatrists but not yet trickled down to rest of the population yet?

  51. onyomi

    Re. OCD, the proposed mechanism reminds me a lot of OCD, of which I’m pretty sure I have a mildish case. This manifested in childhood in more obvious ways like obsessively checking ten times to make sure the door was locked every night (we lived in a high-crime city! it was a legit concern!), but later transitioned into less obvious things like an obsession with food safety (you don’t want to get botulism, do you?).

    The pattern is that once I recognize I’m being obsessive, the fixation tends to go away. It’s almost like there’s a part of my brain which really wants to be obsessed with something, but only legit things; once I figure out it’s obsessing it has to move on to another target. Me realizing this dynamic of shifting obsession has allowed me to get faster at noticing new ones, which helps somewhat, but I can easily see this applying to pain as well, and my mother definitely has a lot of mysterious chronic pain of the IBS/fibro-type stuff. She’s had legit injuries at various points, but is also a very high-stress individual, and I can easily see these being places where she is now just permanently tense as a way of expressing that. I don’t think it needs to be childhood trauma, though; she’s stressed out about events in her life, among them but not limited to her chronic pain, right now.

      1. Mark Z.

        We were young and impressionable and our grandmothers spoke the monster’s name with dread, and then knocked on wood. This is traditionally how one learns about the Devil.

      2. Soumynona

        Me too! But to be fair, the description of the botulinum toxin sounds like a plot for a horror movie. It’s not obsession when the bacteria are really out to get you.

        1. Vanvidum

          Let’s be fair, clostridium botulinum bacteria were simply minding their own business before you decided to disrupt their habitat and eat it. They’re more like the tiniest of Lovecraftian cosmic horrors: They are utterly ignorant of the harm they inflict, and are too alien to understand it.

          We’re just a bigger cosmic horror that fails to appreciate or care about the regular ecocide we casually inflict on microbial communities that normally pass deep beneath our notice.

        2. onyomi

          It definitely does; though, interestingly enough, now that I think of it, botulinum toxin has actually been used to treat chronic pain of the “I can’t stop tensing my neck muscles” variety. It’s better known for the cosmetic use–freezing the muscles in your forehead so you can’t furrow your brow–but because of its ability to induce flaccid paralysis, you can actually inject it into any muscle which is problematically tensing way too much, apparently.

  52. Ninmesara

    Dr. Schubiner is a psychosomatic complaint maximalist. He thinks that just about anything that can’t be traced to a well-understood physiological cause is probably psychosomatic

    My problems with this theory started with this sentence (which might be a simplification that misrepresents the theory). It takes a lot of arrogance to attribute anything that can’t be explained by physiological causes according to current knowledge to “psychological causes”. Unless, of course, you define psychosomatic as something so broad that it loses all meaning (I don’t consider a failure in sensory gating, flr example, as something you can call “psychosomatic”)

    1. Cord Shirt

      I agree. There are plenty of conditions we didn’t used to know existed. We don’t suddenly know everything about all physical illness today.

      I have no objection to giving psychological treatment a try, but going so far as to assume that anything we don’t *already* know is physical is *definitely* psychosomatic…that’s just a bit too much jumping to conclusions for me.

  53. Lambert

    Is the state of neurology such that we can use fMRI or whatever to trace the path of the pain signal through the spine and the brain? If so, one could locate where psychosomatic pain actually originates and is mediated by placebos (placebarum?) ? Or am I thinking about neurology as if it were electrical engineering?

    1. Ninmesara

      I’ve never studied this, and this is what I’ve got from informal conversations with grad students working on fMRI and related techniques. You can use fMRI to monitor areas of brain activity but as far as I know not the “flow along the paths”. fMRI is also quote crude and has low temporal resolution, because most of the time is measures not the neural activity per se, but the effects of neural activity on blood flow, and achanges in blood flow take much longer than changes in neural activity. if you could plant electrodes wherever you wanted you could probably approach neurology as something more akin to electrical engineering, but that’s hard to do without damaging the brain, and it would be hard to find the right spacial resolution for the electrodes: too high and you get the activity of single neurons which are quite noisy, too low and you lose differences between nearby neurons – just imagine trying to piece together the inner workings of a multi CPU supercomputer with a thick nail as the tip of your voltammeter. You can extract some information out of the cables, but you’d probably have to treat the chips as blackboxes. People implant electrodes in mice all the time, though, and there are some neat results.

    2. Garrett

      If it’s distal pain (esp. extremity pain), external electrodes should be able to pick up the nerve impulses being generated.

  54. Lancelot Gobbo

    You might also like “From Paralysis to Fatigue” by Edward Shorter. It’s thesis is that society and the medical profession between them shape the ways in which psychosomatic disorders present, and it’s plain that something does as there are clear fashions in in the presenting symptoms. Some of this is the equivalent of ‘the god of the gaps’ in that such diseases have to live in the interstices of our diagnostic capabilities. Even today, the best resolution MRI cannot tell us if a back is painful or not. Plus, it has become more acceptable to present issues in a more honest way as the psychological matters that they actually are.

  55. suntzuanime

    Is there any way we could use the conversion disorder effect for good? Like invent a disease that makes you friendly and all-around content with your life that’s hard to physically diagnose, and wait for anxious and highly-stressed people to get it?

    1. Jugemu Chousuke

      If this already existed it might not be noticed, since it wouldn’t seem like a problem.

      1. Loquat

        There’s a woman in my area who does both Reiki and Reflexology, and also is a Certified Angel Intuitive, which seems to be sort of an overtly-Christian version of a psychic. As far as I can tell there’s little to no overlap between those three techniques, but maybe that’s deliberate – if poking pressure points on your feet didn’t help your chronic pain, try getting spiritually healed by angels!

    1. Corey

      The same effect works on kids today with “kiss it and make it better”. My 7yo knows all about the placebo effect and it still works on him (placebomancy can still work even when the patient knows it’s placebo).

  56. Julie K

    Maybe we should give more status to the best placebo therapies, to view them as highly perfected works of the placebomantic arts in the same way that powerful medications are triumphs of psychopharmacology.

    When you put it that way, it sort of makes sense for Obamacare to subsidize alternative medicine.

      1. Julie K

        And I suppose it would be a bad thing to try to explain to someone that homeopathy shouldn’t work. (Though they probably won’t believe you.)

        1. jimmy

          Of course it would be bad. To the extent that placebos can help, it’d also be *wrong*.

          Placebos can help so homeopathy can help. That it helps through different mechanism doesn’t make it not help. Heck, you can still be honest about it being a placebo and it’ll still work.

          1. Jiro

            This seems to be another case of utilitarianism not handling blissful ignorance.

            Someone may value knowing the truth enough that they would be willing to be unable to resist some level of pain for it.

          2. Bugmaster

            I don’t know… it might be prohibitively difficult to strike a proper balance.

            If you use too much evidence-based reasoning and are too good at convincing people, then you prevent homeopathy from working, and increase the total amount of suffering in the world. That’s bad.

            But if you dial back the reality too far, people will start using homeopathy to cure cancer and broken bones and such. This might make them feel better in the short term, but kill or cripple them in the long term. That’s also bad.

            So, the trick is to get homeopathy juuuuust right… but how do you do that ?

          3. jimmy

            Well, you don’t say “homeopathy is super powerful! It could probably even cure cancer!”, for one.

            Look at it this way: If we stopped doing placebo controlled trials and just looked at what interventions helped *compared to nothing*, then you’d probably find that things like homeopathy work decently for pain sometimes but less well for cancer. If you’re looking to treat pain, then you just look at how well it works – and how well your options work. If you’re looking to treat cancer, same. If, for example, vicodin is actually more than just placebo but a more powerful placebo of some sort does just as well for pain… then what’s it matter? Pick based on which one is more effective/cheap/free of side effects, etc. You don’t *need* to explain the mechanism to honestly explain that it works (and get “placebo effect”)

            Of course, knowing the mechanism does tell you some very very interesting things, so you can do even better with that information if you’re not stupid about it. If your conclusion from “it works if I expect it to work” is to expect it to not work, then you’re dumb and you’re better off without the extra information. Don’t do that.

            However, if your conclusion is “therefore it’ll work”, then when you realize that there aren’t even any active ingredients, then you don’t have to go purchase sugar pills or magnetic bracelets anymore and you can just flip the mental switch directly.

          4. Tom

            Jimmy, do you think that what you describe in your last paragraph could actually work? It’s appealing, in a futuristic way, but I can’t recall ever seeing something similar in real life. Namely cutting to the chase and getting the benefits of the placebo without the placebo itself.

  57. JoyCS

    “General factor of neural messed-up-ness” seems to describe mental illness well. Indeed everything is comorbid with everything. From talking to the patients, their doctors just pick a few random diagnosis names from the heap. DID? BPD? BD? Any D goes. And childhood abuse, physical, sexual or emotional, tends to lead to a lot of “neural messed-up-ness” that is treatment-resistant.

    Re pain: acute pain can be mitigated by hypnosis and self-hypnosis, and that is what Schubiner is apparently doing, if you look into the linked “illustrative cases”. I have done that to some people myself. I have not tried suppressing the deep tendon reflexes with suggestions only, though. My guess is that it won’t work, as hypnosis only works on the conscious perception, not on automatic or reflexive responses.

    Certainly immobilizing or taking control of someone’s extremity with just hypnosis is a piece of cake, so the conversion disorder is probably just a version of unintentional self-hypnosis.

    The much neglected by modern doctors good bedside manners also make the patients instantly better, using basically the same mechanism as hypnosis.

  58. Anon

    All I can say that several times (under 10) thinking that I have some serious disease (yeah I’m hypochondriac), I have become extremely nauseous. Sometimes I even get a panic attack. One of these instances. I Thought I had suffered a brain stroke. Very soon I felt so ill and nauseous, that I had to go to toilet to throw water into my face.

  59. J

    Sarno’s “Healing Back Pain” sounds a lot like Schubiner’s approach: broad claims about all manner of illness being psychological, and tons of placebomancy. But I watched two people in my immediate family read it and go from chronically disabled (like, couldn’t walk more than a few yards due to pain) to healthy normal abilities. So I’m not going to argue with results.

    1. Arnold Layne

      That’s how I feel too. I have a family member who was having a lot of stress that manifested as hives all over the body. She started doing “yoga” (we later found out it was Dahn yoga, which is basically a cult), and started feeling better. It’s been very hard for the people who care about her to tell her she’s in a cult, because the results have been so dramatic. So, we’re just keeping an eye on her to make sure she’s not spending too much money (more than she’d be spending on allergists/immunologists and medicine) on extra classes and seminars, and glad that things are better. It’s very tough. The rational side of you wants to scream “you’re in a cult, get out while you still can!” But, the results are hard to argue with.

      1. caryatis

        That’s interesting. What makes it a cult? A brief glance at Wikipedia tells me they have some theories about chi that sound like bullshit, but so does basically every yoga teacher.

        1. Loquat

          Seems part cult, part multi-level-marketing scheme – apparently new members are often encouraged to consider becoming masters and opening their own studios, and there’s a fair bit of pressure to spend hundreds or thousands of dollars on more advanced classes, especially if you decide becoming a master sounds like a good idea. If you’re able to resist that, though, it seems totally doable to just treat it like a regular yoga class.

          1. caryatis

            Thank you. Teacher training and workshops are the big moneymakers for lots of yoga studios. I’ve never done Dahn Yoga, but I would say it’s normal for yoga people (who are generally rich urbanites) to spend hundreds or thousands of dollars to, say, fly to Costa Rica and do a workshop. So I agree it’s unethical to put too much pressure on students to buy this stuff or to open studios, but I’m not seeing “cult.”

            Perhaps I’m being pedantic.

  60. Douglas Knight

    Is it really so far outside the mainstream to posit that anorexia is “psychological”?

      1. Nasitrap

        My deep dark secret is that I’m a high-functioning anorexic. I’m somewhat convinced my mother is as well, and possibly my sister. That makes me think genetics play a larger role than people might assume.

        Re: my own experience, I don’t really buy the “pressure from the media” explanation of conventional wisdom. (The introduction-of-television-to-Fiji study is pretty weak if you look into it)

        I’m intrigued by microbiome / anorexia research, and the potential there for shared environment to play a role instead of genetics.

        1. Douglas Knight

          Yes, if microbiomes drive it, then it is not “all in your head,” but I’d still call it “psychological.”

          Microbiomes might be easily manipulable, but that doesn’t mean that they will show up as shared environment. Microbiomes may well be driven by genetics, both the genetics of your gut and the genetics of your food choice. Of course the onset of anorexia is early, when parents do play a role in food choice. But you sound like that no longer applies.

          Of what are you a nasitrap?

          1. Nasitrap

            Onset must have been early; I’ve been aware of it as long as I can remember. I did have a major trauma in early childhood – I was badly injured and could have died in a car accident. (Neither my mother nor my sister were present, FWIW)

            I’m not sure I’m a nasitrap of anything. Maybe closet aixerona. Or closet SONDE, more likely.

  61. Richard

    – whiplash is caused by yanking the neck backwards, not forwards which is why cars come with headrests.

    – Not sure if relevant, but my local GP tends to add on a prescription of slow-release melatonin to just about all pain prescriptions because “All pain is exacerbated by lack of sleep and everybody is sleep deprived these days.” He claims good results with chronic pain.

  62. Titanium Dragon

    Well, one question worth asking is whether or not chronic pain is going up. Given we lead less physically strenuous lives today than we did in the past, if chronic pain is more common today than it was historically, it would indicate either:

    1) It is psychosomatic.

    2) Lack of physical activity increases the risk of chronic pain (do athletes suffer from chronic pain at the same rate as general society?).

    3) Some other factor (obesity?) is to blame.

    If chronic pain is equally or less common, then it is less likely to be predominantly psychosomatic.

    1. Scott Alexander Post author

      All psychiatric disorders appear to be going up, but it’s really hard to tell if it’s just better diagnosis / more willingness to admit to them. My guess is that pain is actually going up and it has something to do with diet, but that’s just a shot in the dark at this point.

      1. Anonymous

        Do you know what I blame this on the breakdown of? Society.

        The break down of hierarchy and tradition have accelerated massively in the last 30 years. Of course people are going to be out of sorts.

        Why does Schubiner even jump from “pain seems to originate in the the inaccessible parts of our mind” to “therefore it is caused by childhood trauma”? How about – “pain that seems to originate in the non-consciously accessible parts of the mind is the mind sounding an alarm that your current life isn’t right” – rather than that something that happened to you as a 5 year old is still important.

        1. onyomi

          “Do you know what I blame this on the breakdown of? Society.”

          I love the grammar of this statement.

          1. Forge the Sky


            I would have written it as “Do you know what I blame this on? Societal breakdown.”

            But it does work either way.

        2. Nancy Lebovitz

          Alternatively, it’s not the breakdown of hierarchy and tradition, it’s that people are more isolated. Or do you count that as part of the breakdown of hierarchy and tradition?

      2. George Dawson, MD, DFAPA

        For psychiatric disorders and pain – a lot of it is iatrogenic. The medical treatments worsen the situation. Some common examples – chronic daily headaches due to analgesic/triptan overuse, worsening chronic back pain due to opioid induced hyperalgesia, worsening chronic pain due to an associated addiction, worsening anxiety due to chronic benzodiazepine overuse, etc. has a slide somehwere that shows American self report of pain has been constant over time but the use of opiids has escalated. In that scenario I would expect to see more depression, anxiety, and insomnia.

        1. Scott Alexander Post author

          I’ve been reading some of your articles on benzodiazepines recently. My attending says (with the admission that he is in the minority on this) that benzodiazepines rarely create tolerance and usually are an effective and well-tolerated long-term treatment for anxiety disorders. He referred me to five studies that showed that, and says he hasn’t found any studies that show the opposite (eg patients generally need large dose escalations for anxiety or claim they stop working). My quick review of the literature seemed to confirm his impression.

          Can you point me to the literature on the long-term negative effects of benzos for anxiety?

          1. Wilj

            Anecdatum: my psychiatrist says the same thing and had me on alprazolam, then clonazepam, for five years. It worked very well and I had no problems. I’m now off both, and still much less anxious.

            This experience has turned me into something of a believer with benzos. (Although — part of it may be that I was careful to take little ~1-3 day “breaks” each ~month due to worry about dependence. Still, this appears to be the consensus among other patients I’ve talked to too, for the very little it’s worth.)

            (Of course, you also always do get the sort who claim psychiatrists ruined their life with ANY drug: “I was on that buspirone shit from some quack, and it MESSED ME UP until a REAL doctor gave me something called Buspar instead!”)

          2. walpolo

            Do benzodiazepines have the same association with mortality as nonbenzodiazepine sleeping pills? I’ve always heard that taking Ambien every night is a very reliable way to increase your chances of dying. Does the same go for benzos? They’re pretty closely related, right?

          3. George Dawson, MD, DFAPA

            The issue of dose escalation with is a complex problem that has not been adequately studied and at this point I doubt that it will. As a result the prevailing clinical opinions are basically political ones – the liberals claiming they are benign drugs that can be given chronically and the conservatives suggesting they are less than benign and present a significant addiction potential. I think that there are a number of sources that suggest why caution is necessary, even against the backdrop of recent literature suggesting that groups using this drugs chronically have higher mortality rates and cognitive impairment.

            The epidemiology (73,75,77,81,82,84) suggests 1-3% of various populations are taking the medications chronically. Very few studies look at the issue of addiction in this population, but a study that did finds it to be significant. There are parallels here with the opioid literature that for decades suggested that pain patients did not escalate the dose of opioids or demonstrate addictive behaviors. Now we know that those largely survey based studies had unrealistically low rates of addiction. The low addiction rate argument was one of the basic arguments used to liberalize opioid prescribing at the turn of the century. Another epidemiological fact is that the majority of users are short term (less than one month) with 7.4 – 17.6% of the population taking them at least once during the year for medical indications.

            Another interesting way to follow the progression of thought on this is to look at what happens to an expert consensus treatment algorithm for panic disorder in a standard text. I have all 5 editions of Principles and Practice of Psychopharmacotherapy –copyright dates 1993 to 2011. When I look at their treatment algorithm for panic disorder there have been some striking changes. The first step psychotherapeutic measures are almost universally ignored – certainly in primary care. The second tier or moderate level is now SSRI + behavior therapy and of course the behavior therapy is almost universally ignored. At the severe level alprazolam XR/clonazepam plus CBT for the first month is recommended. In the previous algorithm indefinite alprazolam was a possibility. In the current algorithm it is not but the wording is definitely more vague. The other algorithms for acute and chronic anxiety suggest more limited use of benzodiazepines.

            Considering the problem of a patient who present for treatment of anxiety or panic illustrates where the problem lies. As opposed to some animal models, we don’t know how to accurately predict if that person is susceptible to addiction and most physicians never ask about their subjective response to the medication. Certainly no primary care physician that I ever met asked their patient if they had an intense euphorigenic effect to the medication after taking the first tablet or they noted other reinforcing factors. The NSDUH survey (p 94) tells us that the vast majority of people with a substance use problem don’t think they need help. Although these folks were not asked if they disclosed their substance use problems to physicians it is likely that they did not. The literature shows that chronic pain patients, methadone maintenance patients, alcoholics, know sedative hypnotic addicts, and other groups like patients with schizophrenia have much poorer outcomes if they take benzodiazepines.

            Despite all of these factors, it is possible that people can take benzodiazepines long term and not suffer any ill effects. There will be a selection effect on that cohort over time because at some point the effects of addiction and excess mortality from a number of factors are taken out. That would allow me to say that if I was seeing a 70 year old woman who was on 2.5 mg of diazepam for 20 years who was stable with no cognitive or neurological effects – I would not be compelled to do anything – even if she had a remote history of alcoholism. It is a much different story on the front end if I am seeing that same woman at age 25, she has active alcoholism, and she is telling me that alprazolam is the only thing that works for her panic attacks, anxiety, and sleep. I don’t know how many men or women with that profile will make it to an old age taking benzodiazepines – but having seen thousands of people in each category – my guess is that they are very few.

            That said – the politics is such that many clinicians insist that there is nothing wrong with prescribing benzodiazepines to addicts and alcoholics. Many of these physicians are well intentioned and believe it is their job to do whatever they can to help the patient. Helping patients with addictive drugs always comes down to a complex probability statement and I think it most helpful for the patient if you come down on the right side of that probability.

          4. Scott Alexander Post author

            @George Dawnson MD DFAPA – Thanks. I might post a fleshed-out summary of my attending’s position here sometime, and I’ll be interested to hear your thoughts on it when I do.

        2. Nancy Lebovitz

          I think there’s also a problem with doctors who tell patients that their problem is hopeless. Some people find it very easy to believe that.

          I realize there are problems on both sides– sometimes doctors and/or patients give up too easily, sometimes a huge amount of effort, money, and pain are spent on attempted cures that don’t work.

          1. George Dawson, MD, DFAPA

            In the case of an unclear or undiagnosable problem – I agree completely. If a doctor tells you that your have an MBS as defined above and that it is hopeless – you should get a second opinion. I would also recall that in some studies looking at the issue of unexplained medical symptoms 30-50% of people do not have an adequate explanation for their symptoms even after significant amounts of testing.

            Equally problematic are the people selling fraudulent treatments for some of these problems.

  63. George Dawson, MD, DFAPA

    I have found that the patients I have treated with the best recovery from various “Mind-Body Syndromes” had to learn an alternate theory of what happened to them. Much of the work in psychotherapy was presenting the alternate theory and convincing them that this was possible. I think people get sidetracked with the approach: “Well you have no seizure activity on EEG when you exhibit these behaviors therefore this is not a seizure disorder, I have nothing else to offer you, and I’m sending you to a psychiatrist.” In many cases, the medical treatment (anticonvulsants, etc) continue despite the patient being told that they do not have seizures.

    The issue of childhood trauma is always problematic because of the various forms and high prevalence. I do agree completely that psychoanalytic interpretations of what the conversions symptoms might be in terms of childhood – fall flat. Any interpretive work needs to immediately accessible and obvious. I see a large number of people who have dropped out of therapy that was essentially an endless exploration of their childhood relationships with no connection to the current problems.

    In many cases the core problem is anxiety and a longstanding anxious temperament. Many of the conversion symptoms serve to confirm that core level of anxiety. In many cases the anxiety was an artifact of an addiction caused by treatment efforts.

    1. Scott Alexander Post author

      By “learn an alternate theory of what happened to them”, do you mean just something like “this is psychosomatic”, or something more complicated? If the latter, can you give an example?

      1. George Dawson, MD, DFAPA

        Sure – the commonest example I can think of the benzodiazepine addicts. By the time I see them they are almost all universally ill with some type of Mind Body Syndrome. They have the MBS and a belief they are significantly ill and disabled as well. Many have pre-existing anxious temperaments and social anxiety. They are lying awake at night focused on the physical symptoms, degree of disability, and what that implies for the future. They have frequently seen numerous physicians who tell them there is nothing medically wrong which of course is not reassuring.

        My job is to reconstruct what happened to them and put the story together so it all makes sense. It is not that difficult to do since most people can recall what their anxiety was like in middle school and high school and realize what is currently happening (increased anxiety and a focus on pain, Lyme disease, fibromyalgia, etc.) was not there. I go back and reconstruct the very first time they encountered those thoughts and how they developed.

        It is more of an explanation of how they got psychosomatic rather than a proclamation that they are psychosomatic. That reconstruction allows for altering the process and getting out of it. At some level this is a more elaborate CBT technique, but I learned it as supportive psychotherapy when treating patients with acute conversion symptoms who were admitted to inpatient psychiatric units. Just from an empathy perspective, if you follow this game plan – the patient appreciates that you have a complete understanding of what has happened to them and that makes you more believable.

          1. George Dawson, MD, DFAPA

            No specific name. Could be called CBT or supportive psychotherapy. I was at a movement disorders conference where there was a discussion of psychogenic movement disorders and the neurologists said they referred to a psychodynamic psychiatrist. Like a lot of things in medicine, you want to see the person who can successfully treat the problem and has a track record. It is fair game to ask that person if they have treated the problem successfully – either on the phone setting up the appointment or in the first session.

    2. Shion Arita

      This is a little OT but the fact that anxiety was brought up made me think of this again and I really want to ask:

      I hear a lot about anxiety and high anxiety disorders seem to be really common in people. But what about the opposite thing? Has anyone heard of a psychological issue where people are incapable of experiencing anxiety? I’m pretty sure I’m like that. I figured it out when I read this one (, and realized that when people say they’re anxious I don’t really know what they mean. As a kid I just thought it meant they were waiting for something. I’m still not quite sure what it means, but I think I have gained some sense.

      I don’t think this really causes me any major harm, but it does cause some friction in interpersonal relationships, baiting a lot of comments like “Don’t you CARE about XYZ?!???” which pisses me off because I usually do ‘care’, but just don’t experience it in the same way as they do, and it’s pretty much impossible to motivate me with either a carrot dangled in front or a whip behind, which I think ends up being good in some ways and bad in some ways.

      I’ve looked online for other examples of this and haven’t found any, so I’m curious to see if anyone knows anything about it or shares my experience.

      1. Jugemu Chousuke

        Do you ever feel fear (eg when something dangerous happens)? I think anxiety is a kind of chronic low-level fear.

        1. Shion Arita

          Yeah, I feel fear. but only at a definite stimulus, not in a chronic low-level way like that.

          1. Shion Arita

            Leading up to it? No, never. During? Well I’ve felt nervous during auditions but tests, no. Even when I knew I was doing badly.

            It pissed everyone off that no matter what they did they never could get me to take notes or study. I did alright in school and got where I wanted to with it, but my practices did lead to some grades that were… not the very best haha.

      2. Bram Cohen

        I’m similar but I don’t think it’s classified as a syndrome. Oddly I still sometimes get the physiological effects of stress. There have been times when it would have made sense for me to be stressed out where I looked at my hands and wondered why they were shaking. But I’ve also gotten the thing where people wondered what was wrong with me when I didn’t panic about something which would cause most people to panic. That one has the contrapositive problem as well, where I have trouble knowing how to be supportive when someone is freaking out.

        Like you, my whole rewards system seems to be broken. Maybe this doesn’t apply to you, but even my reaction to MDMA and cocaine is extremely muted. I suspect this fuels my obsession with puzzles, which seems to hit a reward pathway other than simple pavlovian positive feedback.

        Pros: Low stress/anxiety and lowered associated health issues. Very little fight or flight behaviors (which are extremely inappropriate in the modern workplace!) in response to stress. Apparently extremely low risk of getting addicted to drugs. Extremely hard to discourage, resulting in very high grit.

        Cons: Sometimes poor judgement about things involving personal safety and self-interest. Sometimes don’t give up when it’s better to do so. Difficulty empathizing with others’s distress. Nothing ever feels very good.

        Of these the pros are all extremely good things, to the point where most people are envious when I describe it to them. The cons are mostly minor problems not even coming close to the level of pathology and which can be compensated for with some common sense and judgement. It would be nice if there was an effective treatment for my sensory issues though. Those suck, and I hope you don’t have a similar problem.

        The reaction of most doctors to this all seems to be ‘sounds like a good problem to have’. It isn’t a known syndrome because it isn’t a real problem.

        1. Shion Arita

          Your experience does sound very similar to mine. Great to see someone I can relate to in this way. I figured this would be a place that would have a decent chance.

          I agree that it’s mostly a positive thing, but the negatives are problematic enough that I think it’s worth trying to do something about. I think they would be pathological if I had a low IQ, but like you say I can compensate since I don’t.

          It’s possible for me to get stressed out, but harder than it seems to be for many others. And the results of it tend to be me getting bummed out or annoyed rather than anything like fear.

          I’ve never taken things like cocaine or MDMA, but I think I would probably have a diminished response as well. I can say that I’ve never been able to detect caffiene having any effect on me whatsoever. I never connected that to the anxiety thing though. That’s an interesting thought. In addition, I don’t have an addictive personality in general.

          I wouldn’t say I have poor judgment about personal safety but I do think it’s true for self-interest. And I do have a hard time helping people who are freaking out. I feel bad for them and want to help but I don’t really know what to do because I don’t really have much of a point of comparison.

          Like puzzles for you, the thing that tends to hit the pathway for me is looking at art (I’m obsessed with drawing and animation) or staring at objects in the environment.

          Not sure what you mean by the sensory issues, but I don’t think I have any.

      3. Forge the Sky

        I don’t have this but I’ve had some interesting experiences with anxiety that gives me some perspective.

        In retrospect I had a sort of low-grade social anxiety throughout my childhood/adolescence that I interpreted as ‘just being introverted.’ I wasn’t the most awkward kid but I didn’t socialize if I could help it and did random things like never referring to people by their names (even friends!) in case for some reason I misremembered it and called them the wrong name and they would surely laugh at me/hate me forever.

        It’s a background state of hypervigilance and sort of dwelling upon the worst that might happen.

        Anyways, I got a bit better over time and then got much better when I changed my diet to remove remove barley, which apparently my immune system hates. Now I’m gregarious, love socializing, and rarely worry about all that much unless there’s a real and present threat of some sort (social or otherwise)…. BUT if I, say, drink a beer I get a rebound effect and have panic attacks at the thought of having to talk to people and basically think that everything is bad and nothing will ever fix it.

        Weird stuff. Immune reaction something something inflammation something neurotransmitters, I don’t think we really understand the biology behind all this yet.

        In addition to all this, I’ve taken Phenibut before when I couldn’t sleep one night. It’s an anxiolytic. It didn’t help me sleep that night, but for the next two days I no longer had an anxiety response. It was….weird and a bit unsettling. Everything was just flavored a bit differently, especially social interactions. Like you mentioned, I knew the social norms and was able to sort of consciously replicate them, but I didn’t feel any internal motivation to act in certain ways to avoid getting into threatening proximity to people, offend them, etc.

        I tried to test it. I was talking with someone who was looking out a window, their back to me. Ordinarily if you get too close to someone for your level of intimacy, you start to feel anxious – people instinctively back away if you enter their personal space, it feels weird to put your face right up to someone, etc. So I just sort of moved my head so that my face was well within their personal space and looked directly at them – basically something that would make me want to recoil to a different position immediately – and felt nothing. Just kinda, huh, look at that, a person. Just did it for a second so they wouldn’t notice lol.

        It went away, but it was a strange experience. I can see that being something that would affect your habits/behaviors/social life over time, just by nature of your disincentives being subtly different.

      4. 27chaos

        Anxiety feels a little bit like fear and a little bit like boredom, combined with one particular problem occupying your attention. Emotionally, it does not have the same causes of boredom, but the feeling is similar, like a higher intensity, more intense boredom. Boredom is kind of a persistent emotional pain. Anxiety is a similar kind of pain, but sharper and narrower.

        It’s also a little like adrenaline, when you are waiting to do something challenging.

        Do you recoil when you hear nails on a chalkboard? Imagine that feeling of recoil, continuing for minutes (intensely) or hours (just slightly muted). That is a pretty good approximation of how anxiety feels, I think. Persistent anxiety, thankfully, is much easier to ignore than the sound of nails on a chalkboard. Short term anxiety can feel several times more unpleasant than the sound, in an uncommon intense situation.

  64. James D. Miller

    A few years ago I started waking up with an intensely painful Charley horse (a leg cramp) once every few weeks. This all started during a time of unusual stress for me. During a family dinner my wife’s uncle said that putting a bar of soap in your bed can prevent Charley horses. I thought this was absurd until our waitress said that she too heard this could work. I did some research and apparently this is a big thing. I tried doing this myself and sleeping with soap seems to have reduced the number of Charley horses I got, although they could have started going away because my life became less stressful.

    1. Scott Alexander Post author

      This is interesting because it seems harder for leg cramps to be psychological than other kinds of pain – there seems to be obvious muscular involvement. I Googled it and wow are there a lot of people discussing this. I find this page interesting.

      1. Leo

        What? I get leg cramps whenever I’m stressed.

        You seem strangely reluctant to accept both parts of “psychosomatic” at once. If you find an anatomical cause, you expect it’s the only cause; and if you suspect a psychological cause, you don’t expect an anatomical cause more serious than micro-pains and itches. Why on Earth couldn’t there be an interaction?

      2. Mark Z.

        Is there not muscular involvement with whiplash or lower back pain?

        You mention the somewhat mysterious “pain gating” issue, but it seems like the obvious mediator from psychological trouble to chronic pain is going around with your muscles clenched all the time.

        (For a known example of chronic pain that can be caused by childhood trauma, consider vaginismus. Of course there’s muscle involvement with that.)

      3. TK-421

        I could see it being a second-order side effect. I know that when I’m psychologically stressed, I tend to physically tense up a lot; probably some lizard-brain fight-or-flight response. It seems plausible that more muscle tension would lead to more muscle cramps, especially in people already predisposed to get them.

        1. Yrro

          I had headaches for years that would randomly appear and disappear before my dentist suggested that I was clenching my jaw at work. Now I just… remember not to clench my jaw, and no pain.

          I was trying to associate it with so many other things — diet, allergies, weather… you can bet if something had happened to coincide with a couple days where I didn’t clench my jaw I would have superstitioned the shit out of it.

      4. EvolutionistX

        During pregnancy I got leg cramps often upon waking. (Common pregnancy thing.) I quickly learned to recognize the specific way that I was about to move my muscles that would trigger the cramp, and learned not to do that (even though I was only half-awake and not totally conscious of what I was up to.) Not a problem anymore, but if I can somewhat purposefully learn not to do something to prevent leg cramps, it seems possible that the reverse could happen.

      5. ChristianKl

        Muscles get triggered by the brain, so why doesn’t it seem likely that it has psychological causes?

    2. Titanium Dragon

      I get leg cramps when I wake up in the morning sometimes, but for me, it seems to have to do with dehydration.

      Also, somehow, rubbing the knotted up area does help it get better faster. If I don’t bend my leg and just massage my calf, it will go away pretty rapidly and will only ache slightly for the rest of the day.

      Cramps seem extremely unlikely to be psychosomatic, though, because you can actually tell if a cramp is real or not by feeling the muscle.

      1. FeepingCreature

        For me, the thing that reliably helps is sitting up and putting my foot on the ground, knee at right angle, and pushing down a bit.

        Any idea why?

      2. Neanderthal From Mordor

        I strengthen the leg and pull the top of the foot towards with my hand in a move that is very common for soccer football players warming up.
        The pain ends immediately.

        1. Cliff

          Cramping is the muscle contracting very strongly, so stretch the muscle out manually and the cramp stops.

      3. caryatis

        >Cramps seem extremely unlikely to be psychosomatic, though, because you can actually tell if a cramp is real or not by feeling the muscle.

        Calling something “psychosomatic” doesn’t mean the symptom isn’t real; it means the cause is psychological. If the person is lying about their symptom, they’re just a malingerer, not someone with a psychosomatic illness.

  65. Buck

    childhood shared environment, which presumably includes things like abusive parents

    I don’t think this is necessarily true: there seems to be a reasonable number of stories about parents being very different levels of abusive towards different children. See Will Eden on this topic

    1. Scott Alexander Post author

      I agree the correlation is not 100, but I think it should be significantly greater than zero. I also think that kids with parents who abuse their twins are more likely to have bad childhoods in other ways even if they are not abused themselves.

      1. JoyCS

        In my anecdotal experience listening to people’s life stories, it’s very likely other children are abused, too, though not necessarily in the same way. My guess is that in more than half of all stories I’ve heard other siblings were also abused in some way. Though some describe the “golden child” situation toward one or more siblings, which, while unhealthy, does not qualify as abuse.

      2. NN

        True, but following this train of logic seems to lead to some pretty absurd conclusions. For example, even today one-fifth of American households do not have regular internet access. Taking behavioral genetics studies at face value would therefore indicate that growing up with or without regular access to the internet has no significant effect on adult outcomes. This despite all of the massive social changes over the past 25 years that sure looked like they were caused by increasing availability of internet access.

        More generally, there is whatever is behind the Flynn Effect. We know that there are environmental factors that have an enormous impact on IQ, because some sort of environmental differences between America in the 2010s and America in the 1980s, for example, are responsible for children growing up in the former time period to have IQ scores that are an average 9 points greater than those who grew up in the latter period. So why doesn’t variation in these factors, whatever they are, between different households show up as a shared environment effect on behavioral genetics IQ studies?

        Getting back to the subject at hand, you seem to be pretty confident that back injuries are strongly associated with chronic back pain. Surely there must be shared environment factors that increase or decrease the likelihood of back injuries, right? Just off of the top of my head: being driven to school by a parent who for whatever reason is more likely than other parents to get into car accidents, growing up in a household where you are expected to help with moving furniture and other heavy lifting, growing up in a place that has a lot of opportunities to get involved with sports that have a high risk of back injury. How reasonable is it to conclude that none of these things actually matter?

        It is because of things like this that I continue to have serious doubts about the current state of behavioral genetics research.

      3. Matthew

        I remember you looking at meta-studies of the effect of divorce on adopted kids and biological kids and concluding there was a mild shared environment effect. It seems abuse would also be powerful enough to have an effect.

  66. Alex

    Whiplash and back pain in particular are commonly faked or exaggerated for financial reasons. If Lithuania’s legal system doesn’t let you easily sue someone for thousands of dollars because you got whiplash in a car accident, for example, I wouldn’t at all be surprised that they have very low incidence of whiplash! I don’t think you can really make conclusions about the nature of pain based on the prevalence of these kinds of injuries without considering incentives that people might have to report, not report, or fabricate an injury that causes chronic pain.

    1. Scott Alexander Post author

      See this study, page 7, “Almost All Subsequent Experiments Have Failed To Support Miller’s View”. I don’t know any more on this than what I can find on Google Scholar, but it looks like this theory is out of favor.

    2. Good Burning Plastic

      That’s pretty much what I was writing before reading the first comment.

    3. Steve Sailer

      Whiplash was a common topic of television and Mad Magazine jokes in the late 1960s. Mercenary characters were constantly donning neck braces and feigning whiplash to win lawsuits in sitcoms and sketch comedies. It was a huge theme on television and in the funny papers. “The Whiplash Era” would be a good name for a book about television comedy in the late 1960s.

      Now you don’t hear much about whiplash anymore. Maybe that has to do with the the feds mandating headrests in new cars in 1969. Or maybe something else changed. I don’t know.

      1. Cord Shirt

        Just a hunch, but I’d guess diagnosis has moved toward greater specificity. I’d expect today you’d be less likely to get diagnosed with “whiplash” and more likely to get told “damaged disk/vertebra/etc.”

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